Violence in Adulthood and Mental Health

Abstract

The aim of this study was to describe perceived abuse in adult Spanish and Ecuadorian women and men and to assess its association with mental health.

A population-based survey was conducted in Spain in 2006. Data were taken from a probabilistic sample allowing for an equal number of men and women, Spaniards and Ecuadorians. Mental disorder was measured with the General Health Questionnaire-28. The nine questions on exposure to physical, sexual, and psychological abuse during the previous year were self-administered. Multivariate logistic regression was used to assess the association between exposure to abuse and poor mental health, adjusting for potential confounders.

The sample was composed of 1,059 individuals aged 18 to 54, 104 of whom reported physical, psychological, or sexual abuse. Some 6% refused to answer the questions on abuse. Overall, reported abuse ranged from 13% in Ecuadorian women to 5% in Spanish men. Psychological abuse was the most frequent. Half the abused women, both Spanish and Ecuadorian, reported intimate partner violence (IPV), as did 22% of abused men. Poor mental health was found in 61% of abused Spanish women (adjusted Odds Ratio [ORa] = 5.1; 95% CI: 1.8-14.4), and 62% abused Ecuadorian women (ORa = 4; 95% CI: 2-7.9), in 36% of abused Spanish men (ORa = 3; 95% CI: 0.9-10.7) and in 30% abused Ecuadorian men (ORa = 2.8; 95% CI: 1-7.7).

Interpersonal violence is frequent in relations with the partner, the family, and outside the family, and it seriously affects the mental health. Ecuadorian women stand out as the most vulnerable group.

Keywords

mental health and violence violence exposure anything related to domestic violence domestic violence

Introduction

The negative impact of violence on health outcomes is an emerging issue that has a strong gender component. Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (World Health Organization [WHO], 1996). Violence, often measured as self-reported and self-perceived, is strongly dependent on the social and cultural norms of the context in which it takes place. Gender differences are expressed through different patterns of violence: men tend to be perpetrators of violence toward other men and toward women who are more vulnerable to intimate partner violence (IPV) and sexual violence (WHO, 1996). Men can also suffer IPV, mainly psychological abuse (Coker et al., 2002); it has been reported that women’s use of physical abuse generally stems from efforts to defend themselves or their children against male partner abuse (Bair-Merritt et al., 2010; Swan, Gambone, Caldwell, Sullivan, & Snow, 2008). Extensive IPV occurs independently of age (Mouton, 2003; Amar & Gennaro, 2005), nationality (Prospero & Kim, 2009), and social class (WHO, 2002; Instituto de la Mujer, 2006).

Men and women are also exposed to other types of violence from outside their intimate circle, in the workplace and on the street (WHO, 2002). In the scientific literature, the terms “abuse” and “interpersonal violence” are often used synonymously.

Violence is a public health issue since it produces deaths, increases of morbidity, and decreases of life quality (Rosenberg, 1988). Most of the research in this area has focused on describing the frequency and severity of injuries caused by violence exposure and their impact on terms of burden on health services. However, the role of health services has focused on providing answers to the physical consequences of violence, but not to the mental health impact on their victims. Some studies have established an association between violence exposure and mental health problems, drug and alcohol misuse, sexual dysfunction, coronary disease, and other physical symptoms (Bonomi, Anderson, Rivara, & Thompson, 2007; Coker et al., 2002; Kelly, 2010; WHO, 2002; ). A relationship between violence and negative mental health outcomes has been observed in different countries and contexts throughout the world (Ribeiro, Andreoli, Ferri, Prince, & Mari, 2009)

In Spain, data from the 2006 National Health Survey (SNHS) showed that 3% of respondents, the same in both men and women, reported having suffered some form of maltreatment or injury in the previous year. The rate of violence originating in the home was higher in women (31%) than in men (6%; Ministerio de Sanidad, Política Social e Igualdad and Instituto Nacional de Estadística, 2006). Similarly, in a national population survey on domestic violence against women, 3.6% of women reported abuse in the same period (Instituto de la Mujer, 2006).

The gender axis also affects mental health outcomes: Women are more prone to suffer anxiety or depression disorders while men are more prone to alcohol and drug abuse and suicidal behaviors (Kessler et al., 2005). Migrants are more vulnerable to depressive disorders that are associated with the stress of the migration process and adjustment to a new situation in the host country (de Wit et al., 2008). These findings call for performing the analysis taking into account the gender and immigration status of respondents to gain a deeper knowledge of the phenomenon.

The consequences of violence on mental health have been analyzed in Spain in a representative sample of women attending primary care centers who had suffered IPV. All types of abuse were significantly associated with psychological distress, as well as use of tranquillizers and antidepressants (Ruiz-Perez & Plazaola-Castano, 2005). While IPV in women has been addressed, there are scant data from our context studying mental health outcomes and its relationship with violence in both men and women.

To our knowledge, no studies in Spain have focused on the source of violence against both men and women, including both natives and foreigners, and its consequences on mental health; such studies are also scarce in other countries. Therefore, improved knowledge on how exposure to violence affects mental health in a particular cultural context is key to identify hidden victims.

The objective of this study was to describe recent exposure to physical, sexual, and/or psychological abuse and its association with mental health problems in men and women of Spanish and Ecuadorian origin who participated in a population-based survey in Spain.

Materials and Method

A population-based home survey was carried out among Spanish and Ecuadorian men and women aged 18 to 54 registered in 33 areas (neighborhoods or municipalities) located in four provinces of Spain (Alicante, Almeria, Madrid, and Murcia). Ecuadorians were chosen because they constituted the largest group of economic immigrants, with a similar proportion of men and women, and share a common language with Spain. The areas were selected with the aim of achieving maximum heterogeneity among them, based on criteria related to socioeconomic status and density of the migrant population. Sample size calculations were based on different estimates of the prevalence of the outcome variable, “possible psychiatric case” (PPC; 10%-35%), with precision ranging from 2% to 5%, an alpha error of 5%, and a design effect of 1.5. A probabilistic sample of 1,188 adults aged 18 to 54 was finally obtained. Respondents were drawn from the civil register in each locale, with an equal number of men and women, Spaniards and Ecuadorians, chosen in each area. To minimize nonresponse by invalid addresses, unable to contact, and refusal, six candidates were selected for each interview needed. To maximize response, letters were sent to potential participants informing them about the scientific nature of the survey. A 10-euro token (phone card for Ecuadorians and petrol voucher for Spaniards) was given to encourage participation. Ecuadorians were visited by trained Latin American interviewers, mostly women. At least two documented visits were made at different times of the day before moving to the next candidate. Detailed information on this study has been published previously, but will be summarized here (Alvarez-del Arco et al., 2009).

PPC, the outcome variable, was defined as a score of 5 or more on the Spanish version of the 28-item General Health Questionnaire (GHQ-28; Goldberg & Hillier, 1979) validated in Spain (Lobo, Perez-Echeverria, & Artal, 1986) using the GHQ coding scheme. The exposure variable, recent exposure to abuse was assessed by asking the respondent to fill in a self-administered questionnaire at the end of the interview. Given the sensitive nature of the subject matter, this information was not obtained from a face-to-face interview and people were explicitly given the possibility to refuse. Respondents were asked to complete nine questions asking about exposure during the preceding 12 months to physical, sexual, and psychological abuse. A specific description of what was meant by each type of abuse was contained in the questionnaire: “Have you suffered any physical abuse in the past year (have you been slapped, pushed, beaten with a fist or anything else that could hurt you; has anyone kicked, dragged, threatened you with or used a gun, knife or other weapon against you)?”; “Have you suffered any emotional abuse in the past year (have you been insulted or made to feel bad about yourself, humiliated or made to feel small in front of other people; has anyone purposely tried to scare you with their look, or by screaming or breaking things, or have they threatened to hurt you or someone you love, or not let you out to see your family or friends)?; and “Have you suffered any sexual abuse in the past year (have you been forced to have sex when you did not want to; have you ever had sex when you did not want to for fear of what he/she could do to you, or have you been made to do something sexual that you considered unnatural or unpleasant)?”

The questionnaire included information on the frequency of abuse and its perpetrators. The respondent introduced the information in an envelope with an identification number which was closed and handed to the interviewer. A 24-hr telephone help-line number for victims of abuse was given to all survey participants.

The interviewer also inquired about sociodemographic characteristics; age, nationality, marital status, partner, children, educational level, and employment situation; the question about atmosphere at work was answered using a 5-item Likert-type scale. We inquired about various forms of support: “social support” was measured by the Duke scale (Broadhead, Gehlbach, Degruy, & Kaplan, 1988), categorized in tertiles; “emotional support from partner” was measured with five questions using a 5-item Likert-type scale; “economic support” was evaluated by the question; “Is there someone who could lend you 100€ in case of need?”; financial strain by: “How would you rate your difficulties in making ends meet each month using your monthly income?” (Instituto Nacional de Estadística [INE], 1997) which was answered using a 5-item Likert-type scale.

Interviews were conducted between September 2006 and January 2007. The overall response rate (completed interviews/completed + refusals) was 61%; 60% for men and 62% for women. Of all participants, 6% refused to answer the final self-administered section on exposure to abuse; there were no sociodemographic differences between respondents and nonrespondents.

The sampling frame, questionnaire, psychometric characteristics of the scales, and fieldwork strategies were evaluated and revised based on the results of a pilot study carried out between January and February 2006. Special care was taken to assess the acceptability of the last part of the questionnaire, that is, the self-administered section on exposure to abuse.

Approval for the research was obtained from the clinical research ethics committee of the Carlos III Institute of Health.

Statistical Analyses

Given our objective and according to available scientific evidence; the data were stratified by sex and nationality in all the analyses. To analyze the association between abuse exposure and mental health, we created a dichotomous exposure variable: exposed to any form of abuse and not exposed. Descriptive analyses of participants’ characteristics were carried out using frequency tables.

To analyze the association between abuse exposure and mental health, we first calculated the corresponding crude odds ratio (95% CI). Second, bivariable analyses using Mantel-Haenszel methods were carried out to calculate the odds ratio (95% CI) for abuse exposure and mental health adjusted for each potential confounder. The crude and the adjusted odds ratio were compared to assess whether the crude effect of abuse exposure and mental health could be explained by the effect of the potential confounder. To identify potential effect modification, stratum-specific odds ratios for abuse exposure and mental health were obtained; the test of homogeneity of ORs was used to test for effect modification. Third, multivariable analyses were carried out using logistic regression models to obtain a “fully” adjusted measure of abuse exposure and mental health, controlling for more than one confounder simultaneously. Confounders were added one by one, starting with the strongest, and kept in the model if the effect of abuse exposure changed after the inclusion of the confounder in the model. The inclusion of potential confounders in the final model was based on a change of ± 10% in the odds ratio (OR) of interest. Finally, and once confounders were included in the multivariate logistic regression models, we tested for interactions between abuse exposure and variables included in the model. Wald tests were used to derive p values. All analyses were performed in Stata 10.

Results

Of the 1,144 persons interviewed, 2 had no information on the outcome variable, 20 subjects were age 55 or over, and 63 did not answer the questions on abuse, giving a final sample of 1,059 subjects. The sociodemographic characteristics of the sample, stratified by sex and nationality, are shown in Table 1. There were more single Spanish men (56%) than women (39%), and more Ecuadorian women (84%) and men (73%) had children compared to Spanish females (56%) and males (42%). Women reported lack of social and partner support more often than men of the same nationality. A larger proportion of men worked outside the home and more than half of Ecuadorian women (56%) reported financial difficulties making it through the month.

Table 1.

Sex and Nationality-Specific Distributions of Sociodemographic Characteristics.

	Spanish		Ecuadorian
	Women n = 266 [n (%)]	Men n = 259 [n (%)]	Women n = 267 [n (%)]	Men n = 267 [n (%)]	p value
Age (years)					0.000
≤25	62 (23)	78 (30)	61 (23)	53 (20)
26-35	77 (29)	69 (27)	142 (53)	130 (49)
36-45	78 (29)	80 (31)	56 (21)	69 (26)
>45	49 (18)	32 (12)	8 (3)	15 (6)
Education					0.000
Primary or less	101 (38)	91 (35)	92 (34)	104 (39)
Secondary	93 (35)	113 (44)	154 (58)	148 (55)
University	72 (27)	55 (21)	21 (8)	15 (6)
Has children					0.000
No	118 (44)	149 (58)	44 (16)	72 (27)
Yes	148 (56)	110 (42)	223 (84)	195 (73)
Has a partner					0.000
No	70 (26)	90 (35)	44 (16)	46 (17)
Yes	196 (74)	169 (65)	223 (84)	221 (83)
Marital status					0.000
Single	104 (39)	144 (56)	92 (34)	98 (37)
Separated/widowed/divorced	24 (9)	7 (3)	29 (11)	14 (5)
Married	138 (52)	108 (42)	146 (55)	155 (58)
Employment					0.000
Not working	115 (43)	58 (22)	46 (17)	17 (6)
Working currently	151 (57)	201 (78)	221 (83)	250 (94)
Economic difficulties					0.000
Little/one	86 (32)	104 (40)	54 (20)	66 (25)
Not much	69 (26)	66 (25)	61 (23)	77 (29)
A lot/some	101 (38)	82 (32)	150 (56)	123 (46)
Unknown	10 (4)	7 (3)	2 (1)	1 (0)
Atmosphere at work					0.000
Excellent/good	127 (48)	174 (67)	154 (58)	203 (76)
Average/bad	23 (9)	25 (10)	63 (24)	46 (17)
Unknown/not working	116 (44)	60 (23)	50 (19)	18 (7)
Economic Support					0.000
No	15 (6)	16 (6)	66 (25)	41 (15)
Yes	246 (92)	238 (92)	196 (73)	223 (84)
Unknown	5 (2)	5 (2)	5 (2)	3 (1)
Partner emotional support					0.000
Low	50 (19)	27 (10)	79 (30)	43 (16)
Medium/High	146 (55)	142 (55)	144 (54)	178 (67)
Has no partner	70 (26)	90 (35)	44 (16)	46 (17)
Social support					0.000
Medium/high/unknown	204 (77)	216 (83)	129 (48)	149 (56)
Low	62 (23)	43 (17)	138 (52)	118 (44)

Overall, 67 women (13%) and 37 men (7%) reported exposure to any form of abuse in the preceding 12 months. In both cases, the proportion was higher in Ecuadorians than in Spaniards: 17% versus 8% for women (p < 0.004) and 9% versus 5% for men (p = 0.38; Figure 1).

Figure 1.

Prevalence of recent exposure to abuse in Spanish and Ecuadorian men and women, by type and person who inflicted the abuse.

The prevalence of all types of abuse was higher in Ecuadorian than in Spanish women: emotional (14% vs. 8%), physical (9% vs. 1%), and sexual (3% vs. 1%) abuse. Among men, Ecuadorians were also more exposed than Spaniards to physical abuse (6% vs. 2%), but differences were not statistically significant (p = 0.15). Emotional abuse was reported by a very similar proportion of men, both Spanish (4%) and Ecuadorian (6%).

The perpetrator of the abuse was unknown for 18% of the women and 30% of the men. Among those with a known source of abuse, intimate partners were the main perpetrators for females, both Spaniards (52%) and Ecuadorians (48%) and an important source for abused Ecuadorian men (30%) but much less so for Spanish men (7%).

The next most common source of abuse was that perpetrated by persons other than relatives (Figure 1). Ecuadorian women were more exposed to abuse from persons other than relatives (28%) than were Spanish women (10%). More women reported exposure to frequent episodes of abuse; 32% of abused women reported having been abused many times in the preceding year, higher among Spanish (38% vs. 30%), compared to 11% of the abused men (p = 0.046).

Abuse was more frequent among Spanish men with low social support, with average/poor atmosphere at work, and without economic support. Among Spanish women, abuse was more common in those separated/widowed/divorced, with economic difficulties, lacking economic support, and with low partner and social support (Table 2). Ecuadorian women were more prone to suffer abuse and frequently had lower emotional partner and social support.

Table 2.

Prevalence of PPC (Possible Psychiatric Case) and Exposure to Abuse in Ecuadorian and Spanish Men and Women, by Sociodemographic Characteristics.

	Spanish Women				Spanish Men				Ecuadorian Women				Ecuadorian Men
	Mental Health		Has Been Abused		Mental Health		Has Been Abused		Mental Health		Has Been Abused		Mental Health		Has Been Abused
	Good	Poor	No	Yes	Good	Poor	No	Yes	Good	Poor	No	Yes	Good	Poor	No	Yes
	n = 203 [n (%)]	n = 63 [n (%)]	n = 245 [n (%)]	n = 21 [n (%)]	n = 228 [n (%)]	n = 31 [n (%)]	n = 245 [n (%)]	n = 14 [n (%)]	n = 174 [n (%)]	n = 93 [n (%)]	n = 221 [n (%)]	n = 46 [n (%)]	n = 230 [n (%)]	n = 37 [n (%)]	n = 244 [n (%)]	n = 23 [n (%)]
Age (years)	(p = 0.212)		(p = 0.624)		(p = 0.142)		(p = 0.409)		(p = 0.461)		(p = 0.025)		(p = 0.549)		(p = 0.770)
≤25	52 (84)	10 (16)	59 (95)	3 (5)	70 (90)	8 (10)	75 (96)	3 (4)	45 (74)	16 (26)	55 (90)	6 (10)	48 (91)	5 (9)	48 (91)	5 (9)
26-35	61 (79)	16 (21)	70 (91)	7 (9)	65 (94)	4 (6)	67 (97)	2 (3)	89 (63)	53 (37)	114 (80)	28 (20)	109 (84)	21 (16)	117 (90)	13 (10)
36-45	56 (72)	22 (28)	70 (90)	8 (10)	66 (83)	14 (18)	74 (93)	6 (8)	35 (63)	21 (38)	48 (86)	8 (14)	59 (86)	10 (14)	65 (94)	4 (6)
>45	34 (69)	15 (31)	46 (94)	3 (6)	27 (84)	5 (16)	29 (91)	3 (9)	5 (63)	3 (38)	4 (50)	4 (50)	14 (93)	1 (7)	14 (93)	1 (7)
Education	(p = 0.000)		(p = 0.358)		(p = 0.973)		(p = 0.998)		(p = 0.380)		(p = 0.085)		(p = 0.116)		(p = 0.460)
Primary or less	64 (63)	37 (37)	90 (89)	11 (11)	80 (88)	11 (12)	86 (95)	5 (5)	59 (64)	33 (36)	76 (83)	16 (17)	84 (81)	20 (19)	94 (90)	10 (10)
Secondary	74 (80)	19 (20)	87 (94)	6 (6)	100 (89)	13 (12)	107 (95)	6 (5)	104 (68)	50 (32)	124 (81)	30 (19)	132 (89)	16 (11)	135 (91)	13 (9)
University	65 (90)	7 (10)	68 (94)	4 (6)	48 (87)	7 (13)	52 (95)	3 (5)	11 (52)	10 (48)	21 (100)	0 (0)	14 (93)	1 (7)	15 (100)	0 (0)
Has children	(p = 0.000)		(p = 0.289)		(p = 0.949)		(p = 0.558)		(p = 0.065)		(p = 0.118)		(p = 0.235)		(p = 0.377)
No	104 (88)	14 (12)	111 (94)	7 (6)	131 (88)	18 (12)	142 (95)	7 (5)	34 (77)	10 (23)	40 (91)	4 (9)	65 (90)	7 (10)	64 (89)	8 (11)
Yes	99 (67)	49 (33)	134 (91)	14 (9)	97 (88)	13 (12)	103 (94)	7 (6)	140 (63)	83 (37)	181 (81)	42 (19)	165 (85)	30 (15)	180 (92)	15 (8)
Has a partner	(p = 0.642)		(p = 0.201)		(p = 0.622)		(p = 0.218)		(p = 0.250)		(p = 0.291)		(p = 0.519)		(p = 0.257)
No	52 (74)	18 (26)	62 (89)	8 (11)	78 (87)	12 (13)	83 (92)	7 (8)	32 (73)	12 (27)	34 (77)	10 (23)	41 (89)	5 (11)	44 (96)	2 (4)
Yes	151 (77)	45 (23)	183 (93)	13 (7)	150 (89)	19 (11)	162 (96)	7 (4)	142 (64)	81 (36)	187 (84)	36 (16)	189 (86)	32 (14)	200 (91)	21 (10)
Marital status	(p = 0.002)		(p = 0.000)		(p = 0.540)		(p = 0.545)		(p = 0.091)		(p = 0.764)		(p = 0.413)		(p = 0.512)
Single	87 (84)	17 (16)	98 (94)	6 (6)	125 (87)	19 (13)	136 (94)	8 (6)	68 (74)	24 (26)	78 (85)	14 (15)	87 (89)	11 (11)	87 (89)	11 (11)
Separated/widowed/divorced	12 (50)	12 (50)	17 (71)	7 (29)	7 (100)	0 (0)	6 (86)	1 (14)	17 (59)	12 (41)	23 (79)	6 (21)	13 (93)	1 (7)	13 (93)	1 (7)
Married	104 (75)	34 (25)	130 (94)	8 (6)	96 (89)	12 (11)	103 (95)	5 (5)	89 (61)	57 (39)	120 (82)	26 (18)	130 (84)	25 (16)	144 (93)	11 (7)
Employment	(p = 0.719)		(p = 0.340)		(p = 0.160)		(p = 0.569)		(p = 0.728)		(p = 0.187)		(p = 0.640)		(p = 0.170)
Not working	89 (77)	26 (23)	108 (94)	7 (6)	48 (83)	10 (17)	54 (93)	4 (7)	31 (67)	15 (33)	35 (76)	11 (24)	14 (82)	3 (18)	14 (82)	3 (18)
Working currently	114 (76)	37 (25)	137 (91)	14 (9)	180 (90)	21 (10)	191 (95)	10 (5)	143 (65)	78 (35)	186 (84)	35 (16)	216 (86)	34 (14)	230 (92)	20 (8)
Economic difficulties	(p = 0.012)		(p = 0.007)		(p = 0.748)		(p = 0.244)		(p = 0.264)		(p = 0.917)		(p = 0.600)		(p = 0.693)
Little/one	71 (83)	15 (17)	82 (95)	4 (5)	94 (90)	10 (10)	101 (97)	3 (3)	37 (69)	17 (31)	44 (81)	10 (19)	60 (91)	6 (9)	58 (88)	8 (12)
Not much	55 (80)	14 (20)	68 (99)	1 (1)	56 (85)	10 (15)	60 (91)	6 (9)	44 (72)	17 (28)	51 (84)	10 (16)	65 (84)	12 (16)	71 (92)	6 (8)
A lot/some	67 (66)	34 (34)	86 (85)	15 (15)	72 (88)	10 (12)	78 (95)	4 (5)	91 (61)	59 (39)	124 (83)	26 (17)	104 (85)	19 (15)	114 (93)	9 (7)
Unknown	10 (100)	0 (0)	9 (90)	1 (10)	6 (86)	1 (14)	6 (86)	1 (14)	2 (100)	0 (0)	2 (100)	0 (0)	1 (100)	0 (0)	1 (100)	0 (0)
Atmosphere at work	(p = 0.003)		(p = 0.608)		(p = 0.021)		(p = 0.031)		(p = 0.023)		(p = 0.611)		(p = 0.024)		(p = 0.184)
Excellent/Good	102 (80)	25 (20)	115 (91)	12 (9)	160 (92)	14 (8)	168 (97)	6 (3)	108 (70)	46 (30)	129 (84)	25 (16)	181 (89)	22 (11)	189 (93)	14 (7)
Average/Bad	11 (48)	12 (52)	21 (91)	2 (9)	20 (80)	5 (20)	21 (84)	4 (16)	32 (51)	31 (49)	53 (84)	10 (16)	34 (74)	12 (26)	40 (87)	6 (13)
Unknown/Not working	90 (78)	26 (22)	109 (94)	7 (6)	48 (80)	12 (20)	56 (93)	4 (7)	34 (68)	16 (32)	39 (78)	11 (22)	15 (83)	3 (17)	15 (83)	3 (17)
Economic Support	(p = 0.021)		(p = 0.011)		(p = 0.004)		(p = 0.046)		(p = 0.187)		(p = 0.581)		(p = 0.018)		(p = 0.289)
No	7 (47)	8 (53)	11 (73)	4 (27)	10 (63)	6 (38)	13 (81)	3 (19)	37 (56)	29 (44)	54 (82)	12 (18)	30 (73)	11 (27)	37 (90)	4 (10)
Yes	192 (78)	54 (22)	230 (94)	16 (7)	214 (90)	24 (10)	227 (95)	11 (5)	134 (68)	62 (32)	162 (83)	34 (17)	198 (89)	25 (11)	205 (92)	18 (8)
Unknown	4 (80)	1 (20)	4 (80)	1 (20)	4 (80)	1 (20)	5 (100)	0 (0)	3 (60)	2 (40)	5 (100)	0 (0)	2 (67)	1 (33)	2 (67)	1 (33)
Partner emotional support	(p = 0.560)		(p = 0.036)		(p = 0.000)		(p = 0.335)		(p = 0.231)		(p = 0.015)		(p = 0.756)		(p = 0.111)
Low	36 (72)	14 (28)	43 (86)	7 (14)	17 (63)	10 (37)	25 (93)	2 (7)	46 (58)	33 (42)	59 (75)	20 (25)	36 (84)	7 (16)	36 (84)	7 (16)
Medium/High	115 (79)	31 (21)	140 (96)	6 (4)	133 (94)	9 (6)	137 (96)	5 (4)	96 (67)	48 (33)	128 (89)	16 (11)	153 (86)	25 (14)	164 (92)	14 (8)
Has no partner	52 (74)	18 (26)	62 (89)	8 (11)	78 (87)	12 (13)	83 (92)	7 (8)	32 (73)	12 (27)	34 (77)	10 (23)	41 (89)	5 (11)	44 (96)	2 (4)
Social support	(p = 0.001)		(p = 0.000)		(p = 0.047)		(p = 0.048)		(p = 0.127)		(p = 0.008)		(p = 0.097)		(p = 0.420)
Medium/high/unknown	165 (81)	39 (19)	195 (96)	9 (4)	194 (90)	22 (10)	207 (96)	9 (4)	90 (70)	39 (30)	115 (89)	14 (11)	133 (89)	16 (11)	138 (93)	11 (7)
Low	38 (61)	24 (39)	50 (81)	12 (19)	34 (79)	9 (21)	38 (88)	5 (12)	84 (61)	54 (39)	106 (77)	32 (23)	97 (82)	21 (18)	106 (90)	12 (10)

In men, PPC prevalence was higher in subjects with poor atmosphere at work, in those who lacked economic support. Specifically among Spanish men, low emotional support from the current partner and low social support appeared also as risk factors.

Figure 2 shows higher prevalence of poor mental health among abused subjects, and higher prevalence in abused women (61%), similar among Spanish and Ecuadorian, than in abused men.

Figure 2.

Prevalence of poor mental health in Spanish and Ecuadorian men and women by abuse exposure.

In the crude analysis, the OR for PPC among Spanish women associated to abuse was 6.4 (95% CI: 2.5-16.5) and 4.1 (95% CI: 1.2-13.4) Spanish men (Table 3). Among Ecuadorians, crude OR was 3.1 (95% CI: 1.2-8.4) for men and 3.7 (95% CI: 1.9-7.3) for women.

Table 3.

Multivariate Analysis of the Association Between Abuse and Poor Mental Health According to Sex and Immigration Status.

	OR for Poor Mental Health and Abuse Exposure (IC 95%)
Stratum	Crude	Adjusted
Spanish women	6.4 (2.5-16.5)	5.1 (1.8-14.4)*
Spanish men	4.1 (1.2-13.4)	3 (0.9-10.7)**
Ecuadorian women	3.7 (1.9-7.3)	4 (2-7.9)**
Ecuadorian men	3.1 (1.2-8.4)	2.8 (1-7.7)**

Note. * Adjusted by age, social support, marital status, and work atmosphere. ** Adjusted by age and work atmosphere.

There was not a statistically significant interaction between sex and nationality on the odds of poor mental health (p = 0.732) but numbers were low.

The multivariate analysis showed that among Spanish women the OR remained high after adjusting for age, marital status, social support and work atmosphere [OR = 5.1 (95% CI: 1.8-14.4)]. For Spanish men, however, after adjusting for age and work atmosphere, the odds of PPC decreased and lost statistical significance [OR = 3.0 (95% CI: 0.9-10.7)]. Among Ecuadorians, the association remains significant in both, women [OR = 4 (95% CI: 2.0-7.9)] and men [OR = 2.8 (95% CI: 1.0-7.7)] and, after adjusting by age and work atmosphere.

Discussion

Exposure to abuse was strongly associated with poor mental health in both women and men, and in both Ecuadorians and Spaniards. Consistent with previous publications, we found a differential distribution of abuse exposure and abuse characteristics linked with gender and immigrant status: victims were mostly Ecuadorian women while Spanish men were the least exposed to abuse. For women, IPV was source of about half of the reported abuse. In men the source of abuse is shared between the partner, relatives, and other persons.

We have previously described in this population how gender and migrant axis could affect mental health in adulthood (Del Amo et al., 2011), and our current approach involves a comprehensive vision of the relationship between mental health and violence from several sources. Our data are consistent with multiple publications that show a negative association of physical (Bonomi et al., 2007; Coker et al., 2002; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008; Kelly, 2010; Pico-Alfonso et al., 2006; Ruiz-Perez & Plazaola-Castano, 2005; Sutherland, Bybee, & Sullivan, 1998), psychological (Borrell et al., 2010a; Borrell et al., 2010b; Coker et al., 2002; Kessler, Mickelson, & Williams, 1999; Pico-Alfonso et al., 2006; Ruiz-Perez & Plazaola-Castano, 2005), or sexual (Coker et al., 2002; Pico-Alfonso et al., 2006) abuse with mental health, although most of these studies deal with IPV or other specific types of violence such as workplace harassment, child or elder abuse, or rape.

In Spain, the partner is the main source of violence for women (Instituto de la Mujer, 2006; Ministerio de Sanidad & Instituto Nacional de Estadística, 2006) and this also applies for migrant women (Carballo, Grocutt, & Hadzihasanovic, 1996; Van Hightower, Gorton, & Demoss, 2010). Ecuadorian women are also more exposed to abuse from persons other than their relatives than are Spanish women. As described in other countries, vulnerability derived from immigrant status could influence both the type of abuse and its implications for mental health (Kessler et al., 1999; Wadsworth et al., 2007). Both gender and ethnic discrimination could be perceived as abuse. Data from the Spanish National Health Survey (SNHS) show that ethnic discrimination (Borrell et al., 2010b) and sexism (Borrell et al., 2010a) have a consistent relationship with poor mental health. Moreover, lack of social and economic resources exacerbates the effects of ethnic discrimination on mental health (Llacer et al., 2009).

In our study, Ecuadorian women suffer higher frequency of exposure to abuse and similar frequency of poor mental health than Spanish women, but higher than both Ecuadorian and Spanish men. Vulnerability derived from migration status is associated with both living and working conditions. As previously described, the Ecuadorians included in our sample have more economic constraints, lack of economic support, and bad atmosphere at work than Spaniards. In addition, Ecuadorian women are employed as caregivers of elderly people and cleaners, characterized by precarious conditions and job insecurity (Parella, 2003). Integration of Ecuadorian women into labor market and their progressive empowerment has to face the “cultural machismo” and patriarchal social structure of their culture of origin, leading to situations where the woman’s identity is compromised.

In our study, most of the abused men who identified the perpetrator reported a source other than a relative. Around one third of abused Ecuadorian men pointed to their partner as compared to 7% of Spanish men; likewise, the SNHS showed the partner as the source of abuse in 6% of men. In our study, a large proportion of men did not report who perpetrators of abuse were, and this could hide partner abuse in addition to abuse occurring in the workplace or on the street. Some studies show that for men the context and source of violence is more diffuse (Butchart & Brown, 1991; Crowell & Burguess, 1996; Heise, 1993; Koss, Koss, & Woodruff, 1991; Tjaden & Thoennes, 2000; WHO, 2002). In fact, there is evidence of unreported IPV in males (Caetano, Schafer, & Cunradi, 2001). In the SNHS survey, 37% of abused men reported this had occurred at their place of work or study, while 32% said the incident occurred in the street, and 14% referred to recreational settings (Ministerio de Sanidad & Instituto Nacional de Estadística, 2006). Some studies conducted in high income countries report similar rates of IPV perpetrated by men and women (Allen et al., 2009) but the data for Spain differ: the SNHS survey (Ministerio de Sanidad & Instituto Nacional de Estadística, 2006) found that abuse is largely perpetrated by men, against both males (90%) and females (84%).

Our study presents some limitations. The content and format of the questions in the survey instrument designed to collect information on abuse were tested in a pilot study, but their validity was not assessed. As has previously been noted, there is a lack of information on the source of abuse, especially among men. Furthermore, the sample size of abused persons was too small to allowing more detailed analysis. In spite of the strong association found is not possible to establish casual relationships; the cross-sectional design of the study does not permit any conclusions as to the direction of the association. Moreover, since abuse is a subjective experience (WHO, 2002), people with poorer mental health would be more likely to reporting higher rates of exposure to abuse.

To our knowledge, this is the first population-based study on the association between violence exposure and mental health in Spaniards and Ecuadorians male and females in Spain. As previously discussed, the so called gender violence is more complex than the IPV against women. Men are also exposed to it, mainly to psychological abuse.

Our findings show that in studies addressing mental health, it is necessary to take into account the history of exposure to violence. Our findings also stress that health care services have to integrate interpersonal violence as a current threat to the health of their patients. Incorporating screening programs in Primary Health Care and making health professionals sensitive to abuse could help in the early detection of situations of interpersonal violence.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work has been funded by the Spanish Research Fund (FIS PI041026). Débora Álvarez was employed by CIBERESP (Ciber of Epidemiology and Public Health). Débora Álvarez and Inma Jarrín are employed with funds from RIS (Spanish HIV Research Network for Excellence), RD06/006.

Author Biographies

Debora Alvarez-del Arco is Sociologist at the National Center of Epidemiology in Madrid (Spain). She does research on social factors related with inequalities in health, mainly in the fields of mental health and HIV.

Julia del Amo is a Tenured Investigator at the National Center for Epidemiology from the Public Research Agency (OPI) Instituto de Salud Carlos III. She is a medical epidemiologist with an interest in migrant health and gender and socio-economic inequalities.

Rocio Garcia-Pina is Epidemiologist and Public Health Technician Unit in the Epidemiological Surveillance Unit at the Department of Epidemiology of Murcia Regional Health Council.

Ana Maria Garcia-Fulgueiras is Epidemiologist and Head of the Epidemiological Surveillance Unit in the Epidemiological Surveillance Unit at the Department of Epidemiology of Murcia Regional Health Council.

M. Angeles Rodriguez-Arenas is medical epidemiologist at the Spanish National School of Health in Madrid. She has a large experience working with vulnerable populations. She has extensive practice as researcher and professor in Public Health.

Vicente Ibañez-Rojo is psychiatrist at Hospital Torrecárdenas Almería. He was associate professor in the Department of Neurosciences at the University of Almería until two years ago and previously in the Department of Psychiatry at the Universidad Autónoma de Madrid. He is principal investigator and collaborator on several projects related to mental health and immigration and other fields related with severe mental disorders. He is author of articles and book chapters in these areas of research.

Domingo Díaz-del Peral is psychiatrist at the Andalusian Health Services. Is Head of Unit of Mental Health Clinical Management of Almería (Spain).

Inma Jarrin is a Researcher of the Spanish AIDS Research Network, working at the National Center of Epidemiology from the Public Research Agency “Instituto de Salud Carlos III”, Madrid (Spain). She is a Statistician with a great interest in the analysis of survival data and data from surveys with multilevel structure.

Alberto Fernandez-Liria is psychiatrist, director of the Psychiatry and Mental Health Unit of the University Hospital Principe de Asturias and associated professor in the University of Alcala (Madrid). He is member of the Technical Advisory Board for the Spanish Strategy in Mental Health.

Maria Victoria Zunzunegui is professor of Social and Preventive Medicine at the University of Montreal. She does research on social factors in aging and global health.

Visitación Garcia-Ortuzar is Epidemiologist and Public Health Technician Unit in the Epidemiological Surveillance Unit at the Department of Epidemiology of Murcia Regional Health Council.

Lucia Mazarrasa is Nurse and Head of the Department of Health and International Development, at the Spanish National School of Health. She has conducted research in the field of sexual and reproductive health, domestic violence, mental health and migrant population with a gender perspective, working also in the evaluation and planning of Health Plans. She participates in the feminist movement since 1975.

Alicia Llacer is epidemiologist. She has worked for over thirty years in Public Health in public health institutions at local, regional and national levels. Her areas of interest are gender issues and health and migration and health.

References

Allen

C. T.

Swan

S. C.

Raghavan

(2009). Gender symmetry, sexism, and intimate partner violence. Journal of Interpersonal Violence, 24, 1816-1834.

Alvarez-del Arco

Llacer

Del Amo

Garcia-Fulgueiras

Garcia-Ortuzar

Rodriguez-Arenas

M. A.

Zunzunegui

M. V.

(2009). Methodology and fieldwork logistics of a multilevel research study on the influence of neigbourdhood’s characteristics on natives and Ecuadorian’s mental health in Spain. Revista Española de Salud Pública, 83, 493-508.

Amar

A. F.

Gennaro

(2005). Dating violence in college women: Associated physical injury, healthcare usage, and mental health symptoms. Nursing Research, 54, 235-242.

Bair-Merritt

M. G.

Crowne

S. S.

Thomson

D. A.

Sibinga

Trent

Campbell

(2010). Why do women use intimate partner violence? A systematic review of women’s motivations. Trauma Violence Abuse, 11(4), 178-189.

Bonomi

A. E.

Anderson

M. L.

Rivara

F. P.

Thompson

R. S.

(2007). Health outcomes in women with physical and sexual intimate partner violence exposure. Journal of Women’s Health (Larchmt.), 16, 987-997.

Borrell

Artazcoz

Gil-Gonzalez

Perez

Rohlfs

Perez

(2010a). Perceived sexism as a health determinant in Spain. Journal of Women’s Health (Larchmt.), 19, 741-750.

Borrell

Muntaner

Gil-Gonzalez

Artazcoz

Rodriguez-Sanz

Rohlfs

Alvarez-Dardet

(2010b). Perceived discrimination and health by gender, social class, and country of birth in a Southern European country. Preventive Medicine, 50(1-2), 86-92.

Broadhead

W. E.

Gehlbach

S. H.

Degruy

F. V.

Kaplan

B. H.

(1988). The Duke-UNK functional social support questionnaire: Measurement of social support in family medicine patients. Medical Care, 26, 709-723.

Butchart

Brown

D. S.

(1991). Non-fatal injuries due to interpersonal violence in Johannesburg-Soweto: Incidence, determinants and consequences. Forensic Science International, 52(1), 35-51.

10.

Caetano

Schafer

Cunradi

C. B.

(2001). Alcohol-related intimate partner violence among White, Black, and Hispanic couples in the United States. Alcohol Research Health, 25(1), 58-65.

11.

Carballo

Grocutt

Hadzihasanovic

(1996). Women and migration: A public health issue. World Health Statistics Quarterly, 49, 158-164.

12.

Coker

A. L.

Davis

K. E.

Arias

Desai

Sanderson

Brandt

H. M.

Smith

P. H.

(2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23, 260-268.

13.

Crowell

Burguess

(1996). Understanding violence against women. Washington, DC: National Academy Press.

14.

Del Amo

Jarrin

Garcia-Fulgueiras

Ibanez-Rojo

Alvarez

Rodriguez-Arenas

M. A.

Llacer

(2011). Mental health in Ecuadorian migrants from a population-based survey: The importance of social determinants and gender roles. Social Psychiatry and Psychiatric Epidemiology, 46, 1143-1152.

15.

De Wit

M. A.

Tuinebreijer

W. C.

Dekker

Beekman

A. J.

Gorissen

W. H.

Schrier Verhoeff

A. P.

(2008). Depressive and anxiety disorders in different ethnic groups: A population based study among native Dutch, and Turkish, Moroccan and Surinamese migrants in Amsterdam. Social Psychiatry and Psychiatric Epidemiology, 43, 905-912.

16.

Ellsberg

Jansen

H. A.

Heise

Watts

C. H.

Garcia-Moreno

(2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: An observational study. Lancet, 371(9619), 1165-1172.

17.

Goldberg

D. P.

Hillier

V. F.

(1979). A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145.

18.

Heise

(1993). Violence against women: The hidden health burden. World Health Statistics Quarterly, 46, 78-85.

19.

Instituto de la Mujer (Ministerio de Sanidad, Política Social e Igualdad). (2006). III National Survey on violence against women 2006. Retrieved from http://www.inmujer.migualdad.es/mujer/mujeres/estud_inves/violencia%20final.pdf

20.

Instituto Nacional de Estadística (INE). (1997). Spanish continuous survey on household budget. Methodology. Retrieved from http://www.ine.es/daco/daco43/metodo_ecpf.doc

21.

Kelly

(2010). Intimate partner violence, physical health, posttraumatic stress disorder, depression, and quality of life in Latinas. Western Journal of Emergency Medicine, 11, 247-251.

22.

Kessler

R. C.

Berglund

Demler

Jin

Merikangas

K. R.

Walters

E. E.

(2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.

23.

Kessler

R. C.

Mickelson

K. D.

Williams

D. R.

(1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behavior, 40, 208-230.

24.

Koss

M. P.

Koss

P. G.

Woodruff

W. J.

(1991). Deleterious effects of criminal victimization on women’s health and medical utilization. Archives of Internal Medicine, 151, 342-347.

25.

Llacer

Amo

J. D.

Garcia-Fulgueiras

Ibanez-Rojo

Garcia-Pino

Jarrin

Zunzunegui

M. V.

(2009). Discrimination and mental health in Ecuadorian immigrants in Spain. Journal of Epidemiology & Community Health, 63, 766-772.

26.

Lobo

Perez-Echeverria

M. J.

Artal

(1986). Validity of the scaled version of the General Health Questionnaire (GHQ-28) in a Spanish population. Psychological Medicine, 16(1), 135-140.

27.

Ministerio de Sanidad, Política Social e Igualdad and Instituto Nacional de Estadística. (2006). National health survey (ENSE). Retrieved from http://www.msps.es/estadEstudios/estadisticas/encuestaNacional/encuesta2006.htm

28.

Mouton

(2003). Intimate partner violence and health status among older women. Violence Against Women, 9, 1465-1477.

29.

Parella

(2003). Women, migrant and worker: The triple discrimination. Barcelona, Spain: Anthropos Editorial.

30.

Pico-Alfonso

M. A.

Garcia-Linares

M. I.

Celda-Navarro

Blasco-Ros

Echeburua

Martinez

(2006). The impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. Journal of Women’s Health (Larchmt.), 15, 599-611.

31.

Prospero

Kim

(2009). Mutual partner violence: Mental health symptoms among female and male victims in four racial/ethnic groups. Journal of Interpersonal Violence, 24, 2039-2056.

32.

Ribeiro

W. S.

Andreoli

S. B.

Ferri

C. P.

Prince

Mari

J. J.

(2009). Exposure to violence and mental health problems in low and middle-income countries: A literature review. Revista Brasileira de Psiquiatria, 31(Supplement 2), S49-S57.

33.

Rosenberg

M. L.

(1988). Violence is a public health problem. Transactions and Studies of the College of Physicians of Philadelphia, 10(1-4), 147-168.

34.

Ruiz-Perez

Plazaola-Castano

(2005). Intimate partner violence and mental health consequences in women attending family practice in Spain. Psychosomatic Medicine, 67, 791-797.

35.

Sutherland

Bybee

Sullivan

(1998). The long-term effects of battering on women’s health. Women’s Health, 4(1), 41-70.

36.

Swan

S. C.

Gambone

L. J.

Caldwell

J. E.

Sullivan

T. P.

Snow

D. L.

(2008). A review of research on women’s use of violence with male intimate partners. Violence and Victims, 23, 301-314.

37.

Tjaden

P. G.

Thoennes

(2000). Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/183781.pdf

38.

Van Hightower

N. R.

Gorton

Demoss

C. L.

(2010). Predictive models of domestic violence and fear of intimate paterns among migrant and seasonal farm worker women. Journal of Family Violence, 15, 137-154.

39.

Wadsworth

Dhillon

Shaw

Bhui

Stansfeld

Smith

(2007). Racial discrimination, ethnicity and work stress. Occupational Medicine(London), 57(1), 18-24.

40.

World Health Organization (WHO). (1996). Prevention of violence: A public health priority. 49th World Health Assembly Geneva, May 20-25, 1996. Retrieved from http://www.who.int/violence_injury_prevention/resources/publications/en/WHA4925_eng.pdf

41.

World Health Organization (WHO). (2002). World report on violence and health. Retrieved from http://whqlibdoc.who.int/hq/2002/9241545615.pdf. 2002