Mediating Roles of Intimate Partner Violence,Stress,and Social Support on Depressive Symptoms Among Thai Women

Abstract

Prior research has shown that intimate partner violence (IPV), stress, and social support are associated with depressive symptoms. However, a possible mediating role of these variables linking depressive symptoms has not been fully investigated in Thailand. This study was conducted to assess the mediating roles of IPV, stress, and social support in the relationships between childhood abuse (CA), number of sexual partners (NSP), and depressive symptoms among 400 Thai women attending gynecology clinics. Results indicated that IPV was significantly positively correlated with stress and depressive symptoms but negatively correlated with social support. CA and NSP were significantly positively correlated with IPV, stress, and depressive symptoms, but negatively correlated with social support. Structural equation models (SEMs) showed that not only did IPV severity exhibit significantly indirect effect on depressive symptoms (β = .178; p < .05), but it also had a significant, positive total effect on depressive symptoms (β = .252; p < .05). In particular, IPV severity had the fully mediating effect on depressive symptoms through social support (β = –.204; p < .05) and stress (β = .158; p < .05). CA severity and NSP exhibited the significant indirect effect on depressive symptoms through IPV severity, stress, and social support. All the models analyzed showed that stress had an important mediator role (β = .583; p < .05) on depressive symptoms. The model fitted very well to the empirical data and explained 53% of variance. Findings affirmed the important role of these mediators as well as the need to design interventions for reducing stress or increasing support for women experiencing IPV. Utilizing an empowerment approach among female outpatients to decrease stress and depressive symptoms is recommended.

Keywords

depression intimate partner violence mediation stress social support Thai women

Introduction

Women and girls are at increased risk of multiple forms of violence including intimate partner violence (IPV), childhood abuse (CA), and sexual violence (World Health Organization [WHO], 2013a). IPV often results not only in serious physical injury but also puts women at risk for the development of mental health problems including depression, post-traumatic stress disorder [PTSD], anxiety, and suicide (Beydoun et al., 2012; Devries et al., 2013; Dillon et al., 2013). Among health problems reported, depression is one of the most prevalent mental disorders among women who have experienced IPV. For example, female victims who had suffered IPV in the past year were found to have their relative risk of depression increased by 3.26 compared to non-abused women (Bonomi et al., 2009). In addition, women exposed to IPV are at higher risk of elevated depressive symptoms and major depressive disorder than women not exposed to IPV, with 9% to 28% of depressive symptomatology attributed to IPV exposure (Beydoun et al., 2012).

The global lifetime prevalence of physical and/or sexual IPV against women is 30%, ranging from 23.2% in high-income regions to 37.7% in the South East Asia region (WHO, 2013b). However, the prevalence of IPV has been estimated to be higher in clinical settings than in general population (Campbell, 2002). For example, researchers studying sexually transmitted infection and family planning clinic populations have documented IPV rates up to and greater than 50% (Decker et al., 2011; Mittal et al., 2011). Patients attending these clinics often reported other IPV-related risk factors such as multiple sex partners (Fatusi & Wang, 2009), CA (London et al., 2017), stressful life events (Sundermann et al., 2013), limited social support (Štulhofer et al., 2017), and depression (Erbelding et al., 2001; Hutton et al., 2004). Many of these problems co-occur; for example, childhood sexual abuse (CSA) was associated with IPV (Williams et al., 2010) and depression (Fogarty et al., 2008). IPV was also associated with the presence of risky behaviors, such as history of STIs, multiple sexual partners, inconsistent condom use, partner with known STI/HIV risks, and inability to negotiate safer sexual practices (Jones et al., 2016; Shrestha & Copenhaver, 2016; Stein et al., 2019). Taken together, it is currently unknown whether there was a possible mechanism mediating in the relationship between these factors and mental health problems (e.g., depressive symptoms) among Thai women.

There is some evidence that experiencing CA increases the risk of IPV victimization and leads to mental health problems (Abramsky et al., 2011; Fry et al., 2012). Specifically, the exposure to physical and sexual abuse in childhood has been associated with an increased risk of depression in adulthood (Chan et al., 2018; Hetzel-Riggin & Meads, 2011; Sprang et al., 2017). Empirical studies have highlighted how experiencing both CA and IPV leads to poorer health in comparison with experiencing a single form of abuse, providing support for the position that the effects of abuse are cumulative (Al-Modallal, 2016; Becker et al., 2010). For example, Ouellet-Morin et al. (2015) has explored the effect of exposure to CA and IPV on new-onset depression and found that women who suffered from both victimizations could be four to seven times more likely to suffer from depression in adulthood. It is likely that there is a dose-response relationship between CA and long-term health outcomes (Dube et al., 2010; London et al., 2017). Since CA was found to be correlated with IPV, it is probable that an increase in CA severity could aggravate IPV severity, which in turn could lead to worsening of depressive symptoms. It is, therefore, important to explore CA severity in abused women with depressive symptoms.

Violence in intimate relationships is a chronic stress, which survivors describe as traumatic, uncontrollable, posing threat to their physical and social self (Miller et al., 2007). Victims of abuse therefore process their experiences as traumatic events similar to the response in individuals with post-traumatic stress (Herman, 1992). Moreover, childhood experiences of violence may alter future responses to stress that are mediated through the hypothalamic-pituitary-adrenal (HPA) axis. For example, women with trauma early in life exhibit the greatest abnormalities in ongoing HPA-mediated stress response (Nemeroff, 2004). The stressors associated with violence may overwhelm stress-regulation systems in the body and result in depression (Ross et al., 2017). Thus, greater severity of traumatic experiences is associated with greater depression. Furthermore, experiencing more than one type of abuse increased the probability of having mental health symptoms as well as the severity of those symptoms (Hahm et al., 2017). For example, Sundermann et al. (2013) found that women exposed to more types of IPV (e.g., physical, sexual, or emotional) are at risk for more severe mental health symptoms including depression, dissociation, and PTSD compared to women who are exposed to a single type of IPV or no IPV. It is possible that there might be an interaction between or an additive effect of the different types of IPV and its association with depressive symptoms. Although previous studies examined the mediating effect of stress in diverse study population of women (Alhalal et al., 2018; Coker et al., 2019; Jones et al., 2019; Lilly et al., 2011), to date, it remains unknown whether stress mediates the associations between CA, IPV, and depressive symptoms among abused Thai women.

Among women survivors, social support, which refers to one being part of a supportive social network, has been shown to assist with victim coping after experiencing a traumatic event (Beeble et al., 2009; Escribà-Agüir et al., 2010). Sources of social support include family members, friends, neighbors, and colleagues. Thus, seeking support from a network of people enhances women’s coping skills and mitigates the negative mental health consequences of IPV, including depression (Kamimura et al., 2013; Sylaska & Edwards, 2014). For example, abused women who reported low social support, adjusted odds ratio (AOR) = 4.95, 95% CI (1.69–14.49), or moderate social support, AOR = 2.71, 95% CI (1.00–7.33), were more likely to be depressed than women who reported high levels of social support (Mburia-Mwalili et al., 2010). Furthermore, Lagdon et al. (2018) found that social support, particularly family support, was a significant mediator between the relationship of childhood maltreatment and mental health outcomes including anxiety, depression, and PTSD. Although it is well understood that social support can act as a protective factor, fewer studies have addressed the experience of CA and social support in adulthood, and the extent to which social support is associated with adult psychopathology (Beeble et al., 2009). For example, Sperry & Widom (2013) found that those who had experienced CA reported lower levels of perceived social support in adulthood compared with those who had never had this experience. Despite this evidence, there are substantial gaps in knowledge about whether and how social support acts as a mediator among abused Thai women who experienced CA and IPV.

In Thailand, the issue of IPV must be placed in the context of religion and family (Kerley et al., 2010). Thai culture is predominately Buddhist and there is a strong focus on order, harmony, and responsibility within the family context (Hoffman et al., 1994). Family structure historically has been patriarchal, and wives are expected to place their own self-interests behind those of their husbands and children. Thai family also expects wives to uphold cultural and family values and act in a manner that does not bring shame on the family (Xu et al., 2011). Few abused women receive help and support they need because they are unlikely to disclose their abuse to anyone, even their family or close friends (Rujiraprasert et al., 2009). Thai women may be more reluctant than Westerners to seek help from outsiders unless the IPV situation was severe or life-threatening (Thananowan et al., 2018). Consequently, IPV must be endured and tolerated.

Based on these findings and critical gaps from the literature, this study aimed to assess the mediating roles of IPV severity, stress, and social support in the relationships between number of sexual partners (NSPs), CA severity, and depressive symptoms among Thai women. We hypothesized that IPV severity, stress, and social support will act as mediators between NSP, CA severity, and depressive symptoms. Understanding the role of these mediators will help researchers to develop interventions and services for women who are experiencing IPV.

Method

Design and Setting

This study was part of the Patterns of Causal Relationship of STIs among Women Attending Gynecology Clinics project. A cross-sectional design was used to examine IPV, stress, and social support as mediators. Potential participants were patients attending two outpatient gynecology clinics, including the GYN clinic and the STI clinic located at the university hospital in Bangkok, Thailand. The GYN clinic provides comprehensive care services for women’s health problems such as myoma uteri, endometriosis, and dysfunctional uterine bleeding [DUB], gynecological cancer, etc., whereas the STI clinic provides comprehensive care services for both pregnant and non-pregnant women with STIs. About 200–250 patients are attended the GYN clinic daily, while very ill patients are admitted into the inpatient wards. At the STI clinic, about 40–50 patients are attended monthly. Both clinics run from Monday to Friday during service hours.

Participants

Of the 429 patients who were approached, 29 patients were excluded due to inconvenience. Thus, the total of 400 participants or 93.2% completed the survey. The participants’ age ranged from 17–49 years with the mean age of 36.42 years (SD = 9.457). All participants were Thais, currently in some form of employment (81%), and currently in a marital relationship (52.2%). More than 66% of the participants were patients with STIs. Table 1 shows the sociodemographic characteristics of the participants.

Procedures

All procedures were approved by the institutional review boards of the university hospital. This study was conducted from July 2018 to January 2019. A staff nurse at each clinic reviewed participants’ medical records to identify eligible women for the study (e.g., aged 15–49 years, informed about their diagnoses by the physician, and received counseling at first visit). Data were collected by the PI or research assistants (RAs) who were trained regarding IPV and mental health counseling. Researcher non-systematically approached and recruited participants from the clinic waiting area by their registration number. The patient was escorted to a health consulting room to complete the set of questionnaires in private. Participants were informed of the purpose of the study and were assured that the study was confidential and voluntary. Given the sensitive nature of the issue, verbal consent was obtained from each participant before administering the questionnaire (WHO, 2001). For participants younger than 18, the consent was obtained from both participants and their guardians. To protect women safety, we introduced the study as a women’s health study and asked the women not to share the content of the study with anyone. Women who showed signs of distress during the survey were offered a break and support while keeping eye contact. Once the problem was found, it is important to notify staff nurses to initiate the counseling process to acknowledge a patient’s feeling. Some women were linked with the social worker if additional assistance was needed to manage distress or access services. If women were at risk of suicide, the attending physician in the clinic was informed (Ford-Gilboe et al., 2009). Serial code numbers instead of participants’ names were used on each questionnaire. All participants received a list of services related to IPV and information about mental health services if they wished.

Measures

Sociodemographic characteristics.

Age, marital status, length of marriage, number of marriages, education, career, income, and socioeconomic status were obtained by questionnaires.

Number of sexual partners.

Participants were asked to report their NSPs in the lifetime (Senn et al., 2010): “In your entire life, how many sexual partners have you had sex with?” Those who reported two or more sexual partners were categorized as having multiple sexual partners (coded as 1; those with 1 or no sexual partners were coded as 0).

Childhood abuse.

Using two questions adopted from prior studies (Abrahams et al., 2014; Senn et al., 2010) to assess the participants’ retrospective experience of childhood physical and sexual abuse (CPA and CSA): (1) “Before age 15, have you ever been hit, slapped, kicked, or otherwise physically hurt by someone more years older?” and (2) “Before age 15, have you ever been forced or coerced sexual activities (e.g., kissing, fondling, giving or receiving sexual intercourse)?” Dichotomous response was used (1 = Yes, 0 = No) to capture such experience among participants. Participants who reported physical or sexual abuse before age 15 were considered to have experienced CA. Participants were asked about their frequencies of trauma, and summed to yield a total score for CA severity, with higher scores indicating greater severity.

Intimate partner violence.

IPV was screened using three items adopted from the Abuse Assessment Screen (AAS: McFarlane et al., 1992). These items reported the experiencing of physical, sexual, and emotional abuse: (a) “Within the last year, have you ever been hit, slapped, kicked, or otherwise physically hurt by your partner?”; (b) “Within the last year, has your partner forced you to have sexual intercourse even when you didn’t want to?”; and (c) “Within the last year, have you ever been emotionally hurt, threatened, humiliated, or controlled by your partner?” If a participant answered “yes” to having been physically, sexually, or emotionally abused in the past year, and if the perpetrator was her current or former intimate partner, she was screened positive for IPV. Responses to individuals’ items are summed to produce total scores and scores for three dimensions of abuse. The total score is a continuous measure of IPV severity, where higher scores indicate more severe IPV. The Cronbach’s alpha coefficient for this study was .84, indicating satisfactory to good reliabilities.

Stress.

The Thai version of Perceived Stress Scale (T-PSS–10; Wongpakaran & Wongpakaran, 2010) is a 10-item self-report instrument measuring the degree to which one perceives aspects of one’s life as uncontrollable, unpredictable, and overloading. Participants are asked to respond to each question on a 5-point Likert scale ranging from 0 (never) to 4 (very often), indicating how often they have felt or thought a certain way within the past month. Scores range from 0 to 40, with higher composite scores indicative of greater perceived stress. The T-PSS–10 has demonstrated acceptable internal consistency .76.

Social support.

The Medical Outcomes Study Social Support Survey (MOS-SSS; Rungruangsiripan et al., 2011; Sherbourne & Stewart, 1991) consists of 15 items plus 1 question; the patient was first asked to write a number of close friends and close relatives. This measure was divided into four categories: (a) tangible support, (b) affectionate support, (c) positive social interaction support, and (d) emotional or informational support. Participants were asked to rate the perceived availability of support using a 5-point Likert scale ranging from 1 (none of the time) to 5 (all of the time). Scores were obtained by summing responses, with a range of possible scores from 15 to 75. Higher scores represent higher perceived support. In Malay patients with HIV, the internal consistency for the subscales ranged from .87–.95 and for the overall scale was .96 (Saddki et al., 2017). The internal consistency was .95 for this sample.

Depressive symptoms.

The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977; Trangkasombat et al., 1997) is a 20-item self-report instrument examining the frequency and duration of depressive symptoms. Participants were asked to rate their depressive symptoms over the past week on a 4-point Likert scale ranging from 0 (rarely or none of the time) to 3 (almost or all of the time). A total depressive symptom score was generated by reverse coding positive items (4, 8, 12, 16) and tallying the responses across all items, with higher scores indicating the presence of more depressive symptoms. The total score of the measure can range from 0 to 60, and a cut-off score of 16 or above is considered having depressive symptoms. The CES-D has been examined in a variety of populations and has consistently displayed strong reliability (Ford-Gilboe et al., 2009). For this sample, the CES-D showed an internal consistency of .91, which is comparable to the result obtained by Alhalal et al. (2018; α = .88).

Statistical Analyses

Sociodemographic characteristics and the hypothesized model variables were first summarized using descriptive statistics with SPSS version 18.0. Pearson’s correlation was conducted to examine the correlations among study variables. All statistical tests were performed using a 5% level of significance, and a 95% confidence interval accompanied each estimate, where appropriate. Path analyses were conducted to examine the predictive power of the NSPs, CA severity, IPV severity, stress, and social support for depressive symptoms. Maximum likelihood was used to estimate parameter using LISREL version 8.72.

Sample size calculation was based on the recommendation from Hair et al. (2005), suggesting that absolute minimum sample size for multivariate analyses must be a minimum ratio of at least five respondents for each estimated parameter. However, they suggested that a ratio at 15 to 20 respondents per each estimated parameter considered most appropriate. Taking this into consideration, the sample size in the study should be set to be 360 since the study included 18 estimated parameters. In order to prevent incomplete data, 10% of sample size was increased. Thus, the total sample size in this study is 400 participants.

Results

Tables 1 presented the descriptive statistics of the effective sample, the prevalence of CA and IPV, and the health outcomes. The mean NSP was 3.24 (SD = 6.623). The prevalence of CPA and CSA was 9.5% (n = 38). About 21% of participants (n = 84) had ever experienced any type of IPV in the past year. In regard to depressive symptoms scores, the participants’ mean symptoms reports fell just short of the cut-off score for clinical depression (M = 15.21, SD = 8.903), though 43% of participants (n = 173) achieved a score of 16 or higher (M = 23.23, SD = 6.931), placing them in the clinical range of depression. The prevalence of diseases was sorted from high to low as follows: STIs (33.5%), HIV (33.3%), endometriosis (12.2%), DUB (11.7%), and myoma uteri (9.3%), respectively. A correlation matrix of the major study variables is displayed in Table 2. Results indicated that CA was significantly positively correlated with NSP, IPV, stress, and depressive symptoms, but negatively correlated with social support. NSP was significantly positively correlated with IPV, stress, and depressive symptoms, but negatively correlated with social support. Importantly, IPV was significantly positively correlated with stress and depressive symptoms but negatively correlated with social support. Depressive symptoms were significantly positively correlated with stress (r = .689, p < .01). Additionally, social support showed moderate to strong correlations with stress (r = –.370, p < .01) and depressive symptoms (r = –.462, p < .01), suggesting that social support from family, friends, and significant other are significantly negatively related with both variables.

Table 1.

Sociodemographic Characteristics, Prevalence of CA and IPV, Health Outcomes.

Sociodemographics

Age (years) (M, SD)

36.42 (9.457)

Marital status

Married

Cohabiting

Separated/divorced

Never married

Widowed

209

52.2

18.3

16.8

10.0

2.7

Length of marriage (years) (M, SD)

8.60 (8.098)

Number of marriages

144

181

36.0

45.2

18.8

Education

<High school

>High school

136

264

34.0

66.0

Career

Unemployed

Employed

324

19.0

81.0

Income (per month)

<10,000 (US$ 323)

10,001–20,000

20,001–30,000

>30,001

138

152

34.4

38.0

17.3

10.3

Socioeconomic status

Insufficient

Sufficient

Number of sexual partners (M, SD)

304

3.24 (6.623)

24.0

76.0

Prevalence of CA and IPV

Experienced CA

Childhood physical abuse (CPA)

Childhood sexual abuse (CSA)

9.5

7.0

4.0

Experienced IPV

Physical abuse

Sexual abuse

Emotional abuse

11.2

7.5

15.5

Health outcomes

M (SD)

Range

Stress

Social support

Depressive symptoms

17.70 (4.967)

57.60 (11.900)

15.21 (8.903)

3–34

21–75

0–52

Table 2.

Correlation Matrix of the Major Study Variables (n = 400).

Scales	1	2	3	4	5	6
1. CA	1.000
2. NSP	.187**	1.000
3. IPV	.335**	.228**	1.000
4. T-PSS	.229**	.161**	.255**	1.000
5. MOS-SSS6. CES-D	–.104.209*	–.116.190*	–.209.294	–.370.689	1.000–.462**	1.000

Notes. *p < .05. **p < .01.

CA = Childhood abuse; NSP = Number of sexual partners; IPV = Intimate partner violence; T-PSS = Thai version of Perceived Stress Scale; MOS-SSS = Medical Outcomes Study: Social Support Survey; CES-D = Center for Epidemiologic Studies Depression Scale.

When the hypothesized model was examined by structural equation model (SEM), fit indices showed that the model fitted very well to the empirical data (χ² = 5.956, df = 5, p = .311, RMSEA = .029, GFI = .99, AGFI = .98). The parameter estimates of the model are shown in Table 3 and Figure 1. Overall, this model explained 53% of variance of depressive symptoms. As shown in Table 3, results indicated that NSP had a significant, positive, direct effect (β = .224; p < .05) on IPV severity, indirect effect on depressive symptoms (β = .056, p < .05), via IPV severity, social support, and stress. CA severity had a significant, positive direct effect (β = .318; p < .05) on IPV severity, positive direct effect (β = .139; p < .05) on stress, positive indirect effect on depressive symptoms (β = .161, p < .05), via IPV severity, social support, and stress. IPV severity had a significant, positive total effect on depressive symptoms (β = .252; p < .05), which was decomposed into a negative, non-significant, direct effect and a significant, positive, indirect effect (β = .178; p < .05), via social support and stress, indicating that IPV severity had the fully mediating effect through social support and stress on depressive symptoms. Social support had a significant, negative, total effect on depressive symptoms (β = –.422; p < .05), which was both a significant, negative, direct effect (β = –.232; p < .05) and an indirect effect (β = –.190, p < .05), via stress. Stress not only had a significant, positive, direct effect on depressive symptoms (β = .583; p < .05), but also had the greatest effect in the model. Conceptually, the model suggested that: (a) the effect of CA severity and NSP on depressive symptoms was shown to be mediated through IPV severity, stress, and social support, and (b) IPV severity was found to have a mediating effect on depressive symptoms through social support and stress.

Table 3.

Standardized DE, IE, TE of Latent Variables in the Model.

Independent Variables	Dependent Variables	Type of Effect			R ²
Independent Variables	Dependent Variables	DE	IE	TT	R ²
NSP	IPV	.224*	–	.224*	.178
CA severity		.318*	–	.318*
IPV severity	Social support	−.204*	–	−.204*	.042
NSP		–	−.046*	−.046*
CA severity		–	−.065*	−.065*
CA severity	Stress	.139*	.071*	.210*	.194
IPV severity		.158*	.067*	.225*
Social support		−.326	–	−.326
NSP		–	.050*	.050*
IPV severity	Depressive symptoms	.074	.178*	.252*	.530
Social support		−.232*	−.190*	−.422*
Stress		.583*	–	.583*
NSP		–	.056*	.056*
CA severity		–	.161*	.161*
χ² = 5.956, df = 5, p = .311, RMSEA = .029, GFI = .99, AGFI = .98

Note. DE = Direct effect; IE = Indirect effect; TE = Total effect; IPV = Intimate partner violence; NSP = Number of sexual partners; CA = Childhood abuse.

*p < .05.

Figure 1.

The mediational model illustrating the relationships among the study variables.

Discussion

To our knowledge, this is the first study to investigate the mediation effect of IPV severity, stress, and social support in the relationships between NSP, CA severity, and depressive symptoms among Thai women attending gynecology clinics. Of those who have experienced CA, the overall rates (9.5%) were considerably lower than the worldwide prevalence rates estimated by Stoltenborgh et al. (2015; 22.6% for CPA and 12.7% for CSA). Additionally, the prevalence of IPV in this study (21%) was lower than IPV rates reported in prior research (23%, Kiene et al., 2017; 57%, Mittal et al., 2011; 38%, Senn et al., 2010). However, the difference in prevalence rates could be due to differing population, definitions of abuse, and the measurement of IPV. It should be noted that the current sample was drawn from outpatients attending both GYN and STI clinics; therefore, the experiences of IPV might have been underreported among those who were diagnosed with HIV/STI due to stigmatization (Lipira et al., 2019). In fact, IPV has long been viewed as a private family matter in Thailand, in which outsiders should not intervene (Archavanitkul et al., 2005). Disclosing IPV to anyone or seeking help from others would bring shame to a woman and her family. Thus, many of the abused Thai women remain silent about their experiences of violence (Thananowan et al., 2018), resulting in underreporting of IPV.

The models analyzed showed that the effect of CA severity and NSP were shown to be mediated through IPV severity, stress, and social support on depressive symptoms. It is possible that CA severity results in an intense inflammatory response and hyperactivity of the central nervous system; in adulthood, subsequent stress leads to neurobiological vulnerability for the development of stress-related psychiatric disorders (Gouin et al., 2012). In other words, chronic stress likely plays a role in the formation of pathologic neurocircuitry, especially during childhood, thereby resulting in the impairments observed in depression in adulthood (Ross et al., 2017). Furthermore, IPV severity was found to have a fully mediating effect on depressive symptoms through social support and stress. That is, social support and stress have been shown to mediate the relationship between IPV severity and depressive symptoms. This finding is consistent with the existing literature (e.g., Esie et al., 2019; Illangasekare et al., 2013), which reports that increased severity of the violence experienced has been shown to be associated with greater psychological distress. However, IPV severity was unable to activate abused women to develop depressive symptoms if they received support and decreased stress. Furthermore, the perception of stress can impact how one implements a specific coping mechanism (Lazarus & Folkman, 1984). Perceived controllability of a stressor has been shown to impact internalizing symptoms such as depression (Fassett-Carman et al., 2019). Active and positive coping mechanisms to deal with stress may lead to better mental health outcomes. Moreover, since having a greater NSPs was associated with IPV (Stein et al., 2019) and women with multiple partners had significantly more depression than women with a single abusive partner (Coolidge & Anderson, 2002). It is possible that NSP may be used as a coping mechanism to deal with depressive symptoms (Walsh et al., 2013). Therefore, it is important for health professionals in gynecology clinics to assess NSP and IPV when caring for women with depressive symptoms.

According to Social Learning Theory (Bandura, 1977), witnessing parental violence or having experienced abuse can result in a child feeling powerless or helpless (Finkelhor & Browne, 1985). Although we did not test this theory directly, our findings revealed that women who experienced more CA and NSP tend to have high IPV and stress, which in turn increases the likelihood of depressive symptoms but decreases social support. This finding is consistent with the existing literature, which reports that childhood victimization significantly increased the likelihood of adult depression (Klumparendt et al., 2019) and seeking professional help (Popescu et al., 2010). It may be possible that when the individual becomes unable to handle the stress of everyday life, the hopelessness and/or helplessness can place one at risk for depressive symptoms. Feelings of helplessness may contribute to the associations between IPV victimization and depression in adulthood (Bargai et al., 2007). However, research has shown that abused women use more emotion-focused coping strategies to reduce their stressors and that coping is linked to increased risk of depression (e.g., Choi et al., 2015; Khodabakhshi-Koolaee et al., 2018; Thananowan et al., 2018). In addition, social stigmatization can directly discourage abused women from seeking medical help and create difficulties in obtaining social and emotional support (Štulhofer et al., 2017). Thus, increased perceived social support should help toward building significant resilience, lessening the adverse mental health problems, and allowing abused women to better focus on positive coping.

Overall, health professionals in Thailand should be aware of the role that IPV plays in driving depressive symptoms and make efforts to specifically address this in their care for women. Health care protocols for abused women should include screening for and treatment of IPV to reduce the risk of depressive symptoms. Policies in gynecology clinics should include the training of health professionals to appropriately raise and address patients’experiences with IPV in their clinical encounters. If CA and/or violent partner relationships are detected, screening for depression, as well as stressful events, would be recommended. Treatments for women’s mental health issues found to be effective in the context of IPV, including psychological support and counseling, need to be offered to women in outpatient settings. Finally, the need for primary prevention of abuse and intervention programs should be designed. For example, a three-phased intervention program for IPV survivors showed a reduction in psychological symptoms and increase in social support (Hansen et al., 2014).

This study had some limitations that need to be acknowledged. First, the cross-sectional design does not permit an evaluation of the causal relationship among the study variables. Longitudinal studies are essential for verifying the causal link between CA, IPV, and depressive symptoms. Second, the use of convenience samples in clinical settings may limit the generalizability of the findings to other populations. Future studies should consider using representative samples to examine the problem of depressive symptoms in female survivors of IPV. Third, the use of self-report measures may still be subject to bias and/or limited recall with the participants underreporting the extent of their experiences of CA and IPV. Finally, the associations between mediating variables (e.g., IPV, stress, and social support) and depressive symptoms may be accounted for by variables that were not examined in this study, such as self-esteem and alcohol use. Future studies may explore different potential mediators so as to draw a clearer picture of the pathways and their impact on depressive symptoms.

Conclusion and Implications

The finding highlights the significant mediating roles of IPV severity, stress, and social support on women’s depressive symptoms. Furthermore, our findings underscore the necessity of health care professionals understanding the relationships among CA, NSPs, and depressive symptoms as a foundation for providing good clinical care among Thai women attending outpatient gynecology clinics. Therefore, assessing for abuse experiences (both CA and IPV) as well as identifying and treating stress and provide social support are important strategies that may decrease depressive symptoms among CA and IPV survivors. Routine screening of depression is also needed among female outpatients to better protect their mental health as they develop. Future interventions among abused Thai women may want to utilize an empowerment approach (e.g., Garcia et al., 2019) to decrease their likelihood of experiencing stress and their subsequent risk for depression. Such programs should focus not only on stress reduction but could also focus on social supports as needed.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project study was supported by China Medical Board of New York, Inc., Faculty of Nursing, Mahidol University.

ORCID iD

Nanthana Thananowan

Author Biographies

Nanthana Thananowan, RN, PhD, is an associate professor in the Department of Obstetric and Gynaecological Nursing at Faculty of Nursing, Mahidol University, Thailand. Her research interests are intimate partner violence (IPV), risk and protective factors, and women’s sexual health related to IPV. She is also interested in the impact of IPV on psychosocial outcomes.

Nopporn Vongsirimas, RN, PhD, is an associate professor in the Department of Mental Health & Psychiatric Nursing at Faculty of Nursing, Mahidol University, Thailand. She specializes in research and practice with depressive symptoms among adolescents, school-based intervention for depression, and women’s depression related to IPV.

Akadet Kedcham, PhD, is an assistant professor in the Faculty of Education, Bansomdejchaopraya Rajabhat University, Thailand. His work is aimed at the methodological issues of scientific research, specifically on the design of studies and statistical analysis about positive psychology and mental health.

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