The Relationship between Women’s Resources and Health-Related Quality of Life in a Sample of Female Victims of Intimate Partner Violence

Abstract

While it is known that resource inadequacy increases the risk of exposure to intimate partner violence (IPV) and that women’s health is significantly impacted by IPV, scant research has documented diminished resources as a primary determinant of women’s health. Fifty female victims of moderate to severe IPV completed assessments of their physical, sexual and psychological experiences of IPV, resource profile, symptoms of posttraumatic stress disorder (PTSD) and depression and mental and physical health-related quality of life (HRQoL). Women’s resources, controlling for age, income, psychological abuse and sexual coercion, were unique predictors of symptoms of PTSD, symptoms of depression; and mental HRQoL. The public health implications of the adequacy of women’s resources are discussed in the context of IPV prevention and intervention. Future studies should evaluate the efficacy of economic empowerment programs regarding the impact on IPV survivors’ mental and physical health and safety.

Introduction

One in four women experience some form of IPV during their lifetime (Breiding, Chen, & Black, 2014 ). As such, interpersonal violence is a leading cause of morbidity and mortality for women of all reproductive ages (Gunter, 2007). Interpersonal violence also leaves a devastating public health signature with documented associations with scores of adverse mental and physical health outcomes (Black, 2011; Campbell, 2002; Coker et al., 2002; Dutton et al., 2006; Max, Rice, Finkelstein, Bardwell, & Leadbetter, 2004) and lowers overall health-related quality of life (HRQoL) (Costa et al., 2014; Alsaker & Moen, 2006). While several studies have shown that women with fewer personal and/or family resources are more vulnerable to IPV (Bybee & Sullivan, 2005; Wenzel et al., 2004), there is scant documentation of diminished resources as a unique determinant of women’s health and HRQoL in the context of IPV.

Intimate Partner Violence and Health Outcomes

Physical and sexual IPV adversely affects mental health by conferring risk for symptoms of depression, anxiety, PTSD, suicidality, drug, alcohol and other substance abuse (Bonomi et al., 2006; Caetano & Cunradi, 2003; Campbell, 2002; Coker, et al., 2002; Golding, 1999; Howard, Trevillion, & Agnew-Davies, 2010; McPherson, Delva, & Cranford, 2007; Plichta & Falik, 2001). Symptoms of depression and PTSD have a strong, graded dose-response relationship with IPV (Golding, 1999). IPV also confers risk for adverse physical health conditions across multiple bodily systems, including significant gastrointestinal symptoms and problems; gynecological and reproductive problems, including sexually-transmitted diseases, HIV, and urinary-tract infections; poorer subjective health, serious injury and chronic disease conditions (Bonomi et al., 2007; Campbell, 2002; Coker et al., 2002; Eby, 1996; Sutherland, Bybee, & Sullivan, 1998; Sutherland, Bybee, & Sullivan, 2002). Health-related quality of life (HRQoL), defined as how one views their health, is an understudied, important domain of impact that bridges the emotional and physical sequelae of IPV.

Intimate Partner Violence and Health-Related Quality of Life

Health-related quality of life (HRQoL) is an individual’s subjective perception of the effects of health, illness, and treatment on their quality of life (Ferrans, Zerwic, Wilbur, & Larson, 2005). HRQoL is a multidimensional construct that consists of physiological, psychological, and functional aspects of well-being (Kvarme et al., 2009). Studies have shown that exposure to IPV is associated with lower scores on measures of HRQoL (Laffaye, Kennedy, & Stein, 2003; Alsaker et al., 2006). Wittenberg et al. (2007) assessed the effects of IPV on HRQoL and found that partner violence significantly impacted both the emotional and psychological domains of health functioning (Wittenberg, Joshi, Thomas, & McCloskey, 2007). In a sample of Latina women, Kelly (2010) found that more than half of women receiving IPV-related services indicated that in comparison to other people their own age, their HRQoL was poor to fair. Moreover, bodily pain in the previous month was significantly associated with indicators of poorer HRQoL. The HRQoL and IPV relationship may be unique to women (Sotskova, Coghlan, & Woodin, 2011). Costa & colleagues (2015) found that women with lifetime or past-year physical assault and sexual coercion had lower scores on a measure of HRQoL in terms of functional health and wellbeing during in the previous four weeks. This relationship was not seen in male victims nor women with no exposure to IPV.

PTSD is also associated with functional impairments and lower scores on measures of HRQoL (Huijts, Kleijn, van Emmerik, Noordhof, & Smith, 2012; Rapaport, Clary, Fayyad, & Endicott, 2005; Senneseth, Alsaker, & Natvig, 2012). Laffaye et al. (2003) examined the association between PTSD and HRQoL in female victims of IPV. Victims of IPV scored significantly lower on HRQoL than non-abused women. Furthermore, victims of IPV with PTSD scored significantly lower on HRQoL than victims of IPV without PTSD. These findings suggest the HRQoL is not only influenced by the exposure to but also the impact of IPV. In further support of the unique impact of PTSD, Pittman et al. (2012) found that PTSD had a significant, negative correlation with HRQoL, even when controlling for overlapping symptoms of depression, such as anhedonia, insomnia, and concentration (Pittman, Goldsmith, Lemmer, Kilmer, & Baker, 2012). These results highlight the importance of examining the intersecting influences of PTSD, depression as well as HRQoL within samples of IPV-exposed women.

Intimate Partner Violence and Resource Adequacy

Few studies examining the health consequences of IPV have looked at variations in women’s health based on their life circumstances, including their adequacy of resources (Ford-Gilboe et al., 2009). Many women experiencing IPV do not seek formal services due to shame, fear, and embarrassment, as well as concern for their children and concerns for their partner (Simmons et al., 2011). Individuals with fewer tangible, economic, social and other personal and/or family resources may be more vulnerable to the threat of violence or abuse posed by an intimate partner (Bybee & Sullivan, 2005; Goodman et al., 2005; Wenzel et al., 2004). Bybee and Sullivan (2005) found that women with greater access to resources and social support were less vulnerable to re-victimization than women with fewer resources and levels of support. Wenzel et al. (2004) also found that women who reported fewer tangible resources (e.g. financial resources) were at an increased risk for re-victimization at the six-month follow-up study. Tangible resources may help violence-exposed women obtain treatment and other advocacy services. Professional help-seeking has been associated with increased psychological trauma and PTSD symptom severity, older age, a belief that the cause of the violence is not controllable over time, a higher level of engagement coping, and greater levels of belief that these resources will be helpful. Increased use of personal resources has been associated with longer relationship length, a belief that the cause of the violence is not stable and the belief that the resources will be helpful, as well as lower levels of disengagement coping (Fleming & Resick, 2016). In terms of personal resource benefits, Coker et al. (2002) found that women experiencing IPV who had higher levels of social support were significantly less likely to experience poor mental health outcomes than women with lower levels of social support. Conversely, limited access to resources has been associated with negative mental health outcomes and poor perceptions of quality of life (Schumm, Hobfoll, & Keogh, 2004). These studies highlight that resources come in many different forms, that resource adequacy is intertwined with the experience and trajectory of IPV.

Considering these interconnections, it is not surprising that there is limited research examining resource adequacy as a unique influence on the mental and physical health outcomes, including HRQol, of female victims of IPV. The current study examined the relationship among women’s resources and mental and physical health outcomes in a sample of female victims of IPV. It was hypothesized that:

H1.

Women’s resources adequacy will be negatively associated with severity of symptoms of PTSD and depression. In contrast, women’s resources will be positively associated with mental and physical HRQol.

H2.

Women’s resources will uniquely predict severity of PTSD symptoms, depression, mental and physical HRQOl, and explain more variance in these outcomes than explained by IPV severity.

Method

Participants

Study participants consisted of 50 female victims of moderate to severe IPV who participated in a study that examined the impact of IPV and injury on women’s psychological, emotional and behavioral functioning (Mechanic, Uhlmansiek, Weaver & Resick, 2000). In terms of inclusionary criteria, women had to: (a) be at least 18 years old; (b) have been involved within a romantic relationship for at least three months; and (c) have experienced moderate to severe IPV (with the identified partner). Moderate to severe IPV was defined as at least four minor incidents of violence alone (e.g., pushed, shoved, or grabbed; slapped or hit; thrown things that could hurt; twisted arm or pulled hair) or at least two severe incidents alone (e.g., hit or punched with a fist; caused physical injuries, choked; slammed against a wall or thrown down the stairs; kicked or beaten; or threatened with a weapon), or any combination of four minor and severe incidents. In order to exclude increased levels of distress secondary to recency of violence, women had to be at least two weeks post-violence. About sexual coercion analyses, the sample size was reduced to 49, as one participant elected to discontinue her participation in the study rather than complete questions regarding sexual coercion.

Participants were, on average, 34 years old (SD=8.4) and predominantly African American (61%), unmarried (40%), and were impoverished, earning an annual personal income of $15,000 or less (58%). Nearly half of the sample (48%) had some college education or greater and less than two-fifths (35%) had part- or fulltime employment. In terms of recency of IPV, the women experienced violence an average of nearly two months ago (M=56 days, SD =73 days).

Procedure

Participants were recruited from social service agencies, snowballing, and media outlets and were interviewed at a Midwestern university by one of five female graduate students in clinical psychology who received special training in working with victims of IPV. Upon arrival, participants were taken to a private room within a locked facility. To ensure their safety, participants were asked whether they thought they might have been followed to the study location. None of the participants reported that they had been followed. Participants then reviewed a detailed statement describing the procedures involved in the study. Study procedures included a combination of interview and self-report assessments. Participants were paid $30.00 for their time. The Saint Louis University’s Institutional Review Board approved the study design and procedures

Measures

In the present study, demographic characteristics were assessed including age, race, marital status, level of education, employment status, and income.

Intimate partner violence assessments.

The Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney, & Sugarman, 1996) was administered as an interview and was used to assess physically assaultive and sexually coercive behaviors in participants’ index romantic relationship. Three subscales were administered to assess the frequency and severity of physical assault (12 items), injury (six items), and sexual coercion (seven items). Ratings were made in terms of frequency (0=never, 1=once in the past year, 2=twice in the past year, 3=3–5 times in the past year, 4=6–10 times in the past year, 5=11–20 times in the past year, 6=more than 20 times in the past year). Items assessing physical assault and sexual coercion were used within this current study. Midpoint scoring was used per author instructions, to create a severity index for each subscale. Cronbach’s alpha for the physical assault subscale was .89 and the sexual coercion subscale Cronbach’s alpha was .92.

The Psychological Maltreatment of Women Inventory- Abbreviated Version (PMWI; Tolman, 1989, 1999) was administered as an interview to assess psychological abuse, and consisted of two factor-derived subscales measuring dominance/isolation and emotional and verbal abuse. Each of the 14 items were rated on a five-point frequency scale, ranging from never (1), to very frequently (5). Within the current study, internal consistency was high with coefficient alpha=.81 for emotional/verbal abuse and .82 for dominance/isolation. Regarding construct validity, the PMWI abbreviated version successfully discriminated between groups of women, with female victims of IPV scoring significantly higher than women in distressed, but nonabusive relationships, and women in satisfied/ nonabusive relationships (Tolman, 1999).

Emotional functioning assessment.

The Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997) is a self-report measure of PTSD and provides a checklist of Criterion A stressor events and both a PTSD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), as well as a measure of PTSD symptom severity. Respondents completed 17 items that correspond to the DSM-IV PTSD symptoms (five re-experiencing, seven avoidance, and five arousal). The frequency of each item in the past month was rated on a four-point scale (0 =not at all or only one time; 3=five or more times a week/almost always). The continuous total PTSD symptom score was used in the present study with a coefficient alpha of .93.

The Beck-Depression Inventory Second Edition (BDI-II; Beck et al., 1996) is a 21-item self-report assessment of depressive symptoms. Items were rated on a four-point Likert scale and total scores were calculated by summing the items. The BDI-II has good reliability, with studies demonstrating an internal consistency of 0.86, and validity tests showing a classification rate of 88% (sensitivity, 71%; specificity, 88%; Beck et al., 1996). Cronbach’s alpha for this study was .95.

Resource assessment.

The Family Resource Scale-Revised (FRS-R; Dunst & Leet, 1987; Van Horn et al., 2001) is a 20-item self-report inventory that measures the adequacy of resources across multiple domains, such as food, shelter, childcare, transportation, health, finances, and time for self. The responses were measured on a five-item Likert scale ranging from one (not at all adequate) to five (almost always adequate); higher scores indicated greater resource adequacy. A total score was obtained by summing response values across all the items. The total FRS-R score used in the present study had a coefficient alpha of .93. Individuals without children were given a score of five for each child-affiliated question that did not apply, per author instructions (Van Horn et al., 2001).

Subjective health assessment.

The RAND-36 (Hays & Morales, 2001) is perhaps the most widely used measure of HRQoL. The measure is comprised of 36 items and consists of eight subscales. The eight subscales include physical functioning, role limitations due to physical health, role limitations due to emotional health, energy/fatigue, emotional well-being, social functioning, pain, and general health. The mean scores were computed and rescaled to range from zero to 100. Z scores were then calculated by using U.S. scoring coefficients from the factor analytic standardization sample in 1990 (N =2939). Mental health and physical health composites were then created.

Results

Bivariate Correlations

Zero-order correlations were conducted within the entire sample. Inter-item correlations can be found in Table 2. Greater resource adequacy demonstrated a significant, moderate-negative relationship with symptoms of PTSD and depression. Increased resources were positively associated with increased mental and physical HRQoL. While resource adequacy was not significantly associated with severity of physical violence and sexual coercion, increased resources were associated with less severe symptoms of psychological abuse. In terms of severity of violence, physical violence was not significantly associated with any of the mental health or QoL outcomes. Sexual coercion was significantly and positively associated with severity of PTSD and depression but none of the QoL outcomes and psychological abuse was significantly and positively associated with severity of PTSD and depression and negatively associated with physical (but not mental) HRQol.

Table 2.

Zero-order correlations

		1	2	3	4	5	6	7	8
1.	Depression	1	.70**	−.36**	−.65**	−.60**	.40**	.14	.39**
2.	PTSD	.70**	1	−.243	−.54**	−.55**	.42**	.18	.36*
3.	Physical HRQoL	−.36**	−.24	1	.05	.29*	−.34*	−.08	−.07
4.	Mental HRQoL	−.65**	−.54**	.05	1	.42**	−.20	−.05	−.13
5.	Total Resources	−.60**	−.55**	.29*	.42**	1	−.33*	−.19	−.21
6.	Psychological abuse	.40**	.42**	−.34*	−.20	−.33*	1	.51**	.59**
7.	Physical violence	.14	.18	−.08	−.05	−.19	.51**	1	.55**
8.	Sexual coercion	.39**	.36*	−.07	−.13	−.21	.59**	.59**	1

^*p<.05

^**p<01

¹Depression = Beck Depression Inventory Second Edition (BDI-II)

²PTSD= Posttraumatic Diagnostic Scale (PDS)

³Physical HRQoL= RAND-36, physical related health quality of life subscale

⁴Mental HRQoL = RAND-36, mental health related quality of life subscale

⁵Total Resources = Family Resource Scale Revised (FRS-R), total resources

⁶Psychological abuse = Psychological Maltreatment of Women Inventory (PMWI)

⁷Physical violence = The Revised Conflict Tactics Scale (CTS2), physical assault subscale

⁸Sexual coercion = The Revised Conflict Tactics Scale (CTS2), sexual coercion subscale

Symptoms of PTSD

We used hierarchical linear regression with forced entry to examine unique predictors of symptoms of PTSD¹. Covariates of age and personal income were entered into Step 1; psychological abuse and sexual coercion were entered into Step 2; and total resources was entered in Step 3. In the final model, resource adequacy was the only significant, unique predictor, with the model explaining a total of 32.7% of variance in symptoms of PTSD. Resource adequacy uniquely explained 18.6% the variation in symptoms of PTSD; See Table 3.

Table 3.

Hierarchical regression: Resource adequacy, psychological abuse and sexual coercion variables predicting PTSD

Variable	Step 1 Sociodemographic variables β	Step 2 Psychological abuse β	Step 3 Resource Adequacy β
Constant Demographics
Age	.09	.02	−.05
Personal income	.16	.17	.09
IPV variables
Psychological abuse		.02	.14
Sexual coercion		.23	.18
Resources			−.47**
R2	.00	.14	.33
F	.99	2.94	5.66
ΔR2	.04	.17	.19
ΔF	.99	4.73	13.24

^***p < 0.000

^**p < 0.01

^*p< .05

Symptoms of Depression

We used hierarchical linear regression with forced entry to examine unique predictors of symptoms of depression. Covariates of age and personal income were entered into Step 1; Psychological abuse and sexual coercion were entered in Step 2; and total resources was entered in Step 3. In the final model, resource adequacy was the only significant, unique predictor of symptoms of depression with the model explaining a total of 41.4 % of variance in symptoms of depression. Resource adequacy uniquely explained 23.7% the variation in symptoms of depression; See Table 4.

Table 4.

Hierarchical regression: Resource adequacy, psychological abuse, and sexual coercion predicting depression

Variable	Step 1 Sociodemographic variables β	Step 2 Psychological abuse, & sexual coercion β	Step 3 Resource Adequacy β
Constant Demographics
Age	.06	.01	−.08
Personal income	.23	.24	.14
IPV variables
Psychological abuse		.19	.08
Sexual coercion		.28	.22
Resources			−.54***
R2	.02	.17	.41
F	1.50	3.44	7.78
ΔR2	.06	.18	.24
ΔF	1.50	5.11	19.39

^***p < 0.000

^**p < 0.01

^*p< .05

Mental HRQoL

We used hierarchical linear regression with forced entry to examine unique predictors of mental HRQoL. Covariates of age and personal income were entered into Step 1; Psychological abuse and sexual coercion were entered in Step 2; and total resources was entered in Step 3. In the final model, resource adequacy was the only significant predictor of mental HRQoL with the model explaining a total of 20.6% of variance in mental HRQoL. Resource adequacy uniquely explained 16.4% the variation in mental HRQoL; See Table 5.

Table 5.

Hierarchical regression: Resource adequacy, psychological abuse, and sexual coercion predicting mental health related quality of life

Variable	Step 1 Sociodemographic variables β	Step 2 Psychological Abuse β	Step 3 Resource Adequacy β
Constant Demographics
Age	.04	.10	.17
Personal income	−.06	−.06	.02
IPV variables
Psychological abuse		−.19	−.10
Sexual coercion		−.02	.03
Resources			.45**
R2	−.04	−.05	.21
F	.09	.46	2.23
ΔR2	.00	.04	.16
ΔF	.09	.86	8.89

^***p < 0.000

^**p < 0.01

^*p< .05

Physical HRQoL

We used hierarchical linear regression with forced entry to examine unique predictors of physical HRQoL. Covariates of age and personal income were entered into Step 1; Psychological abuse and sexual coercion were entered in Step 2; and total resources was entered in Step 3. In the final model, none of the constructs significantly predicted physical HRQoL. While age and personal income was forced as predictor in the initial step for each of the primary outcome domains, younger age was a unique predictor for physical health QoL. In fact, age and income predicted a total of 16.5 percent of the variance in the first model, whereas they were nominal predictors in the other analyses.

Discussion

Women experiencing IPV report numerous resource concerns, including unemployment, lack of transportation, substandard housing, and general financial difficulties (Eby, 1996). In the current study, inadequate resources were a unique predictor (controlling for age, personal income, psychological abuse and sexual coercion) of symptoms of PTSD, depression, and mental health QoL. Conservation of Resource Theory (COR; Hobfoll & Lilly, 1993; Hobfoll, 2001) asserts that perceived resource loss is a critical factor in psychological distress and decreasing the probability for easing symptoms (Walter & Hobfoll, 2009). According to COR, those who do not initially have resources, such as the women within the present study, are vulnerable to downward spirals of “resource loss” (Hobfoll & Lilly, 1993). Resource inadequacy has long been documented to have a strong, negative association with mental health (Lang et al., 2011). Scarce resources converge with a variety of stressors (in addition to IPV) that threaten well-being and mental health, including community violence, crime, substance use and drug accessibility, unemployment, as well as housing and food insecurity (Slopen, Fitzmaurice, Williams, & Gilman, 2010; Snowden, 2014). Moreover, those with few resources may have less access to buffers between trauma-related stressors and mental health outcomes such as PTSD and depression (Bryant-Davis et al., 2010; Cutorna et al., 2000; Golin et al., 2016; Lorant et al., 2003; Panaite et al., 2019) and may experience accumulative stress (Allen et al., 2014). In their systemic review, Hollifield et al. (2016) found that resource loss was pathogenic and resource gain, including during interventions, was beneficial after traumatic exposure. For example, Walter, Horsey, Palmieri, & Hobfoll (2010) found that resource loss among low-income, inner-city women was predictive of later PTSD. Specific to IPV, continuous economic hardship (i.e. material hardship, including difficulty finding stable housing, food insecurity, and utility disconnection) as a result of economic abuse results in depression and PTSD (Scharg, Robinson, & Ravi, 2019). When economic security is linked with abuse, power, and control, economic-related trauma triggers may develop and persist (Scharg, Robinson, & Ravi, 2019). For example, reviewing a credit report or evaluating banking options that have been impacted by such experiences as exploitation or control may be triggering (Scharg, Robinson, & Ravi, 2019). Depressive symptomatology may stem from the longer consequences of economic hardship, including preventing the victim from gaining and/or maintaining economic opportunities, or impacting the victim’s ability to financially care for her children (Stylianou, 2018).

Of the three different forms of IPV, only psychological maltreatment evidenced a significant, negative association with resource availability. The relationship between diminished resources and psychological maltreatment may arise from coercive control. Economic abuse is one form of coercive control. Economic abuse in IPV includes tactics that hinder economic self-efficacy and sufficiency, such as financial control and exploitation, or sabotaging one’ s ability to obtain and maintain employment, with the aim of trapping the partner within the abusive relationship (Adams & Beeble, 2019; Adams, et al., 2008; Stylianou, 2018; Weaver, Sanders, Campbell & Schnabel, 2009). Using coercive control, an abuser creates an environment in which refusing a demand or questioning behavior related to finances is dangerous and can lead to credit damage and financial dependence (Adams, Littwin, & Javorka, 2019). Economic abuse has proven to be a unique predictor of psychological outcomes such as depression, PTSD, and quality of life (Adams & Beeble, 2019; Postmus et al., 2012; Schrag, Robinson, & Ravi, 2018; Stylianou, 2018). For example, Stylianou (2018) found that economic abuse experiences were significantly associated with depressive symptoms; and not physical, psychological, or sexual abuse experiences. Scharg and colleagues (2019) found that economic hardship mediated the relationship between economic abuse and depressive and PTSD symptoms. Preventing victim/survivors from gaining and/or maintaining economic opportunities may lead to a diminished overall quality of life, especially related to personal safety, opportunities for independent fun and enjoyment, as well as other personal freedoms (Adams & Beeble, 2019; Eriksson & Ulmestig, 2017; Stylianou, 2018).

Beeble, Bybee, & Sullivan (2008) examined the impact of resource constraint on the psychological well-being of survivors of IPV. They found that only psychological abuse was related to survivors’ reported difficulties in obtaining community-based resources. In a follow- up study, they found that the mental health consequences of ongoing psychological abuse such as depression and quality of life, were fully explained by ongoing resource constraints (Beeble, Bybee, & Sullivan, 2010). While the devastating impact of psychological abuse on women’s health and well-being has been documented (Follingstad et al., 1999; Mechanic, Weaver, & Resick, 2008; Pico-Alfonso et al., 2006; Lagdon et al., 2014), a lack of resources may confer additional health risk (Beeble, Bybee, & Sullivan, 2010) and may be entangled with the tactics of psychological forms of IPV such that both psychological maltreatment and lack of resources may be mutually reinforcing.

Within the current study, resource adequacy was a unique predictor of mental but not physical QoL. Although previous research has shown that the availability of resources is associated with better physical health, the limited sample size in the current study may have contributed to the non-significant associations. Failure to find this connection may have also been associated with limited measurement of some of the factors related to physical health. Specifically, the revised resource scale omits original scale items related to public assistance and medical care access due to not being applicable for all families in the standardization sample. Younger age in general is associated with better health. However, in our sample, younger age was also associated with shorter durations of relationships. Longer relationships confer greater risks for conflicts to escalate to more severe forms of violence (Johnson et al., 2015).

Economic dependence and limited financial resources have been identified as compromising women’s safety, including entrapping those who may wish to leave abusive relationships (Bybee & Sullivan, 2005) Moreover, often perpetrators interfere with a woman’s attempt to garner independent resources, including her attempts to work (Alexander, 2011). Adams and Colleagues (2012) compared the economic well-being of women receiving Temporary Assistance for Needy Families (TANF) who did not experience IPV during the study, women who recently experienced IPV, women whose IPV ended less than 3 years prior to the study and those whose relationships ended 3–5 years prior to the study. They found that in comparison to women who did not experience IPV, women who recently experienced IPV and women whose IPV ended three years prior to the study, experienced greater job instability and struggled with greater objective material hardships such money to pay bills. These results could be explained by the fact that abusive partner’s often employ a variety of control tactics that directly and indirectly interfere with their partner’s efforts to find and sustain employment (Adams et al., 2008; Swanberg & Logan, 2005). For example, a partner’s controlling behaviors may lead to poor attendance at work, surveillance phone calls or visits during work hours- all of which can often result in job loss (Swanberg & Logan, 2005; Moe & Bell, 2004; Wettersen, 2004). Even after leaving an abusive relationship, abuse-related emotional and physical health problems may impact job performance (Swanberg & Logan, 2005). Furthermore, those who experienced recent IPV had a greater negative perspective about their financial future than women who had never experienced IPV.

Because financial instability and dependency coincide with IPV perpetration, asset building can be a crucial component for improving women’s safety, health and wellbeing. Tangible resources such as housing, childcare, and employment increase a women’s financial independence and improve the likelihood that she would have greater options if her relationship became unsafe. Interpersonal resources such as contact with friends and family may reduce the psychological impact of partner abuse. For example, Thompson and colleagues (2002) found that the relationship between self-efficacy and suicidal attempts was mediated by perceived social support and effectiveness of obtaining resources within a sample of IPV-exposed, African American women presenting to a medical clinic for a suicide attempt. In addition, legal resources such as the use of civil protection orders may protect victims by enhancing their sense of safety and control, while encouraging and enabling them to seek help from the justice system. For example, Wright & Johnson (2012) found that survivors of IPV who filed and obtained a civil protective order against their abuser endorsed significantly less PTSD symptoms when compared to women who did not use this legal resource. Furthermore, the accumulation of assets has been shown to act as a protective factor against IPV (Farmer & Tiefenthaler, 1997; 2003, Tauchen et al., 1991), though this finding has produced mixed results (see Abramsky et al., 2019; Atkinson, Greenstein & Lang, 2005; Bonnes, 2016; Chio & Ting, 2008 and Jewkes, 2002 for contrasting results).

Recently, programs offering economic education services and credit counseling have been developed to promote economic and financial well-being among victims of IPV (Sanders & Schnabel, 2006). General features of these programs include financial literacy, economic self-efficacy, and self-sufficiency. Financial literacy is used to increase survivor’s knowledge about obtaining resources and making financial decisions, while economic self-efficacy and self-sufficiency target a survivor’s beliefs about their ability to obtain resources and be financially successful and enhances behaviors that are needed to engage in personal financial management (Postmus, 2010). Dichter and Rhodes (2011) found that over three-quarters of a sample of 175 women who had experienced police response to IPV had high levels of interest in and need for housing, employment and financial assistance. Notably, participants in these services exceeded their interest in more traditional services of law enforcement or IPV counseling and shelter. Hahn & Postmus (2014) suggested that economic empowerment programs can increase financial literacy, economic self-efficacy and self-sufficiency. They cautioned that the current organization of these services, however, is fragmented, and that effective coordination within and among these programs is critical and could be achieved by modifying current policy structures. In service of this coordination, they proposed that a subsection of the Violence Against Women Act (VAWA) provide funding and provisions for programming for impoverished IPV survivors. Another ongoing effort to increase access to resources for IPV survivors is establishing in-house community health teams within primary care settings. As primary care team members, Community health workers (CHWs) typically have close ties to the populations which they serve and fulfil important nonclinical roles such as providing social support to clients and connecting them to community resources (American Public Health Association, 2009). The literature on CHWs aimed at addressing IPV, however, is limited (Wennerstrom et al., 2018). Future studies may wish to focus on increasing women’s access to community resources or evaluating programs or systemic strategies such as the utilization of community mental health workers that address the intersection of IPV and poverty. Outcome studies are needed not only to evaluate the efficacy of specific economic empowerment programs on financial literacy, economic self-efficacy and sufficiency, but also to assess how survivor engagement in such programs impact their mental and physical health and safety.

Limitations

Study findings are limited by the following. First, the sample size was limited and recruitment criteria was selective for more severe forms of violence exposure. These criteria resulted in decreased variability in the severity of physical violence and could have contributed to the non-significant associations of severity of physical violence with several outcomes including PTSD. The sample was also generally impoverished which could have magnified findings related to inadequate resources.

Conclusion

The current study highlights poverty and the limited access to resources as a significant public health issue for women’s mental health and wellbeing. The intersecting public health concerns of IPV and economic disenfranchisement highlights the importance of continuing to develop and evaluate economic empowerment programs to improve the health, safety and well-being of violence-exposed women.

Table 1.

Demographics N=50

Characteristics	n (%)	Mean	SD
Age		34	8.12
20–29	15 (26%)	--	--
30–39	22 (44%)	--	--
40–59	15 (30%)	---	--
Ethnicity
African American	30 (60%)	--	--
Caucasian	18 (36%)	--	--
Hispanic	2 (4%)	--	--
Employment
Unemployed	22 (44%)	--	--
Employed	28 (56%)	--	--
Incomea
Less than $15,000/year	31 (63%)	--	--
More than $15,000/year	14 (29%)	--	--
Unsure	4 (8%)	--	--
Education
Some high school	7 (14%)	--	--
Graduated high School, vocational school, GED	17 (34%)	--	--
Some college	13 (26%)	--	--
Completed 2 or 4 year degree or higher or other	11 (22%)	--	--
Other	2 (4%)
Marital status
Married	8 (16%)	--	--
Separated/Divorced/Widowed	21 (42%)	--	--
Never married	21 (42%)
Recency of violence in daysa	--	61.09	81.02
Recency of injury in days	--	86.30	117.79
Stalked	15 (30%)	--	--

^aN=49