标题：A Multilevel Analysis of Individual, Household, and Neighborhood Correlates of Intimate Partner Violence Among Low-Income Pregnant Women in Jefferson County, Alabama
摘要：Objectives. We examined individual, household, and neighborhood correlates of intimate partner violence (IPV) before and during pregnancy. Methods. We used multilevel modeling to investigate IPV among 2887 pregnant women in 112 census tracts who sought prenatal care in 8 public clinics in Jefferson County, Alabama, from 1997 through 2001. Data were collected from the Perinatal Emphasis Research Center project, the 2000 Census, and the local Sheriff and Police Departments Uniform Crime Reports for 1997 through 2001. Results. Participants were predominantly young, African American, on Medicaid, and residents of low-income neighborhoods. The prevalence of past-year male partner–perpetrated physical or sexual violence was 7.4%. Neighborhood residential stability, women performing most of the housework (lack of involvement among partners), being unmarried (being in an uncommitted relationship), and alcohol use were positively associated with elevated IPV risk. Significant protective factors for IPV included older age at first vaginal intercourse and a greater sense of mastery (e.g., the perception of oneself as an effective person). Conclusions. Both neighborhood contextual and individual and household compositional effects are associated with IPV among low-income pregnant women. The results imply that combined interventions to improve neighborhood conditions and strengthen families may effectively reduce IPV. Intimate partner violence (IPV) experienced by pregnant women is a public health concern in the United States because of its high prevalence and its potential for severe physical harm, including injury and death, to both the mother and unborn child. The prevalence of violence against pregnant women has been estimated at 3.9% to 8.3%, depending on the populations, specific periods of pregnancy, and screening tools. 1 Thus, an estimated 152 000 to 324 000 abused women deliver live-born infants annually. 2 Serious consequences of IPV include delayed prenatal care, miscarriage and spontaneous abortion, and adverse birth and child outcomes. 3 Homicide was the second leading cause of injury deaths among pregnant and postpartum women, 4 and women abused during pregnancy are 3 times more likely to be murdered over the course of their lifetime than women who were abused outside pregnancy. 5 The US Department of Health and Human Services has identified reducing the rate of physical assault by current or former intimate partners to 3.3 per 1000 persons aged 12 years and older to be a Healthy People 2010 health objective. 6 Achieving this national goal will require further study of the factors associated with IPV, including the family characteristics that promote healthy relationships within a broad ecological systems context, 7 – 9 and prevention targeted at potentially accessible populations for which IPV has both serious consequences and high prevalence. More than 95% of pregnant women make routine prenatal care visits, providing a stable opportunity in the community to screen and prevent IPV within a primary care setting. 10 , 11 Because intimate partner violence during pregnancy occurs more often among couples of low socioeconomic status, 1 , 3 , 12 low-income households may require special attention in a community to prevent IPV experienced by pregnant women. Whereas most IPV prevention strategies focus on secondary and tertiary prevention based on identified individual-level risk factors, the national IPV prevention agenda highlights the importance of primary prevention and both contextual and protective factors for IPV. 13 , 14 The use of an ecological systems framework holds promise for the study of IPV because it recognizes the complexity of IPV and puts a equal, joint focus on both the male–female dyad and multiple contexts. 15 , 16 Prior research has identified neighborhood as an important context in understanding the prevalence of IPV. Significant neighborhood influences include low per capita income, high unemployment rate, resource deprivation, and concentrated disadvantage. 17 – 23 Inconsistent findings have been reported for neighborhood residential mobility and neighborhood crime. 18 , 20 , 23 – 25 Compared with the contextual study of IPV in developing countries, 26 this line of research in the United States has benefited from a long history of social science studies examining neighborhood context and crime or delinquency. Despite providing useful insights concerning study design, theoretical perspectives, and analytical methods, previous contextual studies of IPV have important methodological limitations. One ecological study measured IPV on the neighborhood level, but did not allow inferences about IPV at the individual level. 18 Other studies 20 – 22 , 24 , 27 , 28 examined clustered data with logistic regression models, which fail to account for the clustering inherent in the data. Several studies that used multilevel modeling 17 , 19 , 23 , 25 had small samples with an average of about 1.6 to 2.5 study participants per neighborhood, resulting in numerous clusters with a single observation and unstable estimates of variances for binary outcomes. 29 Whereas some studies have underrepresented low-income households in probability samples, 19 – 21 , 25 , 27 , 28 others have overrepresented them in convenience samples, including reported incidents from police, screened events in hospitals, and parent studies on HIV. 17 , 18 , 22 – 24 One contextual study of IPV has focused on women during pregnancy and postpartum. 17 Improved understanding of how low-income couples can cope with environmental stressors and prevent IPV from occurring will greatly enhance the development of primary prevention programs. However, little is known about couple-level protective factors. 13 Previous research has focused on individual- and household-level risk factors for IPV. Although IPV prevalence estimates varied by maternal race and age, consistent risk factors included low socioeconomic status, low educational attainment, and use of alcohol. 1 , 3 , 12 , 19 Household-level risk factors for IPV included social norms (e.g., male dominance in the family), first-time parenting, unplanned or unwanted pregnancy, lack of social support, partner drug use, poor conflict management, stress, and resource inadequacy. 15 , 17 , 23 , 27 , 28 , 30 Family is the primary proximal context for human development. 31 Strong social bonds and good marriages have been shown to reduce street crimes and IPV primarily through informal social control process. 32 – 40 Social bonds refer to “internalization of accepted norms, awareness, and sensitivity to the needs of others which promote conformity in society.” 40 (p534) Each dimension of the bonds among partners—for example, commitment and involvement—ties partners to conventional society and societal rules, thus informally controlling and preventing IPV. 32 , 33 , 40 Research designed to increase our understanding of the association of neighborhood contextual and couple-level factors with IPV among low-income pregnant women is needed. We conceptualized that IPV occurs within an ecological framework ( Figure 1 ) that considers the interplay of neighborhood context, household factors (stressors, resources, and bonds among partners), and individual correlates of IPV. We designed this study to determine whether features of neighborhoods, being in an uncommitted relationship, and lack of involvement among partners were associated with a higher prevalence of IPV at the individual level among low-income pregnant women, when we controlled for relevant individual and household factors. Open in a separate window FIGURE 1 The ecological model of neighborhood and household contexts and influences on the experience of intimate partner violence among low-income pregnant women: Perinatal Emphasis Research Center Project, Jefferson County, Alabama, 1997–2001. Note. Solid arrows depict hypothesized strong connections between 2 domains in the sequence. Broken lines represent weaker associations. Double arrows indicate a mutual influence between 2 domains.
