Intimate partner violence and use of welfare services among California women.

The current study is a population-based investigation of the association between past-year exposure to intimate partner violence (IPV) and current welfare use, while also accounting for the effects of other violence experienced in adulthood and symptoms of posttraumatic stress disorder (PTSD). These data indicate that acute exposure to intimate partner violence is significantly over-represented among women currently on welfare. However, it appears to be a woman's cumulative exposure to interpersonal violence and associated symptoms of PTSD that are uniquely associated with welfare participation. These data highlight the prevalence of violence against women and its consequences for this population. Results suggest that the prevention and detection of violence is an important welfare issue, and highlight the need for more research in this area.

Key words: Intimate Partner Violence; TANF; Family Violence Option; Mental Health; Posttraumatic Stress Disorder

Introduction

With the onset of the Personal Responsibility and Work Reconciliation Opportunity Act (PRWORA), welfare services took the form of federal block grants called Temporary Assistance for Needy Families (TANF), which place increasing responsibility and pressure on individual participants to find employment sufficient to eliminate welfare dependency. This emphasis, including work requirements and lifetime limits for participation have successfully moved many individuals from welfare to work, leaving a welfare population comprised primarily of women caring for children who experience more serious barriers to employment. As a result, much research has begun to focus on factors associated with welfare use and barriers to employment in this population.

This research suggests that intimate partner violence (IPV) may be a major barrier to education and employment (Horwitz & Kerker, 2001; Tolman & Rosen, 2001). The hypothesis that violence against women is both an etiologic and maintaining factor in women's poverty is plausible. Prospective data reveals that a history of violence predisposes women to unemployment and poverty, while poverty further increases a woman's risk for subsequent victimization (Bassuk & Rosenberg, 1988; Byrne, Resnick, Kilpatrick, Best, & Saunders, 1999). However, some data suggest that violence against women, particularly intimate partner violence, is associated not only with poverty but more specifically with the use of welfare. Studies of welfare populations have documented rates of IPV higher than those found in the general population or among low income women (Brush, 1999; Romero, Chavkin, Wise, Smith, & Wood, 2002; Tjaden & Thoennes, 2000; Tolman & Rosen, 2001). These studies have also begun to document these women's problems with employment, health, and mental health. This association is notable because it suggests that violence against women may be a significant determinant of welfare utilization.

IPV among women using Welfare

The few published studies of IPV that have examined welfare populations suggest that the experience of IPV is overrepresented among women using welfare. Tolman and Rosen (2001) administered a modified version of the Conflict Tactics Scale (CTS; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) to a sample of 753 welfare recipients in Michigan and found that 23% of women experienced moderate to severe physical violence in the past year, with lifetime rates of 63%. Women exposed to violence in the past year also had significantly higher rates of psychological disorders, including depression, PTSD, and substance use disorders, when compared to non-exposed women. Another study of 122 welfare recipients enrolled in welfare-to-work training found that 38% of women reported at least one episode of physical violence in their most recent intimate relationship (Brush, 1999). A study of low-income mothers of chronically ill children administered a brief 3-item screen for lifetime exposure to intimate partner violence (Feldhaus et al., 1997) and found significantly lower rates of violence among women who had never received welfare, 16.4%, as compared to women currently participating in welfare, 31.7% and women with pending welfare participation, 40% (Romero et al., 2002). While these studies lack representative samples and consistent definitions of IPV, these estimates do suggest an association between current exposure to IPV and use of welfare.

This association suggests a number of potential implications for intervention. Several authors have noted that increasing access to IPV-focused services may not only increase the safety and well-being of women and their children, but facilitate employment and transition from economic dependence (e.g., Tolman & Raphael, 2002). However, the social context of IPV must be considered, as exposure to IPV often occurs in the context of other violence. Poor women exposed to IPV are at increased risk for living in violent communities (Hien & Bukszpan, 1999), and are likely to have been "re-victimized" as adults, following exposure to violence during childhood (Tjaden & Thoennes, 2000). Furthermore, mental health consequences of violence, such as posttraumatic stress disorder (PTSD), are over represented among individuals in poverty (Bassuk, Dawson, Perloff, & Weinreb, 2001; Davidson, Hughes, Blazer, & George, 1991). In order to fully understand the mental health needs of women using welfare, investigations of the links between IPV and welfare use must also examine the role of prior violence exposure and PTSD.

Under current federal law, states have considerable flexibility to implement a range of interventions using TANF funds. Among these is the Family Violence Option (FVO) which waives federal time-limits for violence-exposed women and allows states to offer violence-related social and mental health services that may satisfy requirements for employment support activities. Violence prevention services are also authorized under current marriage promotion initiatives, though few states utilize this opportunity. Relevant empirical data are needed to guide the development and implementation of these services in order to best facilitate safety, health, and economic independence among these women and their children.

The current study is an epidemiological analysis of the relationship between exposure to IPV and use of CalWorks, California's TANF program. We assess the occurrence of intimate partner violence in the past year in a population-based sample of California women. The ethnic diversity of the state of California makes population-based samples especially relevant for examining such issues. We expand on previous studies of the link between IPV and welfare by accounting for other episodes of violence that may have occurred prior to, or concurrent with, a past-year episode of IPV. We also examine current symptoms of PTSD as a factor that may initiate or maintain a woman's need for welfare. The goals of the current study are to: a) examine the strength of the relationship between past-year IPV and current CalWorks use after adjusting for relevant demographic factors; b) examine the strength of this relationship after accounting for the effects of other violence experienced in adulthood; and c) determine whether the effects of IPV and other violence are accounted for by their psychological sequelae, symptoms of PTSD.

Methods

Data and Sample

This study used data from the 2001 California Women's Health Survey (CWHS), a population-based, random-digit-dial, annual probability survey of California women sponsored by the California Department of Health services and designed in collaboration with several other state agencies and departments. Interviews are conducted by trained interviewers following standardized procedures developed by the Public Health Institute Survey Research Group and the Centers for Disease Control and Prevention. The staff and procedures are identical to California's administration of the Behavioral Risk Factor Surveillance System (Stein, Lederman, & Shea, 1993). The first author, a clinical psychologist, provided additional training to interviewers for violence-related items. Interviews for the CWHS are conducted in English and Spanish and take approximately 30 minutes to complete.

The response rate for the 2001 survey is 74%, yielding a sample of 4018 women aged 18 years and older. The current investigation utilized a sub-sample of 3617 women with complete data for all violence variables. While the sample closely approximates the population of California women in terms of age, ethnicity, education, and household income, data were weighted in analysis to reflect the age and ethnicity distributions of California women.

Measures

Intimate partner violence was assessed according to the Centers for Disease Control and Prevention recommended definition (Building data systems for monitoring and responding to violence against women, 2000), with the time frame of the past 12 months. Items included physical violence, sexual violence, threats of violence, and emotional / psychological abuse. All items referenced a current or former partner. History of interpersonal violence was assessed using items from the Traumatic Stress Schedule (TSS; Norris, 1990), a widely used measure of discrete traumatic events. The TSS is a reliable and valid measure and has demonstrated efficacy in epidemiological studies (Norris, 1992; Norris & Riad, 1997). The items regarding physical assault, sexual assault, and violent robbery, and mugging/attack were used in the current study. Respondents were asked to endorse each item it they had experienced the event in their adult lifetime (aged 18 or over).

Symptoms of posttraumatic stress disorder were assessed using a 5 item screen demonstrated to detect clinically significant PTSD with excellent sensitivity and specificity and performed superior to a standard 17 item assessment instrument (Prins et al., in press). The items include a general trauma probe and 4 items that query the presence or absence in the past month of the four major factors of PTSD symptoms (Asmundson et al., 2000): intrusive trauma-related thoughts, avoidance of trauma-related cues, emotional numbing, and physiological hyperarousal. Participants were classified as having PTSD symptoms (not a diagnosis of PTSD) if they screened positive for trauma and endorsed one or more of the symptom items. IPV and violence items immediately preceded PTSD items in the survey.

Current welfare receipt was defined as an endorsement of survey items that queried current receipt of money on a regular basis from the county, "sometimes called welfare, AFDC, or CalWorks".

Statistical Analyses

Analysis weights were calculated from year 2000 California Department of Finance population estimates for California women. Bivariate analyses and multivariable logistic regression analyses were performed to examine the association of IPV with demographic characteristics (age, race/ethnicity, education, marital status, the presence of children under age 18 living in the household and household income at or below the federal poverty level), current use of CalWorks, prior history of interpersonal violence, and symptoms of PTSD. Multivariable logistic regression analyses were then used to examine IPV, history of interpersonal violence, and symptoms of PTSD as correlates of current use of CalWorks, while adjusting for demographic characteristics. For ease of interpretation, age was entered as a continuous variable in logistic regression analyses. Race/ethnicity was entered as a categorical variable with White as the reference category. SPSS version 11.0 was used to conduct all analyses.

RESULTS

Intimate Partner Violence

Ten percent of the sample reported intimate partner violence in the past year and 2.7% utilized CalWorks services. Table 1 presents the frequencies for the intimate partner violence items. Table 2 illustrates the characteristics of IPV-exposed women as compared to non-exposed women. Women exposed to IPV in the past year were more likely than women not exposed to IPV to be African-American or Hispanic, of younger age, separated or divorced, and not to have completed high school and college. IPV exposure was significantly more common among women with children under the age of 18 living in the home, in fact, the majority of IPV-exposed women lived with children. One quarter of IPV-exposed women were living at or below the federal poverty level, a rate more than twice that of non-exposed women. Over three times as many IPV-exposed women as non-exposed women were currently using CalWorks.

Prior exposure to interpersonal violence was associated with the experience of IPV in the past year, suggesting that IPV often occurs in a life context of violence. Almost one quarter of women exposed to IPV experienced sexual assault, and one half experienced physical assault. Significantly more women exposed to IPV in the past year had also experienced a violent mugging or attack than had non-exposed women. The majority, (63.4%), of women who experienced IPV in the past year, reported current symptoms of PTSD, as compared to 24.2% of women who were not exposed to IPV. Bivariate analyses indicated robust effects for the association of each symptom domain of PTSD (intrusive thoughts, avoidance, hypervigilance, and emotional numbing) with past year exposure to IPV.

Factors Associated with Welfare Use

Among women using welfare, 27.6% experienced IPV in the past year; 53.2% experienced an episode of violence as an adult; and 45.7% reported current symptoms of PTSD. We examined the relationship between IPV exposure in the past year and current use of CalWorks using logistic regression. We examined the effects of past-year IPV, lifetime trauma, and then PTSD symptoms incrementally to detect both the unique and combined effects of these variables. Table 3 shows the results. Specifically, we first estimated a model that examined the association between past year IPV and CalWorks use adjusting for factors associated with both IPV exposure and use CalWorks: ethnicity, age, marital status, children under 18 in the household, and high school education (Model 1). African-American ethnicity, younger age, being divorced or separated, the presence of children under the age of 18 in the household, and not having graduated high school were each associated with current use of welfare in the full model. Intimate partner violence in the past year was associated with current welfare use even after adjusting for these factors. Specifically, past year IPV approximately doubled the odds that a woman was currently using CalWorks.

We then estimated a model (Model 2) that examined association of both past year IPV and a history of interpersonal violence (physical assault, sexual assault, or attack) with current use of CalWorks, adjusting for the same demographic factors as in Model 1. African-American ethnicity, younger age, being divorced or separated, the presence of children under the age of 18 in the household, and not having graduated high school were each associated with current welfare use in this model, with effects of similar magnitudes as the first model. The magnitude of the effect for past year IPV was reduced to nonsignificance. However, adult lifetime history of interpersonal violence emerged as a significant correlate of current welfare use. Having been exposed to violence at any time in a woman's adult life more than doubled the odds that the woman currently used welfare.

The final model (Model 3) examined the association of past-year IPV, adult violence history, and symptoms of PTSD with current use of CalWorks, adjusting for demographic factors. Again, African-American ethnicity, younger age, being divorced or separated, the presence of children under the age of 18 in the household, and not having graduated high school were each associated with current use of welfare, with effects of similar magnitudes as the first two models. IPV remained a non-significant predictor, while adult history of violence and PTSD symptoms were each uniquely associated with current welfare use. Exposure to violence as an adult and current symptoms of PTSD each approximately doubled the odds that a woman currently participated in welfare.

Discussion

Our results identify several important issues relevant to the provision of psychological services to women receiving welfare assistance. These data are population-based and used valid questionnaire items and trained interview personnel to examine issues related to recent intimate partner violence among California women. These data provide confirmation that acute exposure to intimate partner violence is significantly over-represented among women currently on welfare. However, it appears to be a woman's cumulative exposure to interpersonal violence and associated symptoms of PTSD that are uniquely associated with CalWorks participation. These data highlight the important role of trauma exposure and its consequences for this population, and suggest a specific need for mental health services that target these issues.

The data from the current study are cross-sectional, and causality cannot be inferred from the current analyses. However, plausible explanations for the relationship between IPV-exposure and welfare use have been proposed in the literature. While these theories are preliminary, their discussion may help to inform interpretation of the current results. For example, power and control is a central issue in violent relationships which often manifests in a woman's financial dependence on her male partner. Reports from several states that have surveyed women and domestic violence shelter staff suggest that as these women leave violent marriages or cohabitation, the financial assistance from welfare is utilized to help a woman care for herself and her children (Barusch, Taylor, & Deer, 1999; Curcio, 1997). This is consistent with our findings, where the odds of welfare participation among women exposed to IPV in the past year are about twice that seen in non-exposed women. This relationship was observed in particularly conservative statistical analyses that controlled for demographic factors related to welfare participation, including age, ethnicity, education, marital status, and the presence of children under 18 living in the household. It is also possible that the direction of the relationship is reversed, where participation in welfare maintains or increases a women's risk for exposure to IPV. For example, leaving an already violent relationship causes violence and risk of lethality to escalate (McFarlane, Campbell, & Watson, 2002; Sev'er, 1997), further strengthening the relationship between IPV exposure and welfare use. Women receiving welfare report perceptions that taking steps towards financial independence would further increase their risk of harm from former partners (Riger & Krieglstein, 2000). Research is needed which focuses on violence among women initiating welfare participation in order to disentangle these issues, however, the specific implications for intervention are similar.

One of the most striking implications for mental health services that these results yield is the importance of trauma history and PTSD. Effective services for women using welfare need to extend beyond crisis and shelter-based services for current intimate partner violence. Access to these services is absolutely imperative to ensure women's safety. However, these services are not sufficient to help women overcome clinically significant symptoms and to cope with the challenges of employment, financial independence, and to ensure the well-being of their children. Awareness of these issues of individual and family functioning are especially important in light of the fact that the majority of IPV-exposed women had children under 18 in the household. IPV was also significantly associated with an adult history of violence and current (past-month) PTSD symptoms. When PTSD and violence history were added to the multivariate models, IPV was no longer uniquely associated with welfare use. If, as these results suggest, IPV in the past year is a marker for women with chronic histories of interpersonal violence or who are struggling with PTSD, access to both violence prevention services and formal mental health services are needed to adequately address these issues. In these data, both exposure to interpersonal violence as an adult and symptoms of PTSD demonstrated unique effects and approximately doubled the odds of using CalWorks. Interventions that help women resolve the sequelae of violence and chronic PTSD may be essential to prevent subsequent exposure to IPV and help many violence-exposed women gain independence from welfare.

However, it is important to note that facilitating women's access to effective mental health services is not sufficient to prevent violence against women and its deleterious social and economic impact. These data suggest that violence against women may have significant economic costs to society, as has been proposed by significant economic research (Max, Rice, Golding, & Pinderhughes, 1998). In this light, violence prevention is seen as an important social policy issue. The well-being of women exposed to violence and their children depends not only on social and mental health services, but financial resources as well. Both the Family Violence Option and marriage promotion initiatives allow specific funding for violence-focused intervention for women using welfare. Few programs and procedures have been developed to take advantage to these funding mechanisms though implementation of such services would address important issues for these women and children.

This study represents a preliminary investigation into the links between violence against women and welfare utilization, and more research is clearly needed. The results of the current study should be interpreted in the light of several limitations. First, random digit dial techniques are not ideal methods for studying low income and underserved populations. Our estimates of the proportion of women using CalWorks services were accurate according to CDSS data sources (2.7 vs. 2.5%; CalWorks characteristics survev, 2001). The relatively large sample size of this study and the high response rate gives credence to these data, but additional studies focused on the TANF population are needed. The current study is cross-sectional, and longitudinal data would better test hypotheses concerning exposure to violence and initiation of welfare services and length of time using welfare.

Even in light of such limitations, these data highlight the potential economic and clinical benefits for collaboration between psychological services and social services. Screening and identification of violence in social services settings has potential to identify women with unmet mental health needs as well as to provide states the opportunity to implement Family Violence Option waivers and gain exemption from financial penalties for failing to meet federal welfare-to-work requirements and time limits. A large body of research has identified effective methods for screening for violence exposure in health care settings (e.g., Feldhaus et al., 1997; McFarlane, Soeken, & Wiist, 2000; Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000), but little is known about the extent to which these practices are adopted in social service settings. Psychological research that has documented methods to improve access to mental health services for poor women (e.g., Miranda et al., 2003) can further inform these collaborations. Thus, data already exist to guide implementation of psychological interventions within social service systems. Given the financial incentives for such interventions posed by federal welfare time limits, this is a unique opportunity to address significant unmet mental health needs in this under-served population by implementing traumatic stress interventions that improve functional status and family well-being among women on welfare.

Table 1

Prevalence of Intimate Partner Violence.

Intimate Partner Violence Item                         %

Tried to control most or all daily activities          5.3
Pushed, grabbed, slapped                               4.6
Frightened for your safety due to anger or threats     4.2
Thrown something at you                                2.9
Followed or spied                                      2.4
Kicked, bit or hit                                     1.2
Beaten up; choked                                      0.9
Forced sex                                             0.7
Threatened with knife or gun                           0.4
Used a knife or fired a gun                            0
Intimate Partner Violence                             10%

Table 2

Correlates of IPV Exposure No IPV

                           Past     No IPV                95%
                           Year     Past r    Odds     Confidence
                            IPV      Year     Ratio     Interval

Ethnicity
  White                    53.6%     63.5%
  Black                     8.4%      6.5%
  Hispanic                 29.1%     20.2%
  Asian/Other               8.9%      9.8%
Age
  18-24                    26.2%     14%
  25-34                    35.1%     25.6%
  35-44                    22.3%     22.2%
  45-54                    10%       14.1%
  55-64                     2.8%     10.9%
  65+                       3.6%     13.2%
Separated / Divorced       25.4%     10.7%    2.8       (2.2,3.7)
Children under 18 in       61.3%     47.9%    1.7       (1.4,2.2)
  household
No High School             19.3%     13.1%    1.6       (1.2,2.1)
  Education
No College Education       81%       68.5%    1.9       (1.5,2.6)
Fed. Poverty Level         25.1%     11.9%    2.5       (1.9,3.2)
Current CalWorks            7.6%      2.2%    3.6       (2.3,5.6)
Adult Sexual Assault       24%        9.6%    2.99     (2.28,3.91)
Adult Physical Assault     50.7%     18.4%    4.56     (3.64,5.72)
Adult Violent Robbery      14.5%      9.3%    1.65     (1.20,2.27)
Nightmares and             47.2%     18.6%    3.9       (3.0,5.0)
  intrusive thoughts
Behavioral and             49.7%     17.5%    4.6       (3.6,5.9)
  cognitive avoidance
Hypervigilance, startle    33.7%     10.7%    4.2       (3.2,5.5)
Emotionally numb,          37.5%     14.3%    3.6       (2.8,4.7)
  detached
PTSD Symptoms              63.4%     24.2%    5.4       (4.3,6.8)

                            Chi-Square
                             (p value)

Ethnicity                  18.8 (p<.001)
  White
  Black
  Hispanic
  Asian/Other
Age                        91.7 (p<.001)
  18-24
  25-34
  35-44
  45-54
  55-64
  65+
Separated / Divorced
Children under 18 in
  household
No High School
  Education
No College Education
Fed. Poverty Level
Current CalWorks
Adult Sexual Assault
Adult Physical Assault
Adult Violent Robbery
Nightmares and
  intrusive thoughts
Behavioral and
  cognitive avoidance
Hypervigilance, startle
Emotionally numb,
  detached
PTSD Symptoms

Table 3

Adjusted Odds of Currently Using CalWorks

                              Model 1            Model 2
                            Adjusted OR        Adjusted OR
                             (95% CI)           (95% CI)

Past Year Intimate         2.0(1.2, 3.3)      1.6(.94, 2.7)
  Partner Violence
Adult Violence History                        2.4(1.4, 3.8)
PTSD Symptoms
African--American          4.3(2.4, 7.8)      4.2(2.3, 7.7)
  Ethnicity
Age                        .95(.93, .98)      .93(.90, .96)
Separated/Divorced         3.0(1.8, 5.2)      2.6(1.4, 4.4)
Children Under 18 in      13.8(5.1, 37.5)    17.4(6.2, 54.5)
  Household
Not High School            4.7(2.9, 7.7)      4.6(2.8, 7.5)
  Graduate

                              Model 3
                            Adjusted OR
                             (95% CI)

Past Year Intimate         1.3(.76, 2.3)
  Partner Violence
Adult Violence History     2.1(1.3, 3.4)
PTSD Symptoms              1.9(1.2, 3.0)
African--American          4.1(2.2, 7.5)
  Ethnicity
Age                        .93(.90, .97)
Separated/Divorced         2.4(1.4, 4.2)
Children Under 18 in      19.9(6.7, 59.2)
  Household
Not High School            4.4(2.7, 7.2)
  Graduate

Note

Data for these analyses were provided by the California Women's Health Survey (CWHS) Group. The CWHS is coordinated by the California Department of Health Services in collaboration with the California Department of Mental Health, the California Department of Alcohol and Drug Programs, CMRI, and the Public Health Institute. Funding for the survey was provided by collaborators and by a grant from the California Wellness Foundation. Funding for the current report was provided by the Public Health Institute. Analyses, findings, and conclusions described in this report are not necessarily endorsed by the CWHS.

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RACHEL KIMERLING

National Center for Posttraumatic Stress Disorder

Palo Alto VA Health Care System

Palo Alto, CA

NIKKI BAUMRIND

Research and Evaluation Branch

California Department of Social Services

Sacramento, CA