1. African-Caribbean & African American Women’s Study

2. Intimate Partner Violence, Substance Use, and PTSD: Women of African Heritage in Baltimore and the U.S. Virgin Islands Phyllis Sharps, PhD, RN, FAAN Johns Hopkins University School of Nursing

3. Team Members United States Jacquelyn Campbell, PhD, RN, FAAN Phyllis Sharps PhD, RN, FAAN Richelle Bolyard, MSN Jamila Stockman, PhD, MPH Marguerite Baty, PhD, MPH, RN Jessica Draughon, PhD (c), MSN, RN Mary Paterno, BSN, RN, SNM Akosoa McFadgion, MS, MSW Georgette Cox, MPH Sharon O’Brien, PhD Ashley Chappell Naa Ayele Amponsah, BA Chris Kunselman Hossein Yarandi, PhD US Virgin Islands Doris Campbell, PhD, ARNP FAAN Gloria Callwood, PhD, RN Desiree Bertrand, MSN, RN Janis Valmond, MPH Catherine Coverston, PhD, RNC Lorna Sutton, MPA Tyra DeCastro Princess Oneida-Stuard, BSN std Melanie Ruiz, BSN std Natasha Caines, BSN std Jose Negron & Romeo Richardson

4. Prevalence of Intimate Partner Violence  In the US, 29.7% of women (18-65 yrs) report lifetime IPV victimization with African Americans overrepresented (33%) (Coker et al., 2002).  High rates of IPV (30-66% ) have been reported in Afro- Caribbean countries (Krug, Dahlberg, Mercy et al., 2002), but actual prevalence in US Virgin Islands never determined.  Health disparities for African American women – including maternal child health disparities & HIV/AIDS also associated with IPV (Sharps & Campbell, 2006; Campbell et al., 2008).

5. Intersecting Epidemics of IPV, Substance Use and Mental Health  Abused women found to have increased risks of psychosocial and mental health illnesses such as substance use, family and social problems, depression, and anxiety/neuroses compared to never-abused women (Bonomi et al., 2009).  Substance use by both the woman and her partner has been found to independently predict IPV; social support moderated the effect of women’s substance use (Golinelli, et al, 2009).

6. Purpose  To examine the association between intimate partner violence (IPV) and substance use among Afro Caribbean women in the US Virgin Islands and African American women in Baltimore city, Maryland.  To assess post-traumatic stress disorder as a mediating variable in the relationship between IPV and substance use among Afro Caribbean and African American women.

7. Methods  Comparative case (N = 150 in each site) control (N = 150 in each site) study  Eligibility criteria  Women aged 18-55 years  Self-identify as Afro Caribbean or African American  Report of a male sex partner in the past two years  Women recruited from primary care, prenatal or family planning clinics  Questionnaire administered on a touch screen computer with optional headphones - an important methodological strategy  For women of low literacy  For sensitive information  Alerts interviewer if high score on DA or suicidality  Allows increased recruitment among Spanish speaking  Recording in Spanish & English by USVI residents for increased cultural appropriateness  Study period 12/1/09 to present

8. Measures  Intimate Partner Violence (IPV) in one’s lifetime assessed using the Abuse Assessment Screen (McFarlane & Helton - www.nnvawi.org)www.nnvawi.org  Pushed, slapped, hit, kicked, or physically hurt &/OR  Forced sex &/OR  Pushed, slapped, hit, kicked, or physically hurt while currently pregnant  Any of the above by current or former husband, boyfriend, or male or female partner

9. Measures  Substance Use  Drug use in past yr (street, over the counter, non- prescription drugs)  Alcohol use in past month  Cases with history of sexual violence – they or abusive partner under influence of alcohol or drugs during last forced sex incident  Cases – recent abusive partner drug user  Post-traumatic Stress Disorder (PTSD)  Assessed using 4-item Primary Care-PTSD  Scores summed; cutoff of 3 or more = PTSD+

10. Baltimore City, MDUS Virgin Islands Study Population 1,201 screened from both sites 1,025 eligible n=727n=298 333 cases 88 controls 119 cases 104 controls As of 9/10/10 306 unselected controls 75 unselected controls

11. Population-based Prevalence of Lifetime Intimate Partner Violence

12. Population-based Prevalence of Lifetime Psychological Abuse Only Psychological abuse (above cutoff on WEB (Women’s Experiences of Battering) – being afraid &/or controlled by a current or ex-intimate partner

13. Population-based Prevalence of Intimate Partner Violence in the Past 2 years n=63

14. Perpetrator of IPV in the Past 2 years

15. Demographics Age Employment

16. Demographics - Education USVI X 2 =3.63, p=0.30 Baltimore X 2 =2.42, p=0.49

17. Demographics – Marital Status USVI X 2 =8.62, p<0.05 Baltimore X 2 =1.10, p=0.78

18. Proportion of women reporting drug and alcohol use (452 cases and 192 controls) *in the past year;**in the past month X 2 =12.74, p<0.001 X 2 =0.044, p=0.83

19. Does PTSD Mediate the Association Between IPV and Drug Use? Step 1: Is IPV associated with drug use? OR: 3.93; 95% CI: 1.76-8.78 Step 2: Is IPV associated with PTSD (mediator)? OR: 3.88; 95% CI: 2.19-6.88 Step 3: Is PTSD associated with drug use, adjusting for IPV? OR: 3.06; 95% CI: 1.69-5.51 Step 4: Significance testing using the Sobel Test p<0.013

20. Proportion of women reporting substance use involvement during last forced sex among those with histories of sexual violence(n=135)

21. Proportion of abused women reporting a recent substance-using partner (n=452) Note: These women 2 times were more likely to have PTSD symptoms in the past month (AdjOR: 2.09; 95% CI: 1.27-3.43).

22. Conclusions  High rates of IPV, substance use and PTSD among women of African heritage in Baltimore and USVI  High rates of drug use for both abuser and victim in context of forced sex  High rate of drug use by abusers  IPV is associated with drug use but not alcohol use  PTSD mediates the relationship between IPV and victim drug use – self medication hypothesis  Abused women w/substance using abuser more likely to have PTSD  Use of substances as a way to cope with Sx of PTSD

23. Implications  Women disclosing substance use and PTSD need further assessment to include IPV  Women in substance abuse Tx need assessment and interventions for IPV & PTSD  Women disclosing IPV need further assessment to include substance use and PTSD  Interventions targeting abusive partners should take into account substance abuse history