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C 2003) Journal of Family Violence, Vol. 18, No. 2, April 2003 (°
Qualitative Differences Among Rural and Urban Intimate Violence Victimization Experiences and Consequences: A Pilot Study T K Logan,1,2 Robert Walker,1 Jennifer Cole,1 Stephanie Ratliff,1 and Carl Leukefeld1
Relatively little is known about rural women’s intimate violence experiences in comparison to urban women’s experiences, partly because of the difficulty in accessing rural women. This pilot study used a protective order sample of 23 women (15 urban and 8 rural), which provides an access point that is relatively similar for comparisons across rural and urban areas. The number of participants is low and, therefore, results are preliminary. However, several significant findings emerged. Rural women reported significantly less social support, less education, less income, more physical abuse in the preceding year, more childhood physical and sexual abuse, and worse overall health and mental health, as well as encountering abuse earlier in the relationship. Both groups reported higher rates of illegal drug and cigarette use than those among the general population. The findings highlight some overall important themes in examining rural and urban intimate violence victims by suggesting that rural and urban intimate violence victims have different victimization experiences and service needs. Implications for further research and intervention are discussed. KEY WORDS: intimate violence; rural women; health consequences; protective order.
Most studies focused on female victims of intimate violence use urban samples. However, with over 28% of the nation’s population living in rural areas, it is critical to examine the unique problems faced by rural victims. The literature suggests that rates of intimate violence are similar in rural and urban areas (Bachman, 1994; Bachman & Saltzman, 1995; Websdale & Johnson, 1997); however, the experiences of intimate violence victims in rural areas may be vastly different for a number of reasons (Fishwick, 1998; Ivy Fiene, 1995; Kershner et al., 1998). Limited access to services, low education, high poverty rates, and social isolation are all factors that may impact a rural woman’s victimization experiences. Of the 50 million Americans living in rural areas, more than 21 million have too few health care providers to meet their basic primary care needs, and 34 million rural residents
live in designated Mental Health Professional Shortage Areas (Doyle, 1998; Rural Health Bulletin, 1994). In general, rural areas are economically disadvantaged and rural residents tend to have severe health problems (Gesler & Ricketts, 1992). In addition, health care services in rural areas are generally limited to crisis care, and health promotion services are virtually nonexistent (Gesler & Ricketts, 1992; Williams et al., 1997). One study in rural Kentucky found that intimate violence victims in rural areas are pervasively isolated, cannot and/or do not utilize shelters and other intimate violence services, have enormous social stigma regarding intimate violence, have few economic resources, have limited access to the criminal justice system, and are not taken seriously in the court system (Websdale, 1998). Although it is important to examine both a rural and an urban sample in understanding the contextual influences of intimate violence in rural and urban areas, accessing women in rural areas is difficult. Much of the intimate violence information in the literature is drawn from clinical samples including samples from women’s shelters, marriage counseling programs, batterer treatment
1 Center
on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky. 2 To whom correspondence should be addressed at Center on Drug and Alcohol Research, University of Kentucky, 1151 Red Mile Road, Suite 1-A Lexingtoniky 40514-2645.
83 C 2003 Plenum Publishing Corporation 0885-7482/03/0400-0083/0 °
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84 programs, substance abuse treatment, and health service sites (e.g., emergency rooms). However, these services are very limited in rural areas. An alternative to clinical or single service site samples is a protective order sample. A protective order sample provides an opportunity to identify and access intimate violence victims in both rural and urban areas as well as provide an access point that is relatively similar for comparisons across rural and urban areas. A protective order sample may also be more representative of intimate violence victims because it includes both women who do and do not use specialized treatment and social services. In addition to understanding differences in victimization experiences for rural and urban women, it is important to understand potential differences in the associated sequelae of intimate violence, for example, the associated health, mental health, and substance abuse consequences. In general, the literature indicates that the health and mental health of abused women is substantially poorer than that of women who do not report abuse (Follingstad et al., 1991; Plichta, 1996; Scott Collins et al., 1999; Straus & Gelles, 1990). Specific health and mental health concerns associated with intimate violence victimization include chronic pain, miscarriage, irritable bowel syndrome, psychosomatic and somatic complaints, depression, anxiety, and posttraumatic stress disorder (Coben et al., 1999; Dutton et al., 1997; Eby et al., 1995; Holtzworth-Munroe et al., 1997; McCauley et al., 1995; Plichta, 1996; Plichta & Weisman, 1995). Further, research has shown that effects of intimate violence on health and mental health persist even when overall levels of abuse decline, and after controlling for prior levels of health and mental health (Scott Collins et al., 1999; Sutherland et al., 1998; Wolkenstein & Sterman, 1998). Research also indicates that 25–58% of intimate violence victims use alcohol (Kaufman & Asdigian, 1997; Murdoch et al., 1990; Plichta, 1996). Alcohol abuse and dependence rates have been estimated in some research to be almost five times higher among intimate violence victims than in the general female population (Grant et al., 1994; Hamilton & Collins, 1981; Robins & Regier, 1991). However, very little attention has been given to similarities and differences among rural and urban women who experience intimate violence and the consequences associated with abuse. The purpose of this pilot study is to examine preliminary data about intimate violence experiences and associated social support, health, mental health, and substance use sequelae from rural and urban women with protective orders against an intimate partner. This pilot study had a small sample size; thus, results are preliminary. However, results of the pilot study suggest there are a number of
Logan, Walker, Cole, Ratliff, and Leukefeld findings relative to rural and urban differences in victimization, alcohol use, and health. METHOD Participants Twenty-three women (n = 15 urban women, and n = 8 rural women) with protective orders participated in the pilot study. The majority of the women were White (78%), whereas the other 22% were African American. The participants had an average of two children (range-0–6 children). Participants lived in their county for an average of 21 years. Measures Measures focused on six major domains: (1) demographic; (2) socioeconomic; (3) social support; (4) victimization experiences; (5) substance use; and (6) health and mental health complaints as well as service utilization. Qualitative Measures Open-ended questions were used to examine victimization experiences and coping; whether participants had ever told a health professional about the abuse and the result of that disclosure. If they had not told a health professional about their abuse, they were asked their reason(s) for nondisclosure. Participants were also asked about times they believed they should have seen a doctor or a mental health professional, and/or gone to substance abuse treatment but did not. Quantitative Measures Demographic and socioeconomic factors were adapted from the Health Services Research Questionnaire and the Addiction Severity Index described below. Social support questions were adapted from two sources including the UCLA Loneliness Scale (Russell et al., 1978, 1980) and the Medical Outcomes Study Social Support Scale (MOS; Sherbourne & Stewart, 1991). The revised UCLA Loneliness Scale is a 20-item summated rating scale that measures the subjective experience of loneliness. Loneliness has been associated with positive health practices (Mahon et al., 1998). The scale asks participants to report how often, in the past year, they felt they had someone to turn to when they needed with 1 (never) to 4 (often). The higher score indicates they had someone to turn to when they needed and the lower
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Intimate Violence Victimization and Health score indicates more loneliness. The internal consistency of the UCLA Loneliness Scale was high (α = .94) and has been reported elsewhere along with validity (Russell et al., 1980). MOS contains 19 items related to social support including emotional support (the expression of positive affect, empathetic understanding, and the encouragement of expressions of feelings); informational support (the offering of advice, information, guidance, or feedback); tangible support (the provision of material aid or behavioral assistance); positive social interaction (the availability of other persons to do fun things with you); and affectionate support (involving expressions of love and affection). The scale instructs participants to answer on a scale ranging from 1 (never) to 5 (all the time) how often has each of the following kinds of support been available to you in the past year if you needed it. The scale is then summed and the higher the score, the more often support was available. The internal consistence coefficiencies and validity have been reported elsewhere (Sherbourne & Stewart, 1991) but alphas ranged from .91 to .97. Victimization questions were adapted from the National Crime Victimization Survey and intimate violence literature including the Revised Conflict Tactics Scale and Tolman’s Psychological Maltreatment of Women Inventory (Straus et al., 1996; Tjaden & Thonnes, 1998; Tolman, 1989, 1999). In addition to recent victimization experiences, participants were asked about lifetime victimization experiences including the age of first occurrence, number of different perpetrators (caretakers, boyfriends, strangers, and other relatives), and an estimate of the number of times the abuse occurred. Psychological, physical, and sexual abuses were assessed. Internal consistency and validity have been reported elsewhere but are very good for the Revised CTS (alphas ranged from .79 to .86) and the psychological abuse measure (alphas ranged from .88 to .95; Straus et al., 1996; Tolman, 1989, 1999). Substance use questions were adapted from the Addiction Severity Index (McLellan et al., 1980) for both lifetime and current alcohol and drug use and treatment and mental health treatment. The health questions were adapted from the Health Services Research Questionnaire (HSRQ; Chitwood et al., 1998), which was developed and piloted by the University of Miami Health Services Research Center. The HSRQ will be used to measure self-reported medical status, including health symptoms, use of medical services, medical and psychiatric hospitalizations, emergency room visits, outpatient visits, methods of payment, barriers to accessing medical care, and health care needs and beliefs. Mental health questions were adapted from the Brief Symptom Inventory (BSI: Derogatis, 1993).
85 Procedure After being granted a protective order by the court, women were offered information about the study and were asked if they wished to be contacted to participate. In the urban area, Victims Advocates, who are employed by the prosecuting attorney, introduced women to the study. If interested, victims were asked to indicate the preferred mode of contact (receiving a letter or phone call, or calling the researchers) and to provide contact information. If potential participants were interested in the study, their contact information was faxed to the research team and given to the interviewer. In the rural area, there was no Victims Advocate Program, so the interviewer approached the women in court using the same script as the Victims Advocates used. Because of time and financial constraints, the first women who agreed to talk with a research assistant and who scheduled an appointment were entered into the study; thus, the study sample was a convenience sample. Female interviewers contacted participants 1– 2 weeks after the court granted the protective order. Interviewers described the study and set an appointment for the interview if the participant was interested. The interviews began after participants gave informed consent. Interviews took approximately 2.5 hr and generally took place in a local Public Library. Participants were paid for their time. The rural area had a population of approximately 30,000 with 2% who were African American (U.S. Census Bureau, 1990; Zimmerman & Samson, 1998). Only about half of the residents graduated from high school, the unemployment rate was almost 8%, and 33% of the population lived below the poverty level. In addition, almost one in five households did not have automobiles or telephones. The urban area, on the other hand, had a population near 250,000, were much more educated with 80% who graduated from high school, and had a very low unemployment rate (2.4%), and only 16% of the population lived below poverty level. Only 6% of the urban population did not have telephones and 10% did not have automobiles. The barrier comparisons between rural and urban areas begin to be very clear when examining even crude statistics such as these. Specific results of the study are presented below.
RESULTS Sample Characteristics Both groups of women were in their early to midthirties (urban group mean age 35, median age 33; and
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86 rural group mean age 33, median 33) and had, on average, two children. There were no significant differences between the groups on age and the number of children. Thirty-three percent of the urban women were African American compared to 0% of the rural women. Urban women were significantly more likely to have graduated from high school (87%) than were rural women, 25%, χ 2 (1) = 8.7, p < .01; urban women were significantly more likely to be working full- or part-time (80%) than were rural women, 13%, χ 2 (1) = 9.7, p < .01; and rural women were more likely to have reported income from welfare (38%) than were urban women, 0%, χ 2 (1) = 6.5, p < .05. In addition, 88% of the rural women perceived themselves to be homeless compared with 20% of the urban women, χ 2 (1) = 9.7, p < .01.
Social Support Consistent with the literature on rural areas, the rural women reported significantly less social support, MOS Social Support Scale M = 46, F(1, 19) = 27.6, p < .001, than did urban women, (M = 79) and significantly more feelings of loneliness (UCLA Scale M = 49) than did urban women, M = 60, F(1, 21) = 8.2, p < .01. The Social Support Scale differences were highlighted by the qualitative information. For example, when women were asked what they did to cope with their abuse, 8 out of the 15 urban women (53%) mentioned talking to a friend and only 1 rural woman mentioned talking to a friend (13%). In addition, three of the urban women also mentioned talking to family and only one rural woman did. Rural women were also much more likely to mention spending time with their children, spending time driving alone, containing their feelings, and trying to ignore their abuser. One rural woman stated she would “binge and purge—I would eat and eat and then let it all out. Or I would sit and rock; Bite my nails till they bled; Get on the crisis line; Take a bath, put alcohol, peroxide, and betadine on places [injuries]; Go to the ER; Go sit in a room till whenever; Read magazines, books, Bible; Thought about killing myself with pills but didn’t.” Urban women, however, were much more optimistic about their situation. They mentioned getting out and doing things on their own and for themselves, for example, “I told myself not to let it happen again.” Others reported “Obtaining counseling”; “Reading information on abusive situations and co-dependence”; and “Self talk.” Urban women’s responses suggest a sense of strength and empowerment to change the situation as well as the belief that they had the ability and resources (especially so-
Logan, Walker, Cole, Ratliff, and Leukefeld cial support) to change their lives and move on. They conveyed a belief that they do not have to tolerate the abusive situation. Rural women’s responses, however, conveyed much more a sense of loneliness and despair. When rural women were asked to give advice to other abused women they responded similarly to the urban women, indicating that victims do not deserve their abuse. Nonetheless, they appeared to have had a much harder time coping. This suggests a very critical difference in victimization experiences of rural and urban women.
Victimization Experiences Rural women were, on average, 20 years old when they began seeing the partner against whom they had the protective order, where urban women were 29 years old, F(1, 21) = 7.3, p < .05. Both groups reported their relationships lasting an average of 2 years. Also, contrary to what was expected, both groups of women had used between four and five different kinds of services to cope with the abuse, including shelters, crisis lines, and religious counselors. Overall, 100% of the sample reported emotional and physical abuse by the partner against whom they filed a protective order, 26% reported being stalked by the abusive partner, and 57% reported sexual abuse. In general, both groups of women reported the same frequency of psychological abuse in the preceding year; however, rural women reported significantly more physical abuse, F(1, 21) = 4.7, p < .05, than did urban women. Further, about 38% of rural women reported extreme abuse after filing for the protective order compared to 27% of urban women. Although some of the urban women’s stories were similar to rural women’s stories, there was a much wider range of victimization experiences in the urban women’s responses. For example, half of the rural women reported severe violence leading to EPO including specifically mentioning the word beat or the use of a weapon compared with 27% of the urban women. Also, 38% of the rural women specifically reported their partner was threatening to kill them during the incident compared to 20% of the urban women, and 50% of the rural women reported their partner destroyed property during the incident compared to 20% of the urban women. Further, for 100% of the rural women the incident that led to EPO was not the first incident of abuse they had experienced with that partner. However, for 27% of the urban women the first incident of abuse was the same incident that led them to obtain a protective order. For example, one urban woman reported, “A disagreement arose . . . the disagreement resulted in him
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Intimate Violence Victimization and Health hitting me in the chest. I got dressed and went to the police station to file for the DVO.” Although she reported some psychological abuse, this was her first incident of physical abuse. Another urban woman reported, “We argued . . . . He got mad and threatened to shoot me with a shot gun.” That was the first time in their 7-year relationship that anything like that had occurred. In fact, she reported very infrequent psychological abuse, and no other physical abuse. A third urban woman reported being with her partner for 3 years but had never lived with him. The first incident of abuse occurred after 3 years: “I wanted to break up and he did not. He would not let me leave so I was going to call the police. As we were fighting for the phone, he pushed me, and I fell. I called the police and filed for the DVO.” She reported occasional jealousy and once in a while he made her account for her whereabouts—but no other abuse of any kind. Rural women, on the other hand, indicated such things like “He started beating me, and I ran, he broke the door down with an ax” and “he jumped onto the hood of her car, broke the windshield out, then busted the passenger window out and tried to get in. He was threatening to kill me the entire time” and, “he came into the house, threatened to kill me, kicked the door in and knocked me down the steps.” Interestingly, another qualitative difference among rural and urban women is how soon into the relationship the first incident of abuse occurred. Half of the rural women compared to none of the urban women reported the first incident of abuse occurred within 1 month of the beginning of the relationship with the abusive partner. Eighty-eight percent of the rural women reported the first incident of abuse occurred within 6 months of seeing that person compared to 40% of the urban women. Only one rural woman reported the first incident of abuse occurred after 3 years of involvement with that partner compared with 20% of the urban women. Even more interesting, 63% of the rural women reported the first incident of abuse occurred before they moved in together compared to only 23% of the urban women. For example, one rural woman reported the first incident of abuse occurred after knowing him for 2 days, “He wanted to have sexual intercourse. He pushed me into the shower and punched me in the mouth. I pushed him after he punched me.” Another rural woman experienced abuse within the first 3 weeks of dating. Her partner wanted to go out to a club and drink, but she wanted to stay home. He punched her in the face and set her hair on fire with his cigarette. Another rural woman experienced the first incident of abuse 1 month after dating. She reported, “He was drunk and accused me of flirting. He hit me in the eye, busted my mouth and kicked me.”
87 Lifetime Victimization Experiences Child Abuse As Table I shows, 75% of the rural women reported being sexually abused as a child, compared to 27% of the urban women, F(1, 21) = 5.0, p < .05. Specifically, 50% of the rural women reported being forced to have sexual intercourse, compared to 7% of the urban women, F(1, 21) = 5.8, p < .05. Smaller proportions of both groups indicated they were forced into sexual acts other than sexual intercourse. Women across both groups who reported child sexual abuse indicated they were, on average, 5 years old the first time they were sexually abused. In addition, 75% of the rural women reported physical abuse as a child compared to 27% of the urban women, F(1, 21) = 8.4, p < .05. Twenty-five percent of the rural women reported a parent or caretaker used a knife or a gun to threaten them, whereas none of the urban sample reported being threatened with weapons. In addition, 75% of Table I. Rural and Urban Child Abuse, Health, and Mental Health Indicator Differences Urban Child abuse (%) Child sexual abuse Physically forced you to do sexual things other than sexual intercourse Physically forced you to have sexual intercourse Child physical abuse Beat you up Used a knife or gun to threaten you Child emotional abuse Witness mother being abused Health Overall rating of health past year Number of health complaints Number of days sick past year Number of times in ER past two years Number of times in hospital past two years Number of times in ER lifetime Number of times in hospital lifetime Mental health Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism ∗p
< .05. ∗∗ p < .01.
Rural
27 20
75∗ 50
7
50∗
27 7 0 33 27
75∗ 63∗ 25 75 88∗
2.7 4.5 11.7 1.5 .2
3.9∗ 8.0∗∗ 137.6∗∗ 12.5∗ 3.9∗
6 6
41 16
.48 1.1 .65 .97 .73 .63 .35 5.5 .74
1.3∗ 2.0∗ 2.3∗∗ 1.8 1.8∗∗ 1.3 1.7∗∗ 10.6∗ 1.7∗
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88 the rural and 33% of the urban sample reported being emotionally abused as a child. Further, more rural women reported witnessing their mother being abused (88%), compared to urban women, 27%, χ 2 (1) = 7.7, p < .01. Examination of the qualitative data illustrates important differences in past and current abuse experiences and suggests the importance of considering a lifetime developmental perspective when examining victimization. The timing of victimization experiences in an individual’s life may have important implications for future victimization and coping capacity. Given that 75% of the rural sample experienced childhood abuse, examinations of the impact childhood victimization may have on current abuse and coping capacity is critical. For example, one rural woman reported that at the age of 5, a 26-year-old male sexually abused her frequently. In addition, she indicated severe childhood psychological and physical abuse, including humiliation, yelling, and name calling on a nearly daily basis, being beaten, threatened with weapons, and attacked with weapons on a weekly basis beginning at age 5. She also witnessed her mother being physically abused numerous times for most of her life by two different male partners. She reported seeing her mother abused when she was as young as 3 years old. Another woman also reported child psychological abuse, including verbal abuse and humiliation as well as being physically abused on a weekly basis from age 12 to 14. She reported being beaten about once a month during those 2 years. She did not report sexual abuse; however, she did report frequently witnessing abuse against her mother beginning when she was 7 years old. One consequence of early victimization experiences may be susceptibility to other victimization experiences as young women begin to date. In fact, rural women were slightly more likely to report multiple relationships in which physical abuse occurred compared to urban women.
Other Victimization Experiences Thirty-six percent of the sample reported emotional abuse by more than one intimate partner (33% of urban and 38% of rural women), and 26% reported physical abuse by more than one partner (13% of urban and 38% of rural women). Further, 27% of the urban women and 0% of the rural women reported experiencing stranger victimization in their lifetime. One of the more alarming issues that several women (both urban and rural) had in common was that they became involved with a new partner fairly quickly after the breakup with the partner against whom they had filed a protective order. Combined with the fact that a number of women had a short pe-
Logan, Walker, Cole, Ratliff, and Leukefeld riod of acquaintance with the abusive partner before moving in with him, the potential for future victimization exists. One woman even reported that one of the ways she coped with the abuse was “to get a new man.” Given that a number of woman’s previous relationships were abusive and developed quickly, involvement with new partners within a few weeks of filing for the protective order is concerning.
Health Sequelae Rural women rated their overall health as significantly worse than did urban women as Table I shows, F(1, 21) = 4.5, p < .05. Consistent with their overall health rating, rural women reported more health complaints, F(1, 21) = 9, p < .01; more days sick in the past year, F(1, 21) = 8.1, p < .05; more times in the emergency room, F(1, 21) = 4.9, p < .05, and hospital, F(1, 21) = 4.8, p < .05, in the previous 2 years than urban women. However, there were no significant differences across groups for lifetime emergency room or hospital visits (see Table I). Rural and urban differences in health consequences were highlighted by the qualitative questions. When the women were asked whether they believed the abuse had affected their health, 47% of the urban women and 88% of the rural women said they were stressed or more depressed because of the abuse; 13% of the urban women, compared with 63% (Z = 2.4., p < .05) of the rural women directly mentioned health consequences related to the abuse. Some of the health problems rural women attributed to or associated with the abuse were scars, stroke, worsened eyesight to the degree of legal blindness, upset stomach, as well as mental health complaints, which were common to both groups and included stress, tension, depression, anxiety, and lower self-esteem. Over one quarter (27%) of the urban women and 50% of the rural women reported ever having told a health or mental health professional about their abuse. Only 27% of the urban sample and 38% of the rural sample reported a health or mental health professional ever asked them about abuse. When asked what could have helped them to discuss the abuse with a health professional, several women responded that nothing would have helped, or they did not feel the need to discuss it with anyone. Conversely, several women suggested that a number of tactics could have facilitated discussion of the abuse with health professionals, including health professionals easing into the topic, simply asking about the abuse, and persisting in their inquiries. One woman also stated that fear of the health professional reporting the abuse prevented her from discussing it.
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Intimate Violence Victimization and Health Mental Health Sequelae The self-reported mental health of rural women was also much worse than the mental health of urban women. For example, as Table I shows, rural women scored significantly higher on the BSI somatization, F(1, 21) = 4.6, p < .05; obsessive compulsive, F(1, 21) = 4.8, p < .05; interpersonal sensitivity, F(1, 21) = 14.8, p < .01; anxiety, F(1, 21) = 8.9, p < .01; phobic anxiety, F(1, 21) = 19, p < .01; paranoid ideation, F(1, 21) = 7.6, p < .05; and psychoticism, F(1, 21) = 4.8, p < .05, subscales. Participants were also asked to list three things they did that they were proud of in the past week. Urban women mentioned work most often (e.g., “satisfied customers,” “worked by myself on a busy night,” “accomplished a lot at my job”), personal independence (e.g., “started looking for a place of my own,” “took my life back,” and “moved”), and focusing on their children (e.g., “planned a party for my daughter,” “got my daughter a new pediatrician,” “spent time with my kids,” and “bought the children a pool”). Rural women, in contrast, mentioned following through with the protective order most often as something they were proud of (urban women did not mention it at all), and mentioned second most often their children. Rural women were not at all likely to mention work or personal independence. When the women were asked to list three things they liked most about themselves, 50% of the rural women could not think of anything or stated explicitly that they did not like themselves compared to 0% of the urban women. In addition, urban women mentioned a wider range of things they liked about themselves (six different categories—looks, personality, children, skills, no substance use, and religion), compared to rural women (three different categories—personality, children, and no substance use). Urban women were most likely to mention children (e.g., “I am a good mother,” “My kids,” “I like how I raise my children”), next most likely to mention looks (e.g., “My eyes,” “My hair,” “I am attractive”), personality (e.g., “I am a good person,” “I have a big heart”), and skills (e.g., “I am athletic,” “I am good at my job”). Rural women were most likely to mention personality— especially in contrast with how they used to be (e.g., “I say more about what I’m feeling,” “I am more outgoing than I used to be,” “I try to get along with everybody”), and then children (e.g., “I have 2 good children that love me,” “I take care of my kids”). Substance Use About 43% of the sample used alcohol in the 2 years preceding the interview, 60% of the urban and 13% of
89 the rural women, χ 2 (1) = 4.8, p < .05. In addition, of those who reported any alcohol use in the past 2 years, 67% reported drinking almost every month in the 24-month period. Further, 63% of rural and 47% of urban women used cigarettes. Forty-eight percent of the urban women and 13% of the rural women reported using other illegal drugs, which was not significantly different. Several women reported that they smoked cigarettes or used alcohol or drugs to cope with the abuse. In fact, one urban woman reported smoking marijuana as one of her two abuse coping strategies. She had been involved with her abusive partner, whom she reported frequently abused her physically, psychologically, and sexually for over 10 years. Her periods of marijuana use corresponded with periods in which her partner isolated her from friends and family, monitored her time, stopped her from leaving or going where she wanted, and physically abused her. Another young woman reported she had been involved with two abusive partners during the 2-year period preceding her interview. Her alcohol use escalated from no use or one to two times a month during months in which no abuse was reported to drinking almost every day and sometimes to extreme intoxication during the months when abuse was occurring. These examples suggest that the cooccurrence of intimate violence and substance use is very likely for some women, which may have additional health consequences.
DISCUSSION Some of the findings in this pilot study were similar to what was expected on the basis of the research literature comparing rural and urban areas. For example, rural women were significantly less likely to have had a job and had lower overall incomes. However, some of the differences between the rural and urban women were dramatic. For example, almost all of the urban women graduated from high school, compared to only one quarter of the rural women. In addition, almost 90% of the rural women reported they were homeless, compared with 20% of the urban women. Being less educated and having no financial independence may have significant implications for leaving the abusive partner (Kalmuss & Straus, 1982; Strube & Barbour, 1983). If women feel they have no options for escape, they are potentially more vulnerable to future abuse. In addition to limited economic options, rural women reported very few social support options. For example, rural women reported having no one in their life to turn to except their children. This is interesting given that half
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90 of the rural women actually reported talking to a health or mental health professional, compared to less than one third of the urban women. Also, rural and urban women both reported utilizing on average four or five different services to cope with the abuse. It may be important in future research to examine satisfaction differences with the different services. Further, the stereotype that rural families are very close and provide social support for each other was not the case for the rural women in this sample. Rural and urban differences in social support were especially clear when coping was examined. Rural women’s responses were more introverted—“driving alone,” “holding everything in,” and “trying to ignore the abuser”—when compared to urban women’s responses. It was also clear that rural women had a more difficult time coping with the abuse, which was evident in comments on their struggle to escape the abuse. For example, when rural women were asked to talk about things they had done in the past week of which they were proud, many of the answers were focused solely on the abuse or the abuser. In contrast, none of the urban women mentioned these issues. When rural women were asked what they liked best about themselves, half of the rural women could not think of anything or stated explicitly that they did not like anything about themselves in contrast to urban women. Urban women were much more positive about their situation overall. They talked about getting out and doing things on their own and for themselves. Their answers also reflected the fact they had positive views of themselves. Another difference between rural and urban women was their victimization experiences. Rural women encountered abuse significantly earlier in their relationship than urban women. In fact, half of the rural women reported the first incident of abuse occurred within the 1st month of dating, whereas none of the urban women reported the first incident of abuse occurred that soon in their relationship. In addition, over 60% of the rural women, compared to only 23% of the urban women, reported the first incident of abuse occurred before moving in with their partner. Rural women were as likely as urban women to report psychological and sexual abuse; however, rural women reported more frequent and severe physical abuse. This finding may be a reflection of the sampling method. In other words, it is possible that women in rural areas do not seek or are not granted a protective order until they have experienced much more severe abuse than have urban women. This is supported by the differences in the range of experiences reported by urban women compared to rural women. In other words, there were several urban women who never lived with the partner against whom they had a protective order, and there were several ur-
Logan, Walker, Cole, Ratliff, and Leukefeld ban women who reported only one incident of abuse in their history with that partner. Rural women reported neither of these experiences. Future research should examine whether differences between rural and urban victims are attributable to a lower threshold for obtaining protective orders in urban areas or if they reflect actual differences in victimization characteristics. There were also dramatic differences in child abuse experiences of the participants of this study. Rural women reported significantly higher rates of childhood physical and sexual abuse than did urban women. For example, 63% of the rural women reported a parent or caretaker using a knife or a gun to threaten them as a child, compared with 7% of urban women. Even more concerning are the high rates of sexual abuse reported by rural women with 50% reported having been forced to have sexual intercourse at an average age of 5 years old, compared to 7% of the urban women. Further, almost 90% of the rural women reported witnessing abuse of their mother, and less than one third of the urban sample reported witnessing abuse of their mother. These victimization experiences have implications for health and mental health practitioners, as well as policymakers, in rural areas. It is likely that victims in rural areas may require far more extensive protective and treatment services than may their urban counterparts. The victimization issues in rural areas must be considered within the context of multiple and early victimization experiences. The cumulative effects of abuse also have implications for the victim’s health, mental health, substance abuse patterns, and risk for future victimization. In this study and contrary to the literature, substance use was different among rural and urban intimate violence victims (Booth et al., 1999; Conger, 1997). Urban women were much more likely to use alcohol than rural women. About 60% of the urban women reported alcohol use, which is similar to past year alcohol use rates reported for women 12 and older in the general population (Substance Abuse and Mental Health Services Administration [SAMHSA], 1997). However, both groups were as likely to use cigarettes or illegal drugs. Cigarette use (52%) was much higher than the rates of women smokers in Kentucky, which is 29% (O’Leary Morgan & Morgan, 1999). In addition, illegal drug use reported among the sample for both groups, especially urban women at 48% was much higher than the 9% rate of past year illegal drug use reported for women aged 12 and older in the 1995 general population (SAMHSA, 1997). Finally, reported health and mental health problems were much more severe among rural women than among urban women. For example, rural women reported more mental health symptoms and more health complaints. The
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Intimate Violence Victimization and Health literature indicates that, in general, the health needs in rural areas are much greater than that in urban areas. Numerous years of abuse, not only from caretakers but also from multiple male partners, exacerbate the health and mental health consequences for rural women. It is critical that health and mental health treatment providers as well as intimate violence service providers begin to address both of these issues together. Intimate violence treatment providers may want to encourage women to establish a relationship with a health care provider and encourage them to take positive steps toward better health. Health and mental health care providers in rural areas need to assess and provide referrals for victimization. In summary, it is clear that rural and urban intimate violence victims have different experiences and different needs within the context of health and victimization. However, accessing rural women is difficult. A protective order sample provides an opportunity to identify and access intimate violence victims in both rural and urban areas as well as provides an access point that should be similar for comparisons. This pilot study examined the feasibility of that sampling procedure for rural and urban women as well as preliminary findings. Although this was a small study, there were some important differences between women in rural and urban areas that are highlighted by some of the themes identified in this study. Despite the high estimates of intimate violence and the strong connection between alcohol use, intimate violence, and health, there are few comprehensive studies in the literature. In addition to understanding substance use and health among intimate violence victims in rural and urban areas, it is important to understand the developmental aspects of victimization and to understand the long-term consequences. Finally, it is important to recognize that the different experiences and needs of rural victims suggest that different services are critical in rural areas. In addition to needing adequate shelter services, rural areas critically need outreach workers who can travel to help women and their children, transportation to health care and other service providers for victims, batterers treatment programs, and interventions for children of these families.
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