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P O P U L AT I O N S AT R I S K

Utilization of Services by Abused, Low-income African-American Women

Anuradha Paranjape, MD MPH,1 Sheryl Heron, MD MPH,2 Nadine J. Kaslow PhD3 1Division of General Medicine, Emory University School of Medicine, Atlanta, GA, USA; 2Department of Emergency Medicine, Emory

University School of Medicine Atlanta, GA, USA; 3Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine

Atlanta, GA, USA.

BACKGROUND: Little is known about health care and service utiliza-

tion patterns among low-income African-American women, particularly

those who report intimate partner violence (IPV).

OBJECTIVES: (1) Identify utilization patterns among low-income Afri-

can-American women. (2) Demonstrate utilization differences by IPV

status.

PARTICIPANTS: One hundred and fifty-three African-American wom-

en from medical care clinics at a large inner-city public hospital.

DESIGN: Case–control study. Predictor variable IPV assessed by the

Index of Spouse Abuse. Outcome variables, health care, and service

utilization, determined using the Adult Service Utilization Form.

RESULTS: Of the 153 participants, 68 reported high IPV levels. The

mean age was 32 years, majority were poor and unemployed, and

15.7% were homeless. The overall utilization rates were low. When

controlled for homelessness and relationship status, high IPV levels

were associated with greater psychiatric outpatient utilization. We

found differences in the use of other medical or community services

by IPV group.

CONCLUSIONS: Women reporting high IPV levels are more likely to

receive mental health services than women reporting low IPV levels, but

may not have access to other needed services. Primary care providers

should assess the mental health, legal, and social service needs of

abused women, which will facilitate receipt of services.

KEY WORDS: intimate partner violence; vulnerable populations; health-

care utilization.

DOI: 10.1111/j.1525-1497.2005.00314.x

J GEN INTERN MED 2006; 21:189–192.

I ntimate partner violence (IPV), a common problem in wom-en seeking medical care,1,2 is associated with health prob- lems, poor health status, and greater health care utilization.3–5

Patients from ethnic minority groups still experience barriers

to health care and community services, despite strides made in

understanding health care access in the United States.6 Re-

search reveals that being a poor, uninsured woman is a triple

threat to receiving adequate health care.7 Currently, little is

known about health care and community service utilization

rates among low-income African-American women, including

those who are abused. Available health care utilization studies

have either no or small proportions of low-income African-

American women; health care utilization rates in these studies

range from 36% to 46%, with 95% of abused women reporting

45 visits/year.5,8 Studies on the utilization of directed IPV

services that include African-American women focus primarily

on access to shelters or the criminal justice system and sug-

gest that barriers such as lack of insurance, finances or trans-

portation, distrust in the system can limit access to health care

and community services.9–12

To our knowledge, no study has investigated health care

and service utilization in low-income, African-American wom-

en or has compared health care and service utilization between

abused and nonabused, low-income African-American wom-

en. This paper reports the results of a small study examining

overall health care and service utilization rates and differences

in these rates between low-income African-American women

with and without reported high IPV levels. We hypothesized

that overall utilization rates by these women would be low, and

utilization rates would be higher in those reporting higher IPV

levels.

METHODS

Participants

The study sample consists of 153 African-American women,

ages 18–65, recruited for the project Supporting African-Amer-

ican Families, Empowering Their Youth (SAFETY) from 2 emer-

gency care centers and 2 urgent care clinics of a large, inner-

city, public hospital. Eligibility criteria were: (1) being a care-

giver for at least one, 8-12-year-old child, and (2) reporting ei-

ther no lifetime IPV or IPV in the past year, as determined by

the Universal Violence Prevention Screening Protocol.13 Exclu-

sion criteria included: (1) medical instability; (2) cognitive im-

pairment; or (3) psychotic symptoms.

Measurements

Trained interviewers collected the data in a single in-person

structured interview, and documented responses on the study

questionnaire. All participants provided written informed con-

sent; they received $50 plus transportation costs upon com-

pleting the interview. The protocol was approved by the

Institutional Review Board. Demographic items included in

this analysis were age; relationship status; length of relation-

ship; history of homelessness and unemployment; and house-

hold income. Intimate partner violence was measured using

the Index of Spouse Abuse (ISA), a 30-item valid and reliable

instrument that assesses the presence and severity of physi-

cal, sexual, and emotional IPV that has 2 valid subscales:

Manuscript received April 1, 2005

Initial editorial decision August 23, 2005

Final acceptance September 21, 2005

The authors have no conflicts of interest to report.

Address correspondence and requests for reprints to Dr. Paranjape: 49

Jesse Hill Jr Drive, SE, Atlanta, GA 30303 (e-mail: [email protected]).

189

JGIM

ISA-Physical (ISA-P) and ISA-Nonphysical (ISA-NP).14,15 A

score of 410 on the ISA-P and 425 on the ISA-NP is highly correlated with IPV.14,15 Participants scoring above either of

the 2 cutpoints were classified as ‘‘High IPV,’’ and participants

scoring below both cutpoints were classified as ‘‘Low IPV’’.

Health care and service utilization were measured using the

19-items Adult Service Utilization Form (ASUF) developed for

this study and piloted before use. Participants report on the

frequency of utilization of the following services in the 3

months preceding the interview: medical and psychiatric

emergency services; medical and psychiatric hospitalization;

psychiatric day treatment, counseling, or therapy; medical

clinic; women’s or homeless shelters; and other community

support services (Alcoholics Anonymous, crisis hotlines) and

legal services. Each item has 4 response options—never, once,

twice, and 3 or more times. For the purposes of analysis, these

19 items were grouped into 7 service categories (Appendix A);

due to low overall utilization rates, we categorized utilization

into ‘‘Never use’’ and ‘‘Ever use,’’ except for medical emergency

services, where we classified ‘‘Ever use’’ as 2 or more times, to

account for recruitment site.

Statistical Analyses

After calculating means (SD) for participant age, a t-test was

used to examine differences in age by IPV status. The w2 test, respectively, was used for univariate and bivariate analyses

(by IPV group) for the rest of the demographic variables. Fre-

quencies were calculated for each utilization category, and uti-

lization rates by IPV group were compared with the w2 test. To assess the independent effect of IPV on utilization, individual

multivariate logistic regression models were constructed for

each utilization category, controlling for any significant differ-

ences between IPV groups. Odds ratios (ORs) were calculated

with 95% confidence interval (CI), and a P value of .05 was

used for all tests of significance.

RESULTS

The mean participant age was 32.4 years (SD 6.8 years). The

majority lived with a partner, had been with their partner for

41 year, and were unemployed; 16% reported being homeless. No differences in demographic variables between women who

did and did not report high IPV levels in the past year, except

for homelessness and relationship status, which were added to

all multivariate regression models (Table 1).

Overall Health Care and Service Utilization Rates

Overall rates of health care and service utilization were low,

compared with national averages.16 Participants utilized non-

emergency psychiatry and medical care more often than all

other services, with one-third of the women reporting receiving

both nonemergency psychiatry and medical care. Of note, only

4.4% of the participants reported shelter use, 10.3% reported

using a support group, and 8.1% reported seeking legal as-

sistance in the past 3 months (Table 2).

Health Care and Service Utilization by IPV Group

When homelessness and relationship status were controlled

for in the regression analysis, significant differences by IPV

group were found in only 1 of the 7 utilization categories.

Women reporting higher levels of IPV were 3 times more like-

ly to also report using nonemergency psychiatry services (OR

3.16, 95% CI 1.49 to 6.7). There were no differences by IPV

status in the use of emergency psychiatry or medical care,

Table 1. Sociodemographic Characteristics of the 153 Study Participants

High IPV (N =68) Low IPV (N =85) N =153 P Value

Mean age in (SD) 32.3 (6.5) 32.2 (7) 32.3 (6.8) .93 Relationship status, n (%) .03

Single, unmarried 25 (37.3) 19 (22.6) 44 (29.1) Partner 6 (9) 22 (26.2) 28 (18.5)

Live-in partner 9 (13.4) 16 (19) 25 (16.6) Married 11 (16.4) 17 (20.2) 28 (18.5) Separated 7 (10.4) 4 (4.8) 11 (7.3) Divorced 7 (10.4) 5 (5.9) 12 (7.9) Widowed 0 (0) 1 (1.2) 1 (0.7) Other 2 (3) 0 (0) 2 (1.3)

Length of current relationship, n (%) .24 Less than 1 wk 0 1 0 (0) 1 wk to 1 mo 0 0 0 (0) 1–6 mo 5 2 5 (5.1) 6 mo- 1 y 1 6 7 (7.2) 1–6 y 21 29 43 (44.3) 6–10 y 11 20 28 (28.9) More than 10 y 3 13 14 (14.4)

Is homeless, n (%) 15 (22.1) 6 (7.2) 21 (15.7) .008 Is employed, n (%) 20 (29.8) 32 (38.5) 46 (34.6) .26 Monthly household income, n (%) .13

$0–249 10 (15.1) 10 (11.9) 15 (11.4) $250–499 14 (21.2) 12 (14.3) 23 (17.6) $500–999 18 (30.5) 17 (20.2) 34 (25.9) $1000–1999 13 (19.7) 22 (26.2) 32 (24.4) Greater than $2000 7 (10.6) 22 (26.2) 26 (19.8)

IVP, intimate partner violence.

190 JGIMParanjape et al., Health care and Service Utilization

emergency medical services, nonemergency medical care,

shelter, and support group use by IPV. While use of legal serv-

ices differed by IPV group in bivariate analyses, IPV did not

independently predict use of legal services (Table 2).

DISCUSSION

In this small study, the overall rates of health care and service

utilization are disturbingly low in economically disadvantaged

African-American women, even among those who report higher

levels of IPV. While those women reporting higher levels of IPV

also utilize outpatient mental health services more often, no

other differences emerged in health care or service utilization

rates by IPV status.

Research on health care and service utilization to date has

not focused specifically on utilization by abused low-income

African-American women. That these women use mental

health services more often than women who have no or low

IPV is consistent with prior research. 5,17 Unlike data found in

the literature on health care utilization by abused women, no

other utilization differences emerged in our sample.5 The dis-

parity between the existing literature and the current study

may be because of similar levels of co-morbidity. The findings

may also be explained by access barriers, including financial,

transportation, and distrust in system, which may have pre-

vented appropriate utilization. 9

The results also indicate that abused low-income African-

American women neither seek nor seem to receive community

services that they need. Community services for IPV measured

included shelter use, support group use, and legal assistance.

Overall rates of use were very low (range 1% to 9%); these rates

are consistent with data from prior studies in this field.18,19

The findings regarding use of legal services are not consistent

with prior research. Low legal utilization rates (compared with

national survey data)20 and access barriers such as financial

and transportation constraints, lack of public education, neg-

ative attitudes toward abused women, distrust of child welfare

system, and lack of efficacy of protective orders may explain

the results obtained.9,11

This study has a number of limitations. First, the ASUF

was developed for this study, as there were no valid and reli-

able measures suitable for this population. Measuring utiliza-

tion by self-report may have resulted in recall bias. Second,

survivor perceptions of service need may have affected utiliza-

tion rates. Third, this study is specific to low-income African-

American women, who are caregivers for children and have

access to a hospital, and cannot be generalized to African-

American women from higher socioeconomic strata, or other

low-income groups. Neither can we draw conclusions regard-

ing mechanisms that link IPV to utilization. Other limitations

include the modest sample size, and potential for underreport-

ing IPV as data were collected by in-person interviews. Finally,

our comparison group may have had sufficient women report-

ing low-level IPV to influence utilization rates.

Our study highlights that low-income African-American

women, including those in abusive relationships, have very

low rates of health care and service utilization. More work is

needed to understand the factors that deter appropriate utili-

zation in this population, which will provide the groundwork

for a future targeted intervention to improve health care and

service access in an at-risk population. Meanwhile, generalists

providing care for low-income African-American women

should continue to advocate on behalf of their patients to im-

prove access to the services they need and reduce another

source of health care disparities.

Dr. Paranjape is supported by the Emory Mentored Clinical Re- search Scholars Program (K12 NIH/NCRR RR 017643). The SAFE- TY study is funded by a grant from the Centers for Disease Control and Prevention (grant number #R49/CCR419767-0).

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Table 2. Effect of IPV on Health Care and Service Utilization

Service Utilized High IPV (N =68), n(%)

Low IPV (N =85), n(%)

Crude Odds of Utilization (95% CI)

Adjusted Odds of Utilization (95% CI)w

Emergency psychiatry care 5 (7.35) 5 (5.9) 1.25 (0.35 to 4.32) 1.04 (0.25 to 4.27) Nonemergency psychiatric care 31 (45.6) 18 (21.4) 3.07 (1.51 to 6.22)� 3.16 (1.49 to 6.7)�

Emergency medical care 6 (8.8) 5 (5.9) 1.54 (0.45 to 5.31) 1.51 (0.42 to 5.46) Nonemergency medical care 24 (32.9) 27 (32.9) 1.11 (0.56 to 2.18) 1.18 (0.58 to 2.43) Shelter use 1 (1.49) 5 (6.02) 0.24 (0.03 to 2.07) 0.21 (0.02 to 2.06) Support group use 8 (11.9) 7 (8.33) 1.49 (0.51 to 4.35) 1.13 (0.36 to 3.5) Legal assistance 9 (13.43) 2 (2.38) 6.36 (1.32 to 30.53)� 4.78 (0.95 to 24.02)

�P valueo.01. wModel adjusted for homelessness and relationship status.

IVP, intimate partner violence.

JGIM 191Paranjape et al., Health care and Service Utilization

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Supplementary Material

The following supplementary material is available for this

article online:

Appendix A. Adult Service Utilization Form.

192 JGIMParanjape et al., Health care and Service Utilization