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Intimate Partner Violence in Older Women

Correspondence: Address correspondence to Amy E. Bonomi, Department of Human Development and Family Science, The Ohio State University, 1787 Neil Avenue, 135 Campbell Hall, Columbus, OH 43214. E-mail: bonomi.1{at}osu.edu

	Abstract

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Purpose: We describe the prevalence, types, duration, frequency, and severity of intimate partner violence ("partner violence") in older women. Design and Methods: We randomly sampled a total of 370 English-speaking women (65 years of age and older) from a health care system to participate in a cross-sectional telephone interview. Using 5 questions from the Behavioral Risk Factor Surveillance System (BRFSS) and 10 questions from the Women's Experience with Battering (WEB) Scale, we assessed a woman's exposure to partner violence. We estimated lifetime partner violence prevalence using the BRFSS questions (physical, forced intercourse, forced sexual contact, verbal threats, and controlling behavior), and we estimated past-5-year and past-year prevalence using the BRFSS and the WEB Scale. We estimated violence frequency, duration, and severity using the BRFSS questions. Results: According to the BRFSS, lifetime partner violence prevalence was 26.5%; 18.4% of women experienced physical or sexual violence and 21.9% experienced nonphysical violence (threats or controlling behavior). According to the BRFSS and WEB Scale, past-5-year violence prevalence was 3.5%, and past-year violence prevalence was 2.2%. Many abused women reported more than 20 episodes of violence in their lifetime (from 18.1% for physical violence to 61.2% for controlling behavior). The median duration ranged from 3 years (forced sexual contact) to 10 years (controlling behavior). The proportion of abused women rating their abuse as severe ranged from 39.1% (forced sex or sexual contact) to 70.7% (threats). Implications: The high lifetime partner violence occurrence, frequency, duration, and severity, coupled with results from prior studies indicating long-term adverse health effects of partner violence, suggest a need for increased efforts to address partner violence in older women.

Key Words: Domestic violence • Intimate partner violence • Prevalence • Assessment • Women

Published prevalence studies have operationalized the definition of partner violence in numerous ways, contributing to a wide variation in the prevalence estimates of partner violence in older women. Recent studies have estimated a lifetime prevalence of physical assault or psychological abuse (e.g., verbal threats) ranging from 18.1% in women aged 60 or older who were randomly sampled in the state of Kentucky (Fritsch et al., 2005) to 32% in women aged 50–79 who participated in the Women's Health Initiative observational study component (Mouton et al., 1999). Past-year physical partner violence rates in women aged 65 years or older ranged from 0.1% to 0.2% (Rennison & Welchans, 2002; Weinbaum et al., 2001). In studies that used broader definitions of partner violence, rates of past-year physical and verbal partner violence were 3.5% and 21.7%, respectively, in women aged 70–79 (Mouton, 2003).

Some studies that focused on abuse against older adults did not clearly distinguish abuse perpetrated by spouses from abuse perpetrated by significant others (e.g., relatives or other caregivers; see Kurrle, Sadler, & Cameron, 1992; Lachs, Berkman, Fulmer, & Horwitz, 1994; Mouton et al., 2004; Ogg & Bennett, 1992; Podneiks, 1992). In a large random survey of community-dwelling elderly individuals in the Boston metropolitan area, Pillemer and Finkelhor (1988) found that spouses were common perpetrators of abuse against older adults; in 22% of abuse cases, husbands perpetrated the abuse, and in 36% of cases, wives perpetrated abuse against husbands.

In spite of promising research describing the prevalence of partner violence in older women, we did not find population-based studies that delineated the prevalence, types, duration, frequency, and severity of partner violence experienced by women in the age group of 65 years and older. In the present investigation, we addressed this information gap. Using 5 questions on physical, sexual, and nonphysical (psychological) violence from the Behavioral Risk Factor Surveillance System (BRFSS) questionnaire (Bensley, Van Eenwyk, & Wynkoop Simmons, 2003; Harwell & Spence, 2000; Vest, Catlin, Chen, & Brownson, 2002) and 10 questions from the Women's Experience with Battering (WEB) Scale (Coker, Pope, Smith, Sanderson, & Hussey, 2001; Coker, Smith, Bethea, King, & McKeown, 2000; Smith, Earp, & DeVellis, 1995), we interviewed 370 women aged 65 years and older by telephone to ascertain partner violence prevalence, types, duration, frequency, and severity. In this article we build on prior analyses of partner violence occurrence and related health effects in 3,429 women aged 18–64 years (Bonomi, Thompson, Anderson, Reid, et al., 2006; Thompson et al., 2006).

	Methods

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Setting and Study Sample
We conducted the study at Group Health Cooperative, a health care system that provides health services to more than 500,000 individuals in western Washington State and northern Idaho. Study procedures were approved by Group Health's Institutional Review Board. We randomly sampled 635 English-speaking women aged 65 and older whom we had located through Group Health's automated health plan membership files. We mailed a letter describing the study, and study staff contacted women by telephone to obtain consent to participate in a one-time-only telephone interview. Of 635 women selected, we excluded a total of 55 because of sampling error (5), death (3), severe illness (29), or language or hearing problems (18). Of the 580 remaining women, 178 actively refused participation (30.6%). There were 14 passive refusals (women located but not interviewed), and 14 women who could not be located after 20 phone attempts. The response rate was 64.5% (374/580). We excluded an additional 4 women because they reported never having had an intimate partner in their adult lifetime. The final analytic sample comprised 370 women.

Because of the relatively low response rate (64.5%), we requested additional approval from Group Health's Human Subjects Committee to access additional automated health plan and clinical data to assess whether there was bias in our results based on the likelihood of response or nonresponse. We created propensity scores using logistic regression to estimate the probability that a subject responded to the survey (Austin, Grootendorst, & Anderson, 2006; Huang, Frangakis, Dominici, Diette, & Wu, 2005; Schootman et al., 2006). Our analysis revealed that respondents were slightly younger (75.2 years vs 76.8 years) but enrolled in Group Health for the same length of time (9.2 years vs 9.1 years) as nonrespondents. Using adjusted clinical group scores, we found that nonrespondents were more likely to be both nonusers of health care services and very high users of health care services (i.e., at the tail or extreme ends of the health care distribution) in the year prior to administration of the survey. However, overall health status was roughly equal among respondents and nonrespondents (mean adjusted clinical group scores, 3.4 vs 3.3, respectively). This analysis revealed that non-response bias in our sample was negligible and survey responses were representative of women aged 65 and older in the Group Health delivery system.

Data Collection
The data collected by telephone interview included women's sociodemographic characteristics; women's exposure to partner violence in the past year, the past 5 years, and lifetime; and violence duration, frequency, and severity.

Demographic Characteristics, Social Involvement, and General Health
Women reported information about their age and other socioeconomic indicators, such as education and income. Women also estimated the level of their involvement in voluntary groups or social organizations, from 1 = very active to 3 = not active (see Donald & Ware, 1984; Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997; Veenstra, 2000), and their general health, from 1 = excellent health to 5 = very poor health, by using a single question from the Short Form-36 Health Survey (Diehr & Patrick, 2003; Diehr, Patrick, McDonell, & Fihn, 2003; Ware, Kosinski, & Dewey, 2000).

Partner Violence Definitions and Exposure Classification
Using the Uniform Partner Violence Definitions of the CDC, we defined partner violence as actual or threatened physical and sexual violence used by an intimate partner to cause death, disability, injury, or harm to victims, and psychological abuse used to cause trauma in victims (Saltzman et al., 1999). Intimate partners included spouses, nonmarital partners, former marital partners, and formal nonmarital partners. The CDC has recommended that psychological abuse be considered a type of violence only when there has also been prior actual or threatened physical or sexual violence. Violence prevention experts have included psychological abuse in their operationalization of partner violence. Strauss, a leading violence researcher, includes a sizable psychological violence assessment section in the widely used Conflict Tactics Scale, an instrument used to assess exposure to partner violence (Strauss, Hamby, Boney-McCoy, & Sugarman, 1996).

In our study, victims included women age 65 and older who were the targets of violence and abuse according to the following definitions: (a) physical violence (being hit, slapped, shoved, choked, kicked, shaken, or otherwise physically hurt by an intimate partner); (b) sexual violence (being forced to have oral, vaginal or anal intercourse or forced to have sexual contact that did not result in intercourse); and (c) psychological (nonphysical) abuse (being afraid as a result of an abusive partner's anger or threats, or being repeatedly put down verbally, called names, or having one's behavior controlled).

We operationalized these dimensions of violence and abuse using five questions from the CDC's BRFSS survey (Bensley et al., 2003; Harwell & Spence, 2000; Vest et al., 2002), which asked women if they had ever been: hit, slapped, shoved, choked, kicked, shaken, or otherwise physically hurt by an intimate partner (one question); forced to have oral, vaginal or anal intercourse (one question); forced to have sexual contact that did not result in intercourse (one question); feared for their safety because of their partner's anger or threats (one question); or were repeatedly put down, called names, or had their behavior controlled by an intimate partner (one question; see Appendix A). If women reported that any of these abuse types had occurred in their lifetime, they were then asked whether the violence occurred in the past 5 years and in the past year. We considered women who responded affirmatively ("yes") to any of the specific BRFSS abuse types (sexual, physical, threats, or controlling behavior) to be exposed to that abuse type. We considered women to be exposed to sexual abuse if they reported either forced sexual intercourse or forced sexual contact that did not result in intercourse according to the BRFSS questions.

Because violence researchers have strongly suggested the use of very broad definitions of partner violence to assess abuse exposure (Bonomi, Allen, & Holt, 2006; Coker et al., 2001), we included a second definition of partner violence that reflected women's underlying fear and loss of power and control in their lives associated with exposure to abuse. To assess this dimension of abuse, we used the WEB Scale (Coker et al., 2000, 2001; Smith et al., 1995; see Appendix A). This scale was developed to measure women's fear, loss of control, and disempowerment as a result of abuse exposure. The WEB Scale is viewed as a less intrusive approach to measure partner violence exposure, because it identifies common feelings associated with being a victim of partner violence (e.g., fear and disempowerment) without requiring women to label themselves as victims (or their partners as perpetrators committing abusive acts toward them; see Bonomi, Thompson, Anderson, Rivara, et al., 2006).

For the WEB Scale administration, study staff members first asked women to name their three most recent adult intimate partners. Women answered the 10 WEB questions for each partner. The WEB Scale response options ranged from 1 (strongly disagree) to 6 (strongly agree). Scores of 20 or higher (range = 10–60) indicated occurrence of abuse (Coker et al., 2001). The reliability of the 10 WEB questions (measured by an alpha coefficient) was high across the three partners, with a range from 0.88 for Partner 1 to 0.97 for Partner 3. At the completion of each WEB survey, staff members asked women with WEB scores of 20 or higher to estimate the start and end dates of their abuse to the nearest year. We used these estimates to designate past-year and past-5-year abuse exposure according to the WEB Scale. Because the WEB questions were asked for three partners only, we could not estimate lifetime partner violence prevalence using the WEB Scale.

Analytic Methods
We estimated partner violence frequency in the past year and past 5 years using the WEB and BRFSS questions. We estimated lifetime prevalence of partner violence using the BRFSS questions. We estimated the proportion of women who reported more than one abuse type according to the BRFSS questions. Frequencies and measures of central tendency were used to describe partner violence frequency, duration, and severity for each abuse type (physical, sexual, threats, and controlling behavior) in the BRFSS.

	Results

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Characteristics of Women
Approximately 50% of women were 65–74 years of age and 50% were older than 75 years of age (Table 1). Consistent with Group Health enrollees, most women reported White race (91.4%) and residence in urban areas (84.5%). Of the women, 84% reported an annual income of less than $50,000, and 67.5% completed some college. Fifty-five percent of women reported current involvement in an intimate relationship, and 53.3% were currently married. Finally, 56.6% of women reported fair or very active involvement in organized social groups and 43.9% reported very good or excellent health.

	Prevalence of Partner Violence

TOP Abstract Methods Results Prevalence of Partner Violence Discussion References

	Discussion

TOP Abstract Methods Results Prevalence of Partner Violence Discussion References

The lifetime prevalence of partner violence in older women (26.5%) was consistent with estimates of physical assault and rape in younger women (25%; see Tjaden & Thoennes, 2000) and estimates of physical and sexual abuse and lack of safety with an intimate partner in women aged 59 and older (22%; see Koziol-McClain et al., 2004). However, this lifetime prevalence is lower than one prior lifetime partner violence estimate of 35.5% in women aged 50–56 (Jones et al., 1999), and it is higher than one prior estimate of 18.1% in women randomly sampled from Kentucky (Fritsch et al., 2005). As with any retrospective health risk survey, it is conceivable that older women may not recall or may underestimate abuse they experienced in the distant past. It is also possible that older women may not recall the exact dates of their abuse occurrence, and the frequency and severity of their abuse. For example, there may be a tendency over time to downplay the severity of violence that occurred 20 years ago. However, older women's ratings of the severity of their abuse experiences (Table 5) are similar to the severity ratings reported by 3,429 women aged 18–64 in our parent study (Thompson et al., 2006). In the present investigation, we could not assess the role of cognitive degeneration on older women's responses. However, we did not interview women if they were unable to understand the consent procedures.

The past-year partner violence prevalence estimate of 2.2% in the present study was higher than previous estimates of 0.2% in women asked about past-year physical violence (Weinbaum et al., 2001) and 0.8% in women asked about physical, sexual, and psychological partner violence (Fritsch et al., 2005). This discrepancy may be explained by the inclusion of a broader definition of partner violence in the present investigation, which included dimensions of nonphysical (psychological) abuse captured by the BRFSS questions (threats and put downs, name calling, and chronic controlling behavior) and women's perceived loss of power and control in abusive relationships characterized by the WEB Scale. Mouton (2003) reported past-year physical and verbal partner abuse rates of 3.5% and 21.7%, respectively, in women aged 70–79 years. Studies in younger women indicate that a substantial proportion of women report nonphysical (psychological) partner violence only as captured by the BRFSS (Bonomi, Thompson, Anderson, Rivara, et al., 2006; Thompson et al., 2006), and a significant proportion of women identified as abused by the WEB questions that were not identified by physical partner violence assessment tools (Coker et al., 2001).

We found that the WEB and BRFSS questions identified some women as abused who would have been missed had only one of the instruments been used. The WEB Scale tended to identify more women as abused in the past year and past 5 years that would have otherwise been missed by the BRFSS. This finding corroborates suggestions from prior studies that more than one measurement tool may be useful for screening women for partner violence (Bonomi, Allen, et al., 2006; Bonomi, Thompson, Anderson, Rivara, et al., 2006; Coker et al., 2001).

Our investigation incorporated design features to minimize bias and answer important questions on the presence, types, duration, frequency, and severity of partner violence in older women. Rather than sampling women presenting for clinical services, we randomly selected women from the enrollment files of a large health care organization. Most of the study sample comprised White and urban older women, all of whom had health care insurance. Because the sample did not include older women outside of the health care system, caution is offered against generalizing the results to older women in the United States. Furthermore, our study focused exclusively on intimate partners as perpetrators, whereas many other studies of this age group include a wider range of perpetrators of "elder abuse" (Kurrle et al., 1992; Lachs et al., 1994; Mouton et al., 2004; Ogg & Bennett, 1992; Podneiks, 1992). We therefore caution readers against comparing prevalence estimates from our study to estimates from studies focused on abuse in older women that include a wider range of perpetrator types.

Our prior work confirmed that the response rate of 64.5% from the present investigation is within the response rate range reported in other telephone-based surveys that assess abuse exposure (Thompson et al., 2006). However, as noted in the Methods section, we used propensity scores to determine whether there was bias in our results based on the likelihood of response or nonresponse (Austin et al., 2006; Huang et al., 2005; Schootman et al., 2006). Our results indicated that respondents were slightly younger but enrolled within Group Health for same length of time as nonrespondents. Nonrespondents and respondents also used health services (as measured by adjusted clinical group software) at comparable rates. Thus, non-response bias was negligible and survey responses were representative of women aged 65 and older in the Group Health delivery system.

The present investigation reported detailed information on partner violence prevalence, types, duration, frequency, and severity in older women, addressing an important gap in the research literature on the natural history of abuse in older women. Asking women to respond to the WEB Scale for their three most recent partners captured detailed information about partner violence that women experienced recently in their life. When prevalence data from the present investigation are considered in conjunction with the adverse health effects of partner violence (even long after abuse ceases; see Bonomi, Thompson, Anderson, Reid, et al., 2006; Brokaw et al., 2002; Campbell et al., 2002), a picture of the potential health burden for older women emerges. Over the past several years, a solid consensus has emerged on partner violence program and research development in health care settings. A main focus is the development of large prospective studies to delineate the long-term course of abuse on women's lives and mulitfactorial randomized controlled trials of "best practice" interventions (Cohn, Salmon, & Stobo, 2002; Nelson, Nygren, McInerney, & Klein, 2004; Wathen & MacMillan, 2003). As a starting point, clinicians might routinely assess partner violence using questions from the WEB Scale and the BRFSS, or other measurement tools (Bonomi, Allen, et al., 2006), and ensure a comprehensive and compassionate response to women who report abuse in their relationships (Zink et al., 2004).

Of note, only 3% of women in the present investigation indicated they had been asked by a health care provider about physical or sexual violence by an intimate partner since age 18. Furthermore, 84% of women indicated they would have agreed to do the interview had they known in advance what it would be like for them; 11% were neutral; and 5% of women disagreed. Prior investigations noted that older women may be reluctant to disclose partner violence to their health care provider, and, when women did disclose, some felt discounted and unsupported (Zink et al., 2004). Improvements in screening and response to women's revelation of abuse are warranted.

Results from this investigation could be used as a starting place for partner violence prevention planning in older women. Clinicians with access to automated health information records could use these automated tools with question branching logic to address partner violence and other sensitive health issues (Thompson & Krugman, 2001). In conjunction with routinely asking about partner violence, "best practice" protocols must be in place to guide clinicians when women indicate abuse has occurred. McCaw and colleagues (McCaw, Berman, Syme, & Hunkeler, 2001; McCaw et al., 2002) demonstrated a prototype linking partner violence questioning to clinical services. Future studies that include larger numbers of women should also undertake analyses to examine risk factors for recent (past-year) partner violence in older women, in order to proactively target older women at risk for partner violence.

	Footnotes

 
This research was supported by the Agency for Health Research and Quality. We thank Diana Rowland for assisting with the manuscript preparation and the interviewers from Group Health's Center for Health Studies for telephoning and interviewing the women who participated in the study.

¹ Human Development and Family Science, The Ohio State University, Columbus.

² Center for Health Studies, Group Health Cooperative, Seattle.

³ Harborview Injury Prevention & Research Center and the University of Washington Department of Epidemiology, Seattle.

Decision Editor: Linda S. Noelker, PhD

Received for publication April 12, 2006. Accepted for publication September 6, 2006.

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