Nursing 254: Professional Nursing 2
Article Appraisal
Level of Performance
Meets Expectations
(5)
Nearly Meets
Expectations
(4)
Does Not Meet
Expectations
(3)
Unacceptable
(0)
Introduction
Methods
Results
Discussion
Overall Impression
Total (out of 25 points): _____
Meets Expectations: The writers answer all questions within one coherent paragraph. Answers show both
understanding of the article, but also critique how the article could improve, and highlight strengths and/or
weaknesses in the section. Writing is clear and concise.
Nearly Meets Expectations: The writers answer all questions within one coherent paragraph. Answers show
understanding of the article, but do not adequately critique how the article could improve and/or highlight strengths
and/or weaknesses in the section. Writing style could be improved through enhanced organization and/or clarity.
Does Not Meet Expectations: The writers do not answer all questions within the paragraph. The writing does not
demonstrate understanding of the article, and/or major concepts are missing. Writing is unclear, too long,
unorganized, and/or difficult to understand.
Unacceptable: The section is largely incomplete, incomprehensible, and/or not relevant to the article critique.
Name/Date
Article Critique Form
Article Reference:
Respond to the questions below for each section of the research report. Write your well-crafted answers
in paragraph form with at least one paragraph per section.
Introduction
• Significance – Does the topic appear important to society? Is it personally relevant?
• Language – Is the presentation clear and objective? Is the language consistent with the approach used by the
researchers?
• Literature Review – Is there balance in the point of view found in the citations? Is there an appropriate time
frame, with some older and some more current references? Are primary sources emphasized?
• Research Questions – Are the questions/objectives clearly identified? Do the authors clearly identify the gap
in the literature that the study is filling?
• If the study if qualitative, are the questions/objectives supported by the literature review and/or by the data
that emerged during the study?
• If the study is qualitative, are the questions/objectives open-ended to facilitate theme exploration?
• If the study if quantitative, are the questions/objectives limited to those with direct foundation in the
literature review?
• Do you have any suggestions on how this might be improved?
Method
Participants
• What – Can you identify the target population?
• Who – Is sufficient detail provided about the participants to judge if they are consistent with the target?
• Where – Did the researchers identify the setting, and is that setting appropriate?
• When – Did the researchers identify the time period during which the study was conducted?
• How – Did the researchers specify how participants were selected, and did the selection procedure appear to
be appropriate?
• Why – Was there explanation for why these participants were chosen, and is there reason to suggest a bias in
selection that would influence the findings?
• Do you have any suggestions on how this might be improved?
Procedures
• Completeness – Was sufficient detail provided about the procedures so that the study can be replicated?
• Appropriateness – Do the procedures appear relevant for the research questions/objectives identified for the
study?
• Do you have any suggestions on how this might be improved?
Results
• Clarity – Were the findings clearly reported and understandable?
• Did the authors results answer their initial research question(s)?
• If applicable, are tables and figures clearly labeled, and do they add significantly to the article?
• Do you have any suggestions on how this might be improved?
Discussion
• Style – Is the discussion clearly written?
• Relevance – Is the discussion focused on how the findings are related to the objectives of the study?
• Conclusions – Do the conclusions follow logically from the results?
•
•
Completeness – Are implications, limitations, and recommendations for further research included?
Do you have any suggestions on how this might be improved?
Overall Impression
• What is your overall impression of the article (Very strong, strong, lacking in specific areas, etc)?
• What level of evidence is this article?
• What are the major strengths and weaknesses of the article?
• Would you use this research to guide practice decisions? Why or why not?
Nursing Research January/February 2011 Vol 60, No 1, 58–65
Depression Among Women
Experiencing Intimate Partner Violence
in a Chinese Community
Janet Yuen-Ha Wong
4
Agnes Tiwari
4
Daniel Yee-Tak Fong
b Background: Depression is one of the significant mental
health impacts of intimate partner violence. However, there
is a lack of empirical evidence on the factors associated
with depression among abused Chinese women.
b Objective: The purpose of this study was to identify the factors
associated with a higher level of depression among abused
Chinese women.
b Methods: This was a cross-sectional study with participation
of 200 abused Chinese women in a local community center in Hong Kong. The measurement tools used are the
Chinese Abuse Assessment Screen, the Chinese Beck
Depression Inventory Version II, the Revised Conflict Tactics Scale, the Interpersonal Support Evaluation List 12,
and the demographic data. Structured multiphase regression analysis was used for data analysis.
b Results: Factors significantly associated with a higher level of
depression in Chinese abused women were low educational
level (estimate = j2.49, p = .038), immigration (estimate =
4.99, p = .025), financial support from friends and relatives
(estimate = 4.72, p = .006), and chronic psychological abuse
(estimate = 0.09, p G .001). A protective factor against depression is the perception of social support (estimate =
j1.11, p G .001).
b Discussion: An overwhelming number of abused Chinese
women have moderate or severe levels of depression. There
is a need for more awareness of the detrimental mental
health impact of abuse on women, screening for depression
when women are found to be abused, and provision of social
support at an earlier stage to minimize depression.
b Key Words: Chinese & depression & intimate partner violence
I
ntimate partner violence (IPV) is the use of physical,
psychological, or sexual abuse with coercive control by a
current or former partner who is or was in an intimate
relationship (Ramsay, Rivas, & Feder, 2005). Approximately
95% to 99% of such violence is committed by men against
women (Humphreys & Campbell, 2004). The lifetime prevalence of IPV against women ranges from 10% to 69% as
reported in 48 population-based surveys worldwide (Krug,
Dalhberg, Mercy, Zwi, & Rafael, 2002).
58
4
Janice Humphreys
4
Linda Bullock
Depression is one of the most common mental health
problems in women. An estimated 73 million adult women
suffer a depressive episode each year (World Health Organization, 2009). Depression has been associated with cancer
(Bodurka-Bevers et al., 2000), immigration (Shin, Han, &
Kim, 2007), and pregnancy (Bennett, Einarson, Taddio,
Koren, & Elinarson, 2004). As a stressful life event, IPV is
also known to be associated strongly with depression
(Campbell, 2002). In a meta-analysis of 18 studies, Golding
(1999) found that the weighted mean prevalence of depression among abused women was 47.6% compared with
lifetime rates of 18.6% in the general population. Also, as
shown in a 2009 study, the relative risk of depression in
abused women is three times higher than that for nonabused
women (Bonomi et al., 2009).
Factors associated with depression in adult abused women
include education (Gonzalez-Guarda, Peragallo, Vasquez,
Urrutia, & Mitrani, 2009), employment and poverty (Deyessa
et al., 2009), frequency and severity of physical (Campbell,
Kub, Belknap, & Templin, 1997) or psychological abuse
(Coker et al., 2002), history of child abuse (Koopman et al.,
2007), coping styles (Haden & Scarpa, 2008), lack of social
support (Mburia-Mwalili, Clements-Nolle, Lee, Shadley, &
Yang, 2010), and substance abuse (Horrigan, Schroeder, &
Schaffer, 2000). However, evidence on the relative influence
of the different types of IPV as risk factors for depression is
inconclusive; some researchers have suggested that physical
abuse is a stronger predictor of depression (Campbell et al.,
1997), whereas others suggest that psychological abuse is a
stronger predictor (Follingstad, 2007). Although IPV has been
shown to be a risk factor contributing to depression in abused
Chinese women (Tang, 1997) for the types of abuse, whether
psychological abuse or physical abuse is the stronger predictor
of depression has not been investigated.
Janet Yuen-Ha Wong, MNurs, RN, is Doctoral Candidate and
Clinical Instructor; Agnes Tiwari, PhD, RN, is Associate Professor; and Daniel Yee-Tak Fong, PhD, is Assistant Professor,
School of Nursing, The University of Hong Kong.
Janice Humphreys, PhD, NP, CS, RN, FAAN, is Associate Professor, Department of Family Health Care Nursing, School of
Nursing, University of California, San Francisco.
Linda Bullock, PhD, RN, FAAN, is Professor, School of Nursing,
University of Virginia.
DOI: 10.1097/NNR.0b013e3182002a7c
Nursing Research January/February 2011 Vol 60, No 1
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Intimate Partner Violence and Depression 59
Nursing Research January/February 2011 Vol 60, No 1
A psychodynamic theory named self-in-relation developed
at Wellesley College states that women’s identity and sense
of self are driven by interpersonal relationships with others
(Gilligan, 1977), suggesting that devaluing relationship qualities can cause women to fail to recognize their own value,
which may lead to depression (Kaplan, 1986). This theory
explains why psychological abuse is a stronger predictor of
depression than physical abuse. However, more study is
needed to support this link. Such information is relevant in
the Chinese population because evidence has been found of
repeated psychological abuse, even when there is no evidence
of physical or sexual abuse, among Chinese women in Hong
Kong (Tiwari et al., 2008). Moreover, although some sociodemographic factors (such as financial hardship, a low educational level, in-law conflict) have been found to be risk
factors for IPV among Chinese women (Chan, Brownridge,
Tiwari, Fong, & Leung, 2008; Tiwari et al., 2008), whether
such factors contribute to depression in the abused women
has not been explored.
Furthermore, although the buffering effect of social support on the deleterious mental health outcomes for abused
women has been reported in Western studies (Glass, Perrin,
Campbell, & Soeken, 2007), the same effect cannot be assumed in the Chinese cultural context. It has been suggested
that, for fear of losing face, Chinese people may be more
reluctant than Westerners to seek help from outsiders (Yick,
Shibusawa, & Agbayani-Siewert, 2003). Thus, there is a
need to investigate the influence of the availability of social
support on the mental health of abused Chinese women.
To study the causes and effects of IPV meaningfully, it
is important to recognize IPV in cultural context, in which
healthcare professionals should strive for cultural competence
and interact sensitively and skillfully when caring for abused
women (Campbell & Campbell, 1996). Given the lack of empirical evidence on the factors associated with depression
among abused Chinese women, the aim of this study is to
identify the factors contributing to the high levels of depression in Chinese women experiencing partner abuse. It is
hypothesized that (a) psychological abuse or aggression is the
stronger predictor of depression in IPV among Chinese
women, (b) sociodemographic factors contribute to depression
in IPV, and (c) social support is not a protective factor for
abused women in Chinese cultural context. The findings of
this study will provide important information that can inform
healthcare professionals about the appropriate measures to be
taken to reduce the risk of depression among abused Chinese
women. Such information may assist the abused women to
understand their mental health in spite of their experience of
abuse.
Methods
Baseline data were used from a clinical trial that was
conducted in Hong Kong from February 2007 through
December 2008.
Setting
The study took place in a community center located in a
district of Hong Kong. Of the 18 districts in Hong Kong, the
target district is ranked third highest in terms of the number
of least educated residents, third lowest household income,
and fourth highest in the prevalence of IPV (Census and
Statistics Department, 2008).
Sample
Study participants met the following inclusion criteria: women
who (a) had a history of abuse as measured by the Chinese
Abuse Assessment Screen (C-AAS; Tiwari et al., 2007), (b)
were 18 years or older, and (c) were able to communicate
in Cantonese or Mandarin. A total of 1,753 women were
screened. Two women refused to participate in the study,
giving a response rate of 99.9%. The 200 eligible women
recruited lived or worked in the catchment area of the community center. Their mean age was 38 years (SD = 7.19), and
most of them (72.5%) had at least Grade 7 education. The
majority (89.5%) were married or cohabiting, and more than
60% were immigrants from Mainland China.
Study Procedure
The women were given an explanation of the purpose of
the study and assured that participation was voluntary. The
study was approved by the institutional review board of the
University of Hong Kong, Hospital Authority Hong Kong
West Cluster. A signed consent form was obtained from the
women who agreed to participate. At the start of the study,
data for each woman were collected in a face-to-face interview using structured questionnaires. A team of social
workers working in the community center conducted these
interviews after receiving intensive training on the conduct of
research with abused Chinese women. They provided emotional support in a nonjudgmental manner during the interviews. If necessary, they asked the women if they needed
referral to community resources or a call to the police.
Measures
History of Abuse The C-AAS was used to screen potential
subjects for IPV. The C-AAS addresses physical, psychological, and sexual abuse. It has been validated and has demonstrated satisfactory accuracy in the screening of a Chinese
population (Tiwari et al., 2007). It is a five-item questionnaire requiring yes or no answers. Respondents were considered abused if they reported that they had been hurt
physically or emotionally by someone or forced to have sexual activities within the past year, and the perpetrator was
their intimate partner.
Depression Depressive symptoms were assessed using the
Chinese version of the Beck Depression Inventory Version II
(BDI-II; Chinese Behavioral Sciences Society, 2000), which
was developed from the BDI-II (Beck, Steer, & Brown,
1996). The Chinese version has been validated and has demonstrated good reliability and validity, with an internal
consistency of .94 in study among Chinese community adolescents (Byrne, Stewart, & Lee, 2004). It is a 21-item questionnaire with scoring from 0 (symptom not present) to 3
(symptom strongly present), giving a total sum score ranging
from 0 to 63. The higher the score, the more depressive symptoms were reported by the women.
Chronicity of Abuse The Revised Conflict Tactics Scales
(CTS2; Straus, Hamby, Boney-McCoy, & Sugarman,
1996) was used because it indicates the type of IPV and
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
60 Intimate Partner Violence and Depression
provides information about the chronicity of the behavior
used by the perpetrator during partner conflict over the past
year. Of the 27 items in the CTS2, 8 measure psychological
aggression, 12 measure physical assault, and 7 measure sexual coercion. There is a 7-point scale for each of the items,
indicating how often the behavior occurred (0 = never, 1 =
once, 2 = twice, 3 = 3Y5 times, 4 = 6Y10 times, 5 = 11Y20
times, and 6 = 20 or more times). The total chronicity scoring of psychological aggression ranges from 0 to 200, physical assault ranges from 0 to 300, and sexual coercion ranges
from 0 to 175. The higher the score, the greater the chronicity. This indicates how frequently the perpetrator has
resorted to these acts in respect of each woman.
Social Support The Interpersonal Support Evaluation List
12 (ISEL-12; Cohen, Mermelstein, Kamarck, & Hoberman,
1985), which has good psychometric properties and good
internal consistency (Cronbach’s ” = .88), was used to
measure the perceived social support of abused women. The
12-item questionnaire comprises three subscales, appraisal,
belonging, and tangible support, each of which has four
items. The scoring from 0 (definitely false) to 3 (definitely
true) gives a total sum score ranging from 0 to 36. The higher
the score, the more the women perceive that they received
social support.
Demographics The demographic and the socioeconomic
characteristics of the participants were collected. For the demographic data, age, immigration, years of living in Hong
Kong, educational level, marital status, number of children,
and presence of chronic illness were included. For the socioeconomic data, information on the women’s employment
status, the receipt of social security, and the self-perceived
financial difficulties was collected.
Data Analysis
Descriptive statistics were used to characterize the sample.
To examine the factors associated with depressive symptoms of abused women, a structured multiphase regression
was used to account for a hypothesized sequential causal
relationship between the independent variables in line with
the previous literature (Campbell et al., 1997; Chan et al.,
2008; Follingstad, 2007). First, the independent variables
were grouped into four clusters according to their causal
relationship. Demographic variables, including age, immigration, years of living in Hong Kong, educational level,
marital status, number of children, and presence of chronic
illness, were grouped into Cluster 1. The socioeconomic variables, including employment status and self-perceived financial difficulties, were grouped into Cluster 2. The social support
variables, including whether the women were receiving social security, whether the women received financial support
from others, and the ISEL score, were grouped into Cluster
3. The chronicity of the abuse, including psychological aggression, physical assault, and sexual coercion, was considered as Cluster 4. It was hypothesized that the variables in
Cluster 1 can affect the variables in Clusters 2, 3, and 4, but
not vice versa. Similarly, Cluster 2 variables were assumed
to affect Cluster 3 variables and so forth.
Next, the structured multiphase regression analysis as
used by Cohen, Rubin, Freedman, and Mozes (1999) was
Nursing Research January/February 2011 Vol 60, No 1
performed in four phases. Phase 1 analysis was a forward
stepwise linear regression on all Cluster 1 variables. In Phase
2, a forward stepwise linear regression was done on all
Cluster 2 variables after forcing variables that were significant in the Phase 1 analysis. In Phase 3, using the same
forward stepwise approach, a linear regression on Cluster 3
variables was done after forcing variables that were significant in both the Phase 1 and the Phase 2 analyses. In Phase 4,
the criteria for entry of the variables were the same for all
variables in Cluster 4 and those that were found significant in
Phases 1, 2, and 3.
The structured multiphase regression, rather than a free
multiple regression, was used in this article to avoid simultaneous consideration of variables from the clusters, which may
have resulted in confounded inference among the variables.
Therefore, the variables, arranged in four phases, allowed a
sequential causal relationship among the variables in the
clusters. The automatic procedure of statistical model selection in structured multiphase regression was made from a
number of potential explanatory variables with the consideration of the causal relationships among the variables and
over time.
All data analyses were performed using the Statistical
Package for the Social Sciences for Windows (Version 18;
SPSS Inc., Chicago, IL). A 5% level of significance was
used in all significance tests. The adequacy of the regression
model was checked by examining the residuals using P-P
plots and scatter plots.
Results
Sample Characteristics
The prevalence of IPV was 11.4% (95% confidence interval [CI] = 10.0%Y13.0%). According to the C-AAS,
76% (n = 152) of participants suffered from psychological
abuse only, whereas 22.5% (n = 45) suffered both physical
or sexual abuse and psychological abuse (Table 1).
Depression
A majority of participants (74.5%, n = 149) reported severe levels of depressive symptoms as measured by the
Chinese version of the BDI-II with scores higher than 29
(Table 2).
Factors Associated With Depression
Using the structured multiphase regression analysis, only four
factors were associated with a higher level of depression in
connection with IPV as illustrated in the next paragraph
(Table 3).
In Phase 1 of the analysis, among the seven demographic variables entered in the stepwise linear regression
model, educational level (b = j2.49, 95% CI = j4.83 to
j0.14, p = .038) and immigration (b = 4.99, 95% CI =
0.63Y9.35, p = .025) were found to be significant in contributing to a higher level of depression among abused
Chinese women. In other words, the lower the level of
education the women had received, the higher the level of
the depression they suffered. Also, women born in places
outside Hong Kong were found to become more depressed
when they experienced IPV. Although immigration was one
of the risk factors, when the number of years they had lived in
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Intimate Partner Violence and Depression 61
Nursing Research January/February 2011 Vol 60, No 1
q
TABLE 1. Sample Characteristics
Variables
Women’s age (years; mean T SD)
Husband’s age (years; mean T SD)
Education level
eGrade 6
Grades 7Y13
Tertiary or above
Place of birth
Hong Kong
Mainland China
Indonesia
Years of living in Hong Kong
G2 years
3Y6 years
97 years (including permanent
residents of Hong Kong)
Refused to answer
Marital status
Single
Married or cohabited
Separated or divorced
No. of children
0
1
2
3 or above
Women have chronic illness
Women employed
Self-perceived financial difficulties
Receiving social security
Received financial support from
friends or relatives
C-BDI-II score (mean T SD)
ISEL score (mean T SD)
Psychological aggression (mean T SD)
Physical assault (mean T SD)
Sexual coercion (mean T SD)
n
%
38.07 T 7.21
44.52 T 9.48
j
j
55
136
9
27.5%
68%
4.5%
76
121
3
38%
60.5%
1.5%
20
39
138
10%
19.5%
69%
3
1.5%
8
179
13
4%
89.5%
6.5%
15
82
70
33
26
62
145
42
123
7.5%
41%
35%
16.5%
13%
31%
72.5%
21%
61.5%
T
T
T
T
T
Y
j
j
j
j
37.83
6.85
68.62
2.76
1.10
15.01
7.99
43.72
8.11
7.66
sociated significantly with a higher level of depression resulting from IPV in Phase 2 of the analyses.
However, in Phase 3, when the variable that the women
received financial support from other sources such as friends
and relatives was entered into the model, a significant and
strong association with a higher level of depression was found
(b = 4.72, 95% CI = 1.39Y8.06, p = .006). In addition, the
ISEL score showed that this variable had a significant
protective effect on the level of depression of abused women
(b = j1.11, 95% CI = j1.32 to j0.90, p e .001). In other
words, the higher the ISEL score, the lower the level of
depression.
The history of IPV as measured by the CTS2 showed that
psychological aggression was the only factor associated with a
higher level of depression in abused women that was significant
when it was entered into the regression model in Phase 4 (b =
0.09, 95% CI = 0.05Y0.13, p e .001). The more frequent the
psychological aggression, the higher the level of depression
manifested by the abused women. Neither physical assault
nor sexual coercion was statistically significant when entered
into the model at this phase.
Discussion
In this study, significant factors found to be associated with
higher levels of depression in Chinese abused women were
their educational level, immigration, whether they received
financial support from friends or relatives, perceived social
support, and chronicity of psychological aggression experienced. In view of the hypotheses identified, it was shown
that (a) psychological aggression is the predictor of higher
level of depression in IPV and (b) sociodemographic factors
such as educational level and immigration contribute to
depression in IPV; however, (c) social support is still the
protecting factor in abused Chinese women.
Educational Attainment
Abused Chinese women with a lower educational level were
found to be more depressed than those with a higher
educational level. This finding is consistent with both local
and Western studies (Carlson, McNutt, Choi, & Rose, 2002;
Chan et al., 2008). It is possible that with lower education
the women might be less able to obtain employment or
acquire sufficient economic means to free themselves from
poverty or the abusive relationship because of their economic dependency on their abusers. This situation may lead
q
Note. C-BDI-II = Chinese version of the Beck Depression Inventory
Version II; ISEL = Interpersonal Support Evaluation List.
TABLE 2. Level of Depression in Chinese
Abused Women (n = 200)
Level of Depression
Hong Kong was entered into the model, it was not associated
significantly with a higher level of depression resulting from
IPV. Other variables, including marital status, number of
children, and women and husbands having chronic illness,
were not associated significantly with a higher level of depression attributed to IPV in this model.
When socioeconomic variables were entered, such as the
women’s working status, perceptions of financial difficulties,
and receipt of social security, none of them proved to be as-
Minimal level
Mild level
Moderate level
Severe level
C-BDI-II score
0Y13
14Y19
20Y28
29Y63
n (%)
18
19
14
149
(9%)
(9.5%)
(7%)
(74.5%)
Note. C-BDI-II = Chinese version of the Beck Depression Inventory
Version II.
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
62 Intimate Partner Violence and Depression
Nursing Research January/February 2011 Vol 60, No 1
to feelings of hopelessness and entrapcations for social services and policy
ment that can result in depression. Howmakers. It appears that the challenges
ever, the women’s working status and
and hardships associated with immitheir perceptions of financial hardship did
gration do not fade away with the pasnot prove to be associated significantly
sage of time among the women in this
Abused Chinese women
with a higher level of depression when
study, although they share the same lanwith a lower educational
they were entered into the model of this
guage and culture as that of the natives
study. It is possible that the correlation of
of Hong Kong. Therefore, it should not
level were found to be
a lower educational level with a higher
be assumed that the vulnerability of
more depressed than
level of depression might not be due only
abused immigrant women would imto the lack of economic resources.
prove with time and that efforts to supthose with a higher
Another possibility is that depression
port these women should continue for
educational level.
in abused women with a lower educational
as long as necessary.
level could be caused by a lower sense of
self-efficacy because of a lower level of
Social Support
personal resources. The lower the level of
Perception of social support, as measqqq
self-efficacy, the more likely it is that
ured by the ISEL, was found to be the
individuals will experience depression,
significant protective factor associated
according to the social cognitive theory (Bandura, 1986).
with a lower level of depression in Chinese abused women in
Such women in abusive relationships may perceive themthis study. Abused Chinese women who had higher percepselves as being incapable of controlling the abusive relationtions of social support were found to be less depressed than
ship and even their lives, and this would contribute to higher
those who reported lower perceptions of social support. This
levels of depression. Because there appear to be conflicting
is consistent with the findings on the protective effect of social
suggestions about how lower educational attainment may
support on abused women’s mental health as reported in
contribute to higher levels of depression, further studies on
Western studies (Carlson et al., 2002; Glass et al., 2007).
this aspect are recommended.
The same studies have highlighted the role of social support
in helping women to cope with living in an abusive
Immigration
relationship.
Abused women who had immigrated from Mainland China
Unexpectedly, those abused women who received finanwere found to be more depressed than abused women who
cial support from relatives or friends, as shown in the ISEL,
were born and bred in Hong Kong. Although the immigrawere found to be more depressed than those who did not.
tion effect on abused women’s mental health has been
Therefore, the impact of depression in abused women did not
documented (Midlarsky, Venkataramani-Kothari, & Plante,
appear to be buffered by tangible financial assistance from
2006; Yoshihama, 2002), the negative effect of immigration
others. It is possible that, in Chinese culture, if a person is in
on depression for women in this study appears to be susdebt to relatives and friends, he or she may be more depressed
tained even after they have obtained permanent residence
unless he or she is in a position to reciprocate (Matsudaira,
status in Hong Kong (i.e., after living in Hong Kong for
2003). Thus, abused Chinese women might perceive that
7 years or longer). This is a new finding that has implihaving to accept financial support from others in an outside
q
TABLE 3. Structured Multiphase Regression of Depression in Chinese Abused Women
Variable
Phase 1 (n = 200, R 2 = 5.9%, adjusted R 2 = 4.9%)
Education level
Immigration
Phase 2
Nil
Phase 3 (n = 198, R 2 = 43.5%, adjusted R 2 = 42.4%)
ISEL score
Received financial support from relatives and friends
Phase 4 (n = 196, R 2 = 49.2%, adjusted R 2 = 47.9%)
Psychological aggression
Estimate
95% CI
p
j2.49
4.99
(j4.83 to j0.14)
(0.63 to 9.35)
.038*
.025*
j1.11
4.72
(j1.32 to j0.90)
(1.39 to 8.06)
G.001***
.006**
(0.05 to 0.13)
G.001***
0.09
Note. ISEL = Interpersonal Support Evaluation List; CI = confidence interval.
*p G .05.
**p G .01.
***p G .001.
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nursing Research January/February 2011 Vol 60, No 1
group would mean that they would lose face, a consideration that has high value among the Chinese. This might
lead to a lowering of their self-esteem and result in a higher
level of depression. This finding shows that Chinese women
value their personal efforts to handle their financial problems even when they are in a difficult situation and suffering
hardship.
Chronicity of Different Types of IPV
It was found that the more frequent the psychological abuse,
the higher the level of depression experienced by the abused
women. This significant result was not found in physical
abuse. Evan (1995) revealed that physical abuse might not
be the most significant factor to cause mental health impact
in most abusive relationships. Rather, abused women suffered from the strategy of intimidation, isolation, and control extending to all areas of their lives.
The results also support the theory of relation-in-self because the women’s sense of self-worthiness relies heavily on
their building relationships. Psychologically abused women
lose the affective connection with their intimate partners,
which may lead to a sense of loss which contributes to depression. It was found that psychologically abused Chinese
women were often ridiculed by the perpetrators of the abuse
with respect to their traits and personal characters. The resultant shameful emotions could have led to depression
(Tiwari et al., 2009).
Moreover, the study finding suggests that there is a
doseYresponse relationship between psychological abuse
and depression severity, consistent with previous studies
conducted on non-Chinese abused women (Follingstad,
2007) and on Chinese pregnant women (Tiwari et al.,
2008). The apparent doseYresponse relationship between
psychological abuse and the severity of depression has not
been explored in the Chinese population before this study.
These findings underscore the importance of recognizing
the impact of psychological abuse on the mental health of
Chinese women.
Severe Depression Level in Chinese Abused Women
In previous studies conducted in abused women, the prevalence
rate of depression was 60.6% in shelter samples, 39.2% in
psychiatric patients, 41.3% in emergency room samples, and
44% in the community or in women seeking primary care
(Golding, 1999). In this study on Chinese community-dwelling
women, it was surprising that 74.5% of the abused women
reported severe levels of depressive symptoms (BDI-II scores
range = 29Y63). Because most of the women in this study
suffered from psychological abuse, the possibility was not
ruled out that fear, anxiety, and depression were instilled by
the combination of repeated but minor acts of psychological
abuse such as intimidation and control, as suggested in previous studies (Evan, 1995). In addition, depression in abused
women has been shown to have sustainable long-term negative mental health effects (Zlotnick, Johnson, & Kohn, 2006).
This finding underscores the need to address the mental impact of IPV on abused Chinese women to prevent even more
debilitating effects on these women’s well-being and functioning. Also, it indicates the need to routinely assess for both
IPV and depression. If depression is found in abused women,
early treatment or referrals are necessary.
Intimate Partner Violence and Depression 63
Limitations of the Study
There were several limitations in this study. The data reported
in this study relied on self-report rather than clinical assessment. Also, some measurements, such as on the self-efficacy
and self-esteem of the abused women, were not investigated
but might be found to play an important role in the level of
women’s depression. Moreover, as this was a cross-sectional
study, the causal effect of the factors identified in the findings
on the level of depression could not be guaranteed. However,
the structured multiphase regression model used in the data
analysis has maximized the causal relationship of associated
factors on depression in IPV. Furthermore, only women who
had experienced abuse were assessed. In future research, both
abused and nonabused women should be included in the
analysis to strengthen the understanding of factors that lead
to greater depression resulting from IPV.
Implications for Nursing
‘‘Primary Health Care: Now More Than Ever’’ is the latest
World Health Organization (2008) theme stated in the
World Health Report, urging the need to provide primary
care by organizing a primary care network. This can provide
a comprehensive range of integrated assessment, intervention, and prevention and could be effective for dealing with
both the physical and the mental illnesses of abused women
in the community.
For the assessment component, the use of the C-AAS is a
feasible and an effective screening of abused women in the
community. In this study, only 9% of abused women were
not depressed or had a minimal level of depression, underlying the need for healthcare professionals to identify women
with IPV early and to provide appropriate nursing care for
enhancing their mental health. By using empathetic understanding, well-trained nurses or social workers can establish a
relationship of mutual trust and rapport with those abused
women who choose to disclose their history of abuse.
With respect to intervention, factors associated with high
levels of depression in abused women in the Chinese community were identified. This constitutes the vital information
needed to tailor interventions to Chinese women living in
abusive relationships. For example, low educational attainment was shown to be an important factor that increases the
tendency to depression in abused women. An empowerment
intervention aimed at providing information about IPV and
about access to social resources and help should be implemented to strengthen the resilience of abused women. This
would help to improve their mental health even as they were
enduring the abusive relationship. In addition, abused immigrants from Mainland China who are more vulnerable to
depression need special attention and help to strengthen their
sense of self-efficacy to overcome the hardship of coping with
an abusive relationship. Moreover, the impact of psychological
abuse on the abused women’s mental health should not be
underestimated.
With respect to prevention, the perception of social support
was found to be a significant protective factor against depression caused by IPV. Therefore, empathetic and nonjudgmental listening should be the first priority for healthcare
professionals when dealing with abused women in both a community and a healthcare setting. This would help the abused
women to be more willing to disclose their experiences of abuse,
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
64 Intimate Partner Violence and Depression
share their feelings, and express their needs, in the process helping them cope with the abuse. The earlier the abused women
receive treatment, the better the prospects for their mental health,
even while they are struggling with an abusive relationship.
Conclusions
The findings of this study reveal factors associated with the
high level of depression in abused women in the Chinese
community. Nurses should focus on screening and treating
abused women not only in a healthcare setting but also in the
community. Special attention should be paid to those women
who are immigrants from Mainland China; these women need
more care and support from healthcare providers to reduce the
detrimental impact of IPV on their mental health. q
Accepted for publication October 5, 2010.
This project was funded by the Health and Health Services Research
Fund of the Food and Health Bureau, Hong Kong Special Administrative
Region. Special thanks to Ms. Helina Yuk and Ms. Polly Pang and her
team for screening and interviewing the women covered in this study.
Corresponding author: Daniel Yee-Tak Fong, PhD, School of Nursing,
The University of Hong Kong, 4/F, William MW Mong Block, 21,
Sassoon Road, Pokfulam, Hong Kong (e-mail: [email protected]).
References
Bandura, A. (1986). Social foundations of thought and action: A
social cognitive theory. Upper Saddle River, NJ: Prentice-Hall.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the
Beck Depression Inventory-II. San Antonio, TX: Psychological
Corporation.
Bennett, H. A., Einarson, A., Taddio, A., Koren, G., & Elinarson, T. R.
(2004). Prevalence of depression during pregnancy: Systematic
review. Obstetrics and Gynecology, 103(4), 698Y709.
Bodurka-Bevers, D., Basen-Engquist, K., Carmack, C. L., Fitzgerald,
M. A., Wolf, J. K., Moor, C., et al. (2000). Depression, anxiety,
and quality of life in patients with epithelial ovarian cancer.
Gynecologic Oncology, 78(3 Pt. 1), 302Y308.
Bonomi, A. E., Anderson, M. L., Reid, R. J., Rivara, F. P., Carrell, D.,
& Thompason, R. S. (2009). Medical and psychosocial diagnoses
in women with a history of intimate partner violence. Archives of
Internal Medicine, 169(18), 1692Y1697.
Byrne, B. M., Stewart, S. M., & Lee, P. W. H. (2004). Validating
the Beck Depression Inventory-II for Hong Kong community
adolescents. International Journal of Testing, 4(3), 199Y216.
Campbell, J. C. (2002). Health consequences of intimate partner
violence. Lancet, 359(9314), 1331Y1336.
Campbell, J. C., & Campbell, D. W. (1996). Cultural competence in
the care of abused women. Journal of Nurse-Midwifery, 41(6),
457Y462.
Campbell, J. C., Kub, J., Belknap, R. A., & Templin, T. (1997).
Predictors of depression in battered women. Violence Against
Women, 3, 271Y293.
Carlson, B. E., McNutt, L.-A., Choi, D. Y., & Rose, I. M. (2002).
Intimate partner abuse and mental health: The role of social
support and other protective factors. Violence Against Women,
8(6), 720Y745.
Census and Statistics Department. (2008). Population and household statistics analysed by District Council District 2007. Hong
Kong Special Administrative Region: Census and Statistics Department. Retrieved from www.censtatd.gov.hk.
Chan, K. L., Brownridge, D. A., Tiwari, A., Fong, D. Y. T., & Leung,
W. C. (2008). Understanding violence against Chinese women in
Hong Kong: An analysis of risk factors with a special emphasis
Nursing Research January/February 2011 Vol 60, No 1
on the role of in-law conflict. Violence Against Women, 14(11),
1295Y1312.
Chinese Behavioral Sciences Society. (2000). The Chinese version
of the Beck Depression Inventory, Second Edition. Licensed
Chinese translation. New York: Harcourt Brace.
Cohen, S., Mermelstein, R., Kamarck, T., & Hoberman, H. N.
(1985). Measuring the functional components of social support. In I. G. Sarason & B. R. Sarason (Eds.), Social support:
Theory, research and applications (pp. 73Y94). The Hague, The
Netherlands: Martinus, Nijhoff.
Cohen, Y. C., Rubin, H. R., Freedman, L., & Mozes, B. (1999). Use
of a clustered model to identify factors affecting hospital length of
stay. Journal of Clinical Epidemiology, 52(11), 1031Y1036.
Coker, A. L., Davis, K. E., Arias, I., Desai, S., Sanderson, M.,
Brandt, H. M., et al. (2002). Physical and mental health effects
of intimate partner violence for men and women. American
Journal of Preventive Medicine, 23(4), 260Y268.
Deyessa, N., Berhane, Y., Alem, A., Ellsberg, M., Emmelin, M.,
Hogberg, U., et al. (2009). Intimate partner violence and depression among women in rural Ethiopia: A cross-sectional study.
Clinical Practice and Epidemiology in Mental Health, 5, 8.
Evan, S. (1995). Re-presenting woman battering: From battered
woman syndrome to coercive control. Symposium on Reconceptualizing Violence Against Women By Intimate Partners:
Critical Issues. Albany Law Review, 973, 1Y20.
Follingstad, D. R. (2007). Rethinking current approaches to
psychological abuse: Conceptual and methodological issues.
Aggression and Violent Behavior, 12(4), 439Y458.
Gilligan, C. (1977). In a different voice: Women’s conceptions of self
and of morality. Harvard Educational Review, 47, 481Y517.
Glass, N., Perrin, N., Campbell, J. C., & Soeken, K. (2007). The
protective role of tangible support on post-traumatic stress disorder
symptoms in urban women survivors of violence. Research in
Nursing & Health, 30(5), 558Y568.
Golding, J. M. (1999). Intimate partner violence as a risk factor for
mental disorders: A meta-analysis. Journal of Family Violence,
14(2), 99Y132.
Gonzalez-Guarda, R. M., Peragallo, N., Vasquez, E. P., Urrutia, M. T.,
& Mitrani, V. B. (2009). Intimate partner violence, depression, and
resource availability among a community sample of Hispanic
women. Issues in Mental Health Nursing, 30(4), 227Y236.
Haden, S. C., & Scarpa, A. (2008). Community violence victimization and depressed mood: The moderating effects of coping
and social support. Journal of Interpersonal Violence, 23(9),
1213Y1234.
Horrigan, T. J., Schroeder, A. V., & Schaffer, R. M. (2000). The triad
of substance abuse, violence, and depression are interrelated in
pregnancy. Journal of Substance Abuse Treatment, 18(1), 55Y58.
Humphreys, J., & Campbell, J. (2004). Family violence and nursing practice. Philadelphia: Lippincott Williams & Wilkins.
Kaplan, A. (1986). The ‘‘self-in-relation’’: Implications for depression in women. Psychotherapy, 23(2), 234Y242.
Koopman, C., Ismailji, T., Palesh, O., Gore-Felton, C., Narayanan, A.,
Saltzman, K. M., et al. (2007). Relationships of depression to child
and adult abuse and bodily pain among women who have experienced intimate partner violence. Journal of Interpersonal
Violence, 22(4), 438Y455.
Krug, E., Dahlberg, I., Mercy, J., Zwi, A., & Rafael, L. (2002).
World report on violence and health. Geneva, Switzerland:
World Health Organization.
Matsudaira, T. (2003). Cultural influences on the use of social
support by Chinese immigrants in Japan: ‘‘Face’’ as a keyword.
Qualitative Health Research, 13(3), 343Y357.
Mburia-Mwalili, A., Clements-Nolle, K., Lee, W., Shadley, M., & Yang,
W. (2010). Intimate partner violence and depression in a populationbased sample of women: Can social support help? Journal of Interpersonal Violence, 25, 2258Y2278.
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nursing Research January/February 2011 Vol 60, No 1
Midlarsky, E., Venkataramani-Kothari, A., & Plante, M. (2006).
Domestic violence in the Chinese and South Asian immigrant communities. Annals of the New York Acadamy of Sciences, 1087(1),
279Y300.
Ramsay, J., Rivas, C., & Feder, G. (2005). Interventions to reduce
violence and promote the physical and psychosocial well-being
of women who experience partner violence: A systematic
review of controlled evaluations. London: UK Department of
Health. Retrieved from http://www.dh.gov.uk/assetRoot/04/12/
74/26/04127426.pdf
Shin, H. S., Han, H. R., & Kim, M. T. (2007). Predictors of
psychological well-being amongst Korean immigrants to the
United States: A structured interview survey. International Journal of Nursing Studies, 44(3), 415Y426.
Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B.
(1996). The revised Conflict Tactics Scales (CTS2): Development
and preliminary psychometric data. Journal of Family Issues,
17(3), 283Y316.
Tang, C. S. K. (1997). Psychological impact of wife abuse: Experiences of Chinese women and their children. Journal of
Interpersonal Violence, 12(3), 466Y478.
Tiwari, A., Fong, D., Chan, K., Leung, W., Parker, B., & Ho, P. C.
(2007). Identifying intimate partner violence: Comparing the
Chinese Abuse Assessment Screen with the Chinese revised conflict
tactics scales. BJOG, 114(9), 1Y7.
Intimate Partner Violence and Depression 65
Tiwari, A., Chan, K. L., Fong D. Y. T., Leung, W. C., Brownridge,
D. A., Lam, H., et al. (2008). The impact of psychological
abuse by an intimate partner on the mental health of pregnant
women. BJOG, 115(3), 377Y384.
Tiwari, A., Wong, J., Brownridge, D. A., Chan, K. L., Fong, D. Y. T.,
Leung, W. C., et al. (2009). Psychological intimate partner violence among Chinese women: What we know and what we still
need to know. Open Social Science Journal, 2, 32Y36.
World Health Organization. (2008). The World Health Report
2008: Primary health care (now more than ever). Geneva,
Switzerland: Author.
World Health Organization. (2009). Women and health: Today’s
evidence tomorrow’s agenda. WHO Global Report. Geneva,
Switzerland: Author.
Yick, A. G., Shibusawa, T., & Agbayani-Siewert, P. (2003). Partner violence, depression, and practice implications with families of Chinese descent. Journal of Cultural Diversity, 10(3),
96Y104.
Yoshihama, M. (2002). Battered women’s coping strategies and
psychological distress: Differences by immigration status. American Journal of Community Psychology, 30(3), 429Y452.
Zlotnick, C., Johnson, D. M., & Kohn, R. (2006). Intimate partner
violence and long-term psychosocial functioning in a national
sample of American women. Journal of Interpersonal Violence,
21(2), 262Y275.
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Purchase answer to see full
attachment