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Abuse and mental disorders among women at walk-in clinics in Trinidad
– Reported, March 30, 2012
Female participants from 16 randomly selected walk-in clinics, previously stratified to represent all administrative regions and urban and rural settings, who were 18 years or older, were surveyed during May to August 2007 using the WAST-Short and PRIME-MD questionnaires.
432 women participated (a 92% response rate), Of these 16% were aged 20-29, 11.8% 30-39 and 19% 40-49; 37% were married, 25% single; 44.7% were Indo- and 35% Afro-Trinidadian; 67.8% had achieved education up to age 14 only. 30.3% were employed and 3.0% reported incomes more than $5,001 TTD (Trinidad and Tobago Dollars) per month. Forty percent (173) of all respondents were positive for abuse as scored by the WAST-Short scale. Chi-square analysis suggested associations (p < 0.05) between abuse and age, employment status, being in a current relationship, and having the desire to cut down on alcohol intake. Further there were associations between abuse and the presence of depression, suicidal ideation, post-traumatic stress disorder and somatization as determined by the PRIME-MD scale. Logistic regression showed that the statistically significant (p < 0.05) predictors of woman abuse were age less than 49, wanting to cut down on alcohol use and currently being in a relationship.
Among women of primarily lower socioeconomic status who attend walk-in clinics in Trinidad abuse as measured by the WAST-Short scale is high and there are statistically significant associations with mental disorders as determined by the PRIME-MD scale.
In Trinidad prevalence studies of domestic violence have been conducted in a variety of settings. Point prevalence rates in the general female population have been reported as16% , among currently pregnant, 9.2% , in the emergency room, 8% , and at the fee-for-service family practices, 27% . Additionally, up to 40% of women at emergency rooms report a past experience of domestic violence. However we know little about the mental disorders or the long term consequences that may be associated with this abuse in Trinidad. Recently international studies have focused on the mental disorders associated with such abuse and reports suggest that there is a greater likelihood of depression , multiple somatic complaints and post-traumatic stress disorder symptomatology.
Our objective was to determine the prevalence of woman abuse and the mental disorders associated with this experience, and further to explore which demographic factors may predict the likelihood of such abuse at walk-in clinics in Trinidad.
In Trinidad there are seventy nine (79) health centres, most of which have walk-in clinics (where patients can present without an appointment for any medical problem). These clinics were stratified to represent all regional health authorities (administrative regions) and to capture rural and urban populations. Clinics were then selected using a table of random numbers; given the timeframe to conduct the interviews and the knowledge of attendance rates, 16 clinics were chosen according to the proportion of clinics per administrative region. Consecutive females attending these clinics were invited to participate if they were 18 years and older, willing to take part and had signed the consent form.
Abuse and mental disorders
Violence and PTSD
Eight percent of all women reported physical violence being ‘hit, slapped, kicked, or otherwise physical hurt or being forced into an unwanted sexual act’ in the past 12 months. Additionally, 10.4% of all women reported symptoms suggestive of post-traumatic stress disorder (PTSD), being ‘bothered a lot’ and 15.2% ‘bothered a little’ by ‘thinking or dreaming about something terrible that happened to them in the past’. There was a statistically significant association between reports of abuse and PTSD with 48.9% of the women who were ‘bothered a lot’ and 58.5% of the women who were bothered a little’ reporting abuse, compared with 35.1% of respondents who were ‘not bothered’.
Alcohol abuse
There was a statistically significant association between reports of abuse and women’s report that they would like to ‘cut down on their alcohol intake’. Sixteen (64%) of the 25 women having this wish reported that they had experienced abuse in the past year.
Depression
There was a statistically significant association between reports of abuse and both suicidal thinking and the scoring of major depression.
Somatization
There was a statistically significant association between reports of abuse among women with multiple somatic complaints when compared to those who did not have multiple somatic complaints, with 48.8% versus 36.7% respectively reporting abuse. Further analysis was carried out to describe which somatic complaints were more common among women who reported abuse, it was found that women who complained of being ‘bothered a lot’ in the past 4 weeks with either menstrual cramps, pain or problem with sexual intercourse, headaches, feeling the heart pounding or racing, shortness of breath or nausea, gas and indigestion were more likely to report abuse.
Anxiety and Panic
There was a statistically significant association between reports of abuse and anxiety where of the 25 women (5.8%) reporting symptoms suggestive of anxiety 56% reported abuse versus the 39.7% who reported abuse but had no anxiety symptoms. Of the 21 women with panic symptoms 52.4% had abuse versus 39.4% with no panic disorder. This was not statistically significant.
This study shows that abuse was common and was reported by 40% of female respondents at walk-in clinics in Trinidad and further 8% of all participants reported physical and sexual abuse in the last year. There were associations between abuse and age, employment status, current relationship, and the desire to cut down on alcohol intake. Further analysis suggested that at these primary care walk-in clinics, statistically significant predictors of woman abuse were being of an age less than 50, wanting to cut down on alcohol use and being in a relationship.
This paper supports previous studies that show that abuse is as common in this population as in primary care populations worldwide. Its results add to the Caribbean literature by exploring the association between abuse experienced by women in their relationships and mental disorders in the primary care setting. It further shows that among women who report abuse, depression, somatization and PTSD are common. Suicidal ideation also occurs more commonly among the women who report abuse than those who do not.
Another potentially important finding is the relationship between the symptoms which ‘bothered the participants ‘a lot’ during the past 4 weeks and the reporting of abuse, these symptoms included menstrual cramps, pain or problem with sexual intercourse, headaches, feeling the heart pounding or racing, shortness of breath or nausea, gas and indigestion. These are all common primary care symptoms. The lesson to take away is that if these symptoms are present and somatisation is considered then the physician should explore the possibility of abuse.
This paper has several strengths including the large sample of participants, the good response rate, and the random selection of clinics to represent the various administrative centres and urban and rural centres. The good response rate was thought to be due to 3 factors, the long waiting times at the clinics before patients saw the physician which meant that patients were not rushed and could easily complete the questionnaire before their consultation, the interviewers were all females and so participants may have been more comfortable talking about sensitive topics, and these clinics have been poorly studied in the local medical literature.
The participants are not representative of the entire population since the middle and upper income groups are under-represented. These are free health centers which have large patient populations and long waiting times and attract those of a lower socio-economic status. We also know nothing of the non-responders; their non-participation might have possibly skewed the results. A major weakness is that the instruments employed are screening and not confirmatory tests. Also because this was a cross-sectional study we can draw no conclusion on the causality of violence and mental illness so these results set the scene for further investigation using prospective studies. Future research should focus on refining the prevalence of the mental disorders found and confirming the findings using validated diagnostic tests. Additionally we need to document if the patient’s quality of life is presently severely enough affected such that treatment was required and subsequently if this treatment was successful over time.
This cross-sectional survey of 432 women of primarily lower socioeconomic status who attend walk-in clinics in Trinidad revealed that abuse as measured by the Woman Abuse Screening Test (WAST)-Short scale is high. There were statistically significant associations between abuse and mental disorders such as depression, suicidal ideation, post-traumatic stress disorder and somatization, as determined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) scale.
Credits:Rohan G Maharaj,Colanne Alexander,Candace H Bridglal,Aysha Edwards,Hassina Mohammed,Teri-Ann Rampaul,Sharlene Sanchez,Gina P Tanwing, and Kristy Thomas
More Information at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858716/?tool=pubmed
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