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Teresa Evans-Campbell, PhD, Taryn Lindhorst, PhD, Bu Huang, PhD and Karina L. Walters, PhD

Teresa Evans-Campbell is with the Institute for Indigenous Health and Child Welfare Research, School of Social Work, University of Washington, Seattle. Taryn Lindhorst and Bu Huang are also with the School of Social Work, University of Washington. Karina L. Walters is with the Native Wellness Center of the School of Social Work, University of Washington.

Correspondence: Requests for reprints should be sent to Teresa Evans-Campbell, University of Washington School of Social Work, 4101 15th Ave NE, Seattle, WA 98105 (e-mail: tecamp{at}u.washington.edu).

	ABSTRACT

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Objective. We surveyed American Indian/Alaska Native (AIAN) women in New York City to determine the prevalence of 3 types of interpersonal violence among urban AIAN women and the behavioral health and mental health factors associated with this violence.

Methods. Using a survey, we questioned 112 adult AIAN women in New York City about their experiences with interpersonal violence, mental health, HIV risk behaviors, and help-seeking. The sampling plan utilized a multiple-wave approach with modified respondent-driven sampling, chain referral, and target sampling.

Results. Among respondents, over 65% had experienced some form of interpersonal violence, of which 28% reported childhood physical abuse, 48% reported rape, 40% reported a history of domestic violence, and 40% reported multiple victimization experiences. Overwhelmingly, women experienced high levels of emotional trauma related to these events. A history of interpersonal violence was associated with depression, dysphoria, help-seeking behaviors, and an increase in high–HIV risk sexual behaviors.

Conclusions. AIAN women experience high rates of interpersonal violence and trauma that are associated with a host of health problems and have important implications for health and mental health professionals.

	INTRODUCTION

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Violence against women is a significant public health problem. Although a growing body of literature documents the consequences of interpersonal violence for the health and mental health of women,^1–3 very few studies have examined the relation between interpersonal violence and health and mental health outcomes among American Indian/Alaska Native (AIAN) women. This discrepancy in the literature exists despite findings from the National Violence Against Women Survey, showing that the highest rates of all forms of violence occur among AIAN women, with 34.1% of AIAN women reporting rape, 61.4% reporting physical assault, and 17.0% reporting stalking during their lifetime.⁴ Moreover, other research suggests that AIAN women have a higher rate of victimization through violent crime,⁵ physical attack,⁶ and being a witness to traumatic events.⁶ They may also be disproportionately represented among domestic violence homicides.^7,8

Understanding risk profiles for AIAN women has important implications for health and mental health professionals. In addition to physical injury, violent victimization may lead to an increased risk of developing serious health problems, such as self-neglect, sexually transmitted disease, and poor adherence to medical recommendations.³ Women in abusive relationships may develop stress and anxiety that can lead to long-term health issues and reduced immunity to illness in general,^9–11 as well as specifically increasing their exposure to HIV infection.^12,13 In addition, a history of interpersonal violence is related to health care utilization. For example, female sexual assault victims use more general health and mental health services than nonvictims.³

Women’s mental health also suffers as a result of victimization. Among samples of non-Native women, those who have been battered or who have experienced sexual assault have higher rates of severe mental disorders, including depression, anxiety, and posttraumatic stress disorder.^1,3 In several categories, the rates of distress for survivors of violence are double, and sometimes triple those of women who have not been abused.⁷ Violence itself has been found to be more predictive of depression in battered women than preexisting mental disorders, demographics, or developmental characteristics.³ Among AIAN women specifically, preliminary evidence indicates that violent victimization is related to depression, posttraumatic stress disorder, suicide attempts, and alcohol use.¹⁴

Previous studies of AIAN women represent an initial investigation of interpersonal violence, but most are limited by their use of tribally specific and/or reservation-based samples. The only nationally representative survey to include AIAN women, the National Violence Against Women Survey, relied on a subsample of 88 AIAN women out of a total sample of 16000 for its results. Reservation-based samples typically report high rates of violence across types of victimization. For instance, in 1 of the few studies to explore multiple experiences of victimization across the lifespan of AIAN women,¹⁵ 27% reported childhood physical abuse, 40% reported child sexual abuse, 40% reported experiencing adult sexual assault, and 67% reported physical violence from an adult partner. Yet, although there is ample evidence that interpersonal violence among AIAN women is high, the relation between violence and AIAN women’s health has not been addressed, and research exploring interpersonal violence among urban AIAN women is almost nonexistent.

American Indians and Alaska Natives in Urban Areas
Contrary to their common stereotype as rural or reservation-based people, more than 60% of AIAN people currently live in urban settings.¹⁶ In the past several decades, AIAN people have experienced rapid urbanization, due in large part to federal policies of tribal termination and relocation. The relocation of many Native people from tribal lands has put urban American Indians and Alaska Natives at risk for a host of biopsychosocial problems,^17,18 including vulnerability to HIV infection.¹⁹ Despite these high rates of urbanization, the Indian Health Service, which provides the majority of health care to American Indians and Alaska Natives, has allocated only 1% of its funding to urban areas.²⁰ It is, therefore, of increasing importance to conduct research with Native people living in urban settings, particularly given the fragmented service delivery systems they encounter.

Given the limited empirical evidence about the effects of interpersonal violence on AIAN women, particularly urban AIAN women, we conducted the present study to (1) describe the prevalence of interpersonal violence (domestic violence, lifetime sexual assault, and childhood physical abuse) in a sample of urban AIAN women, and (2) to explore the impact of violence exposure on mental health, HIV risk behaviors, and help-seeking.

	METHODS

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The current investigation was part of a comprehensive assessment of HIV risk behaviors and prevention needs among 197 adult American Indians and Alaska Natives living in the New York metropolitan statistical area (112 women and 85 men). The study was conducted from 2000 to 2003 in New York City, the urban area with the largest population of American Indians and Alaska Natives in the country (98922 American Indian and Alaska Native alone or with other races, according to the 2000 US Census¹⁶). In order to increase item clarity, coherence, and cultural relevance, the survey was piloted and reviewed by American Indian and Alaska Native key informants, focus groups, and research consultants before its administration.

Given the difficulty in randomly sampling urban AIAN populations, and the large sample needed for random-digit dialing, an alternative means for obtaining a representative sample was devised. The sampling plan used a multiple-wave sampling approach with modified respondent-driven sampling, chain referral, and targeted sampling. Respondent-driven sampling has been used successfully with hidden or hard-to-reach populations, and can effectively reduce the biases often associated with chain-referral sampling.²¹

To create the study sample, subjects were recruited in 2 stages. We started with a membership list for a local AIAN community center. In order to be a "member," individuals provided proof of Indian identity (e.g., tribal enrollment card). This membership was not service or consumer based. Members who lived outside the New York metropolitan area were excluded from our list. We selected our first 100 potential nominators through a stratified random sampling technique and divided our list into 18 strata by geographic location and gender (e.g., Brooklyn males and females). The number of potential nominators randomly selected was proportionate to the size of that stratum within the AIAN population, as defined by US Census data (5% sample of individuals and households).¹⁶ Of these initial 100 potential nominators, we ended up with 88 eligible nominators (e.g., because of change in residence or death). For control purposes and validity, we also initially targeted 20 American Indians and Alaska Natives who did not affiliate with the community center, and an additional 18 individuals who volunteered as first-wave "seeds" to see if social networks differed between those who affiliated with the community center and those who did not.

Once enrolled, each of these initial "seeds" provided a list of other American Indians and Alaska Natives whom they knew well (defined as someone they would feel comfortable calling on the phone) and who lived within a 70-mile radius of New York City. Respondent lists varied in size, with some respondents providing only 1 name, and others providing many more. From these network lists, network members were randomly selected to enroll in the study using a predetermined, computerized random number table. Although this method limited the number of potential participants, it allowed for a more representative sample of urban American Indians and Alaska Natives in New York City.

Of the 237 eligible respondents, 197 enrolled and were interviewed, yielding an 83% response rate. Additionally, of the 237 eligible, 16 (7%) refused to participate, and another 24 (10%) agreed during an initial screening, but interviewers were unable to locate them at a later time. Of the 197 participants (men and women) in the final sample, 112 were women and are the focus of the analyses presented here.

Interview Procedure
A research assistant contacted potential participants by telephone and prescreened them according to a structured protocol. A trained interviewer, usually Native, then scheduled an interview at a location chosen by the participant. Interviews were conducted face-to-face and followed a standardized protocol. After obtaining informed consent, interviewers read questions from a printed questionnaire and recorded participants’ responses. All participants indicated that they spoke fluent English, and all interviews were conducted in English. For sexual behavior items, the participant could opt to privately record responses on the interview form. Study participants received $35 compensation per interview for their time.

Participants
Participant age ranged from 18 to 77 years with a mean of 42.6 years. Education level ranged from 6 to 17 years of formal schooling, with a mean of 14 years. Participants’ income levels were quite low compared with residents of New York City in general. Among those who provided the information on income, the median household income level was between $30000 and $39999, compared with a median of $43 393 for residents of New York City overall. At the time of the interview, 39.6% of participants reported that they were working full-time. Over half (63.6%) of participants were born in an urban center; 36.4% were born in a rural area or on a reservation.

Measures
The survey instrument for the original study incorporated 533 questions in 8 sections: demographics and family history; health and health services; stress and mental health; cultural factors; traumatic event exposure; alcohol and drug use; high–HIV risk sexual behaviors (HIV sexual risk); and military service.

Control variables. We explored a number of potential control variables for the study. However, as we had a limited sample size, and most demographic variables were not related to our outcome variables, we chose only two—age and income—in the final analysis. Age was categorized as 18–30 (22.7%), 31–45 (30%), 46–55 (37.3%), and older than 55 (10%) years. Income was dichotomized as less than $20000 (32.4%) versus $20000 or higher (67.6%).

Predictor variables. Interpersonal violence predictors were drawn from a 16-item trauma-event checklist that was used in the American Indian Services Utilization and Psychiatric Epidemiology Risk and Protective Factors Project.²⁰ We included 13 of the 16 items in our original checklist, utilizing only the interpersonal violence items for this study. We explored 5 types of abuse history—childhood physical abuse, lifetime sexual assault, domestic violence (aged 18 years and older), and multiple victimization (experiencing at least 2 of the previous 3 abuse categories). To measure child physical abuse, respondents were asked whether they had been physically abused or hurt by a parent or caregiver before the age of 18 years. To measure domestic violence, respondents were asked if they had been physically abused or hurt by a spouse or romantic partner. Lifetime sexual assault was measured by a combination of 2 questions: "Were you ever raped, or did you ever have sex when you didn’t want to because someone forced you in some way, or threatened harm if you didn’t?" and "Were you ever touched or made to touch someone else in a sexual way because they forced you in some way, or threatened to harm you if you didn’t?"

Outcome variables. We considered self-reported health, mental health, health service utilization, and level of trauma resulting from interpersonal violence events to be our outcome variables. Several areas of health and mental health were explored—self-rated health, lifetime depression and dysphoria, current depression and current anxiety, and HIV sexual risk. To measure self-rated health, participants were asked to rank their general health as poor, fair, good, very good, or excellent. Lifetime depression and dysphoria items were based on the Semi-Structured Assessment for the Genetics of Alcoholism measure²² (e.g., "Have you ever had a period of time lasting at least one week when you were bothered most of the day, nearly every day, by feeling depressed, sad, uninterested, or irritable, even if you felt OK sometimes?"). This assessment has been adapted for and used successfully with urban AIAN populations.²³ Current depression and current anxiety were measured using the Brief Symptom Inventory subscales for depression and anxiety.²⁴ Respondents were asked to rate items on a 5-point scale, from 0 (not at all) to 4 (extremely) for the previous 7 days (e.g., "In the last 7 days, how much were you bothered by feeling no interest in things?"). HIV sexual risk was assessed by asking participants to indicate whether or not they had engaged in any of 10 HIV sexual risk behaviors since 1980 (e.g., sex with an HIV-positive person). The HIV sexual risk questions were developed and piloted specifically for AIAN populations in previous studies,^12,25 and have since been successfully used in other studies.¹³

Two types of help-seeking were assessed: seeking mental health counseling, and seeking traditional Native healing interventions. Seeking conventional mental health counseling was measured by asking, "Have you ever spoken to a professional about any emotional problems you might have had?" Questions related to seeking traditional Native healing were adapted from the American Indian Service Utilization, Psychiatric Epidemiology, Risk, and Protective Factors Project study²⁶ (e.g., "In the past year, have you been to see a medicine man/woman for your health and general well-being?").

Level of trauma in response to interpersonal violence was assessed by asking respondents to rate their level of trauma on a 7-point scale, from 1 (not at all traumatic) to 7 (extremely traumatic), both at the time of the incident and at the time of the interview.

Data Analysis
We began our data analysis by examining the descriptive statistics of study variables. Chi-square tests were then performed to examine the bivariate associations among variables. Because of the strong correlations among the interpersonal abuse variables, 5 sets of multivariate logistic regression models were developed for the data: each model included 1 type of abuse history control for age and income. Complete case analysis was used for modeling, and all variables were retained in each model, regardless of statistical significance. All analyses were performed with SPSS Version 11 (SPSS Inc, Chicago, Ill).

	RESULTS

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Overall, 75.7% of the women rated their health as good to excellent. A majority of the women (64.5%) reported ever having a period of depression, 50.9% reported a history of dysphoria, and 86.9% reported having engaged in unsafe sex. Most women (60.7%) had attended mental health counseling at some point, whereas 67.9% had utilized a traditional Native healing method.

Interpersonal Violence and Trauma
The majority of women in the sample (65.5%) had experienced at least 1 form of interpersonal violence. As shown in Table 1, 28.2% reported a history of childhood physical assault, 48.2% reported a history of rape in their lifetime, 41.7% stated that they had been touched against their will at some point in their life, and 40.0% indicated that they had experienced assault from a spouse or romantic partner as an adult. In addition, 41.0% of the women reported experiencing multiple victimization, defined as experiencing at least 2 types of the interpersonal violence explored in the study. Women who had experienced any type of interpersonal violence had high levels of traumatization at the time of the assault. On a scale from 1 (lowest) to 7 (highest), the average level of trauma reported at the time of the incident was between 6 and 7 for every type of interpersonal violence. Although current levels of trauma in response to these incidents were significantly lower, women still reported violence-related levels of trauma to be between 3 and 4 at the time of the interview.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
Our study provides some of the first data on interpersonal violence in an urban AIAN sample, and some of the first descriptions of the associations between violence exposure and behavioral health/mental health outcomes. Study findings on lifetime exposure to interpersonal violence among urban AIAN women were alarming: more than half (65.5%) of the women in the sample had experienced at least 1 serious form of traumatic interpersonal violence, with the largest percentage reporting some form of sexual assault in their lifetime. When compared with the National Violence Against Women Survey data on AIAN women,⁴ this sample had higher rates of rape, but lower rates of serious physical assault. The rates of rape in this study were markedly higher than the lifetime rate of rape for any other ethnic group in the National Violence Against Women Survey, providing more evidence that AIAN women experience higher rates of sexual assault.

When compared with other tribal estimates of violence, the rates of rape we report here are lower than those found by Bohn,²⁷ and our rates of domestic violence are lower than those found by Bohn,²⁷ Fairchild et al.,²⁸ and Segal.²⁹ Rates of childhood physical abuse are higher than those found in other studies focused specifically on American Indians and Alaska Natives.^30,31 It is important to note however, that the current sample is community-based, whereas these reservation-based research studies have generally taken place within hospitals or treatment settings, where report rates of victimization are likely to be higher. Notably, our rates of childhood physical abuse, sexual assault, and domestic violence are higher than those found in a recent community-based study of trauma exposure in 2 large reservation communities.⁶ Community-based research that compares rates of violence among those living on reservations with that of those in urban settings is needed to determine if there are risk or protective factors associated with differences in geographic location or social capital (e.g., higher level of education).

Although interpersonal violence was associated with a lifetime experience of depression and dysphoria, it was not associated with current mental health, in contrast to previous research findings.^14,15 Two possibilities might explain these differences. First, in this community-based sample, an average of 20 years had elapsed since the time women reported as the worst period of their abuse. During this period, many of the women may have learned successful coping strategies to address their past victimization experiences; or it may be that there is a "window period," during which abuse is most likely to be associated with mental health functioning. Alternatively, it may be that distress patterns are unique among Natives, and traditional mental health measures are not appropriate for use with this population. In any case, our findings suggest a need for further research that evaluates various measures of mental health/distress as well as the developmental trajectories related to adjustment after abuse.

Victimization was also not associated with the respondents’ general self-assessment of health. However, having ever been victimized, having had multiple experiences of victimization, and particularly having been sexually assaulted were all associated with a substantial increase in sexual risk behaviors. Notably, 6% of the women in the sample reported being HIV-positive, a rate that is significantly higher than the rate for AIAN women in general.³² Because the sample size was limited, the actual number of HIV-positive women in our study was low (n = 7), and it was not possible to estimate the association between traumatic victimization and HIV status. However, previous research has found that various forms of violence against women increase the risk of HIV infection,^13,32 suggesting that 1 potential area of increased risk for HIV infection among AIAN women is their history of victimization.

Although the levels of violence and traumatization experienced by the women were high, findings in the area of help-seeking were encouraging. The majority of women with a history of abuse (75%) had accessed a traditional Native American intervention, and 70% had accessed conventional mental health services. Women who experienced sexual assault were significantly more likely than others to access both forms of help. One possible explanation for this finding is that there are an increasing number of services available that specifically target victims of sexual assault. On the other hand, across all types of abuse studied, levels of trauma associated with sexual assault were the highest and, consequently, sexual assault victims may have been more driven to seek out help.

Implications
Our findings have several important implications for research and practice with AIAN women. First, the overwhelming frequency of AIAN women reporting some form of traumatic victimization highlights the need for strong violence prevention efforts targeted at urban communities. Scholars and practitioners should promote culturally responsive standards of training for violence prevention efforts aimed specifically at urban AIAN women. For women who have already experienced violence, providers should focus on the prevention of related health and mental health issues. To assist in this regard, it is incumbent upon service providers to complete an in-depth assessment of interpersonal violence, exploring the types and frequency of interpersonal violence experiences, current levels of trauma associated with these experiences, and the possibility of ongoing health/ mental health sequelae.

Second, our results show that AIAN women are likely to seek out help after experiencing interpersonal violence. In many cases, a health or mental health professional may be the only person a woman can talk to about her experiences, and these professionals have unique opportunities in terms of prevention, assessment, and intervention. Receiving validation from a health care professional is a critical factor in empowering women who experience interpersonal violence.³³ Research has shown that the attitude of caregivers is very important in helping women to disclose abuse and tell their stories.³⁴

Third, AIAN women seek help through both Western-centered establishments and traditional Native interventions. It is critical, therefore, that culturally specific services are offered to women in conjunction with standard mental health services, or as an alternative. Native and non-Native providers should work together to provide comprehensive, culturally responsive services to AIAN women. Relatedly, it is important to note that, although many women had used interventions, we do not have information regarding access to and quality of these interventions. Given the high rate of AIAN women experiencing interpersonal violence, there is a need for in-depth study of help-seeking among AIAN victims, exploring the barriers to access, quality of help received, and satisfaction with help.

Study Limitations and Future Research
This study has several limitations that should be considered when interpreting the results. First, the sample is based on a network sampling strategy for identifying hidden populations, and there are some areas in which the sample may be biased, including the number of respondents who noted higher incomes and education levels than are typically the norm in studies of American Indians and Alaska Natives. Because the sample was generated in New York City, these levels may reflect differences that are unique to that geographic location. In addition, the research design is cross-sectional, and so cannot offer insight into the causal relationships among the constructs studied or the developmental correlates for violence and its health/mental health outcomes, suggesting that longitudinal research related to these factors is needed. Notwithstanding these limitations, our findings highlight the significance of the problem of interpersonal violence in urban AIAN communities, and underscore the need for advanced statistical models that identify mediational pathways to various health and mental health outcomes.

	Acknowledgments

 
This research was supported by the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Md (grant 5R29AA12010-02 to K. L. Walters).

Human Participant Protection
protocol was approved by the institutional review boards of Columbia University, New York, NY, and the University of Washington, Seattle, WA.

	Footnotes

 
Peer Reviewed

Contributors
T. Evans-Campbell and T. Lindhorst conceptualized the study, designed the analyses, interpreted findings, and led the writing of the article. B. Huang managed the data, performed the initial statistical analyses, and contributed to writing. K. L. Walters was principal investigator of the project upon which this study was based, and assisted in editing the article.

Accepted for publication October 25, 2005.

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