# Presentation: 733342

## Child Abuse and Neglect and Mental Disorders among Native American Women in Primary Care

-    American Native Women’s Health and
- Maternity Care
- Indian Health Service
- August 4, 2004,  Albuquerque, New Mexico

- Bonnie Duran, Dr.PH
- UNM SOM MPH

## Presentation Objectives

- Current theoretical models of Mental Disorders (MD) and Child abuse and neglect (CAN)
-   Research design
- Trauma and MD
- (Lack of) Federal priority on Indian Health

## Research Questions

- To determine prevalence rates of psychological disorders among Native American women seeking primary care treatment at an Indian Health Service ambulatory care clinic;
**To investigate relationships among intimate partner violence and child abuse and mental disorders;**

## Methods

- Two-stage sampling design:
- 1st Stage: 484 consecutive presenting Native American women in a primary care clinic screened with a mental health screening instrument
**2nd State: 234 women--50% (N=117) high and 50% (n=117) low on the GHQ interviewed with battery of instruments**
- 3rd Stage: 75% Interviewed again after one year
- Chart abstraction and RPMS data of IHS utilization data

## Source: Broken Promises: Evaluating the Native American Health Care System. (Draft)(2004). 

*Source: Broken Promises: Evaluating the Native** **American Health Care System*. (Draft)(2004).
- Washington DC: US Commission on Civil Rights: Office of the General Counsel.

## Slide 6

## Source: Broken Promises: Evaluating the Native American Health Care System. (Draft)(2004). Washington DC: US Commission on Civil Rights: Office of the General Counsel.

## Instruments/Data Sources

- GHQ-12 item version
- Demographics Questionnaire
- Composite International Diagnostic Interview-I Shell (DSM IV)
- Childhood Trauma Questionnaire
- Conflict Tactics Scale II
- Utilization Questionnaire: Chart Abstraction and RPMS
- Spirituality and Social Support Questions in Phase 3

##  Composite International Diagnostic Interview

| SCREENING QUESTIONS--Depression | Yes | No |
| --- | --- | --- |
| In your lifetime, have you ever had two weeks or longer when nearly everyday you felt sad, empty, depressed for most of the day? |  |  |
| In your lifetime, have you ever had two weeks or longer when you lest interest inmost things like work, hobbies, and other things you usually enjoyed? |  |  |
| DIAGNOSTIC QUESTIONS |  |  |
| Lacking Energy: ....Did you lack energy or feel tired all the time nearly every day, even when you had not been working hard? |  |  |
| Appetite Change: ....Did you have less or more appetite than usual almost everyday? |  |  |
| Sleep Problems: ...Did you have trouble sleeping almost every night for two weeks or more--either trouble falling asleep, waking up in the middle of the night, or waking up too early? |  |  |
| Lack of Confidence: ....Did you feel that you were not as good as other people? |  |  |
| Trouble Thinking: ...Did you have a lot more trouble concentrating than is normal for you |  |  |

## Childhood Trauma Questionnaire1     (28 Items)

-  1 Bernstein, D. P., Fink, L., Handelsman, L., & Foote, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. *American Journal of Psychiatry, 151*(8), 1132-1136.

| 
     When I was growing up.... | Never True | Rarely True | Some-
times True | Often True | Very Often True |
| --- | --- | --- | --- | --- | --- |
|  I didn’t have enough to eat. |  |  |  |  |  |
|  I knew there was someone to take care of me and protect me. |  |  |  |  |  |
| People in my family called me things like “stupid”, “lazy”, or “ugly”. |  |  |  |  |  |
|  People in my family hit me so hard that it left me with bruises or marks. |  |  |  |  |  |
| I was punished with a belt, a board, a cord, or some other hard object. |  |  |  |  |  |
| Someone tried to make me do sexual things or watch sexual things. |  |  |  |  |  |

## Conflict Tactics Scale 21       (78 Items-- both ways)

- 1 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), 283-316.

|  | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 0 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| May partner showed care for me even though we disagreed. |  |  |  |  |  |  |  |  |
| I insulted or swore at my partner; my partner swore or insulted me. |  |  |  |  |  |  |  |  |
| I threw something at my partner’ my partner threw something at me. |  |  |  |  |  |  |  |  |
|  I had a sprain, bruise, or small cut because of a fight with my partner: my partner had these due to a fight with me. |  |  |  |  |  |  |  |  |

| 1 =  Once in the past year | 4 = 6-10 times in the past year |
| --- | --- |
| 2 =  Twice in the past year | 5 = 11-20 times in the past year |
| 3 = 3-5 Times in the past year | 6 = more than 20 times in the past year |
| 7 = Not in the past year, but it did happen I the past | 0 = this had never happened.  |

- How Often Did This Happen?

## How Often Did This Happen?

|  | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 0 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| My partner used a knife or gun on me: I used a knife or gun on my partner. |  |  |  |  |  |  |  |  |
| I passed out from being hit on the head in a fight with my partner: My partner passed out from being hit on the head in a fight with me. |  |  |  |  |  |  |  |  |
| My partner beat me up: I beat up my partner. |  |  |  |  |  |  |  |  |
| I slapped my partner: My partner slapped me. |  |  |  |  |  |  |  |  |
| I accused my partner of being a lousy lover: My partner accused me of being a lousy lover. |  |  |  |  |  |  |  |  |

**How**** ****Often Did This Happen?**

| 1 =  Once in the past year | 4 = 6-10 times in the past year |
| --- | --- |
| 2 =  Twice in the past year | 5 = 11-20 times in the past year |
| 3 = 3-5 Times in the past year | 6 = more than 20 times in the past year |
| 7 = Not in the past year, but it did happen I the past | 0 = this had never happened.  |

## Mental Disorder Models

## World Health Organization. (2001). The world health report 2001 : mental health : new understanding, new hope. Geneva: World Health Organization. Pg. 20

- World Health Organization. (2001). *The world health report 2001 : mental health : new understanding, new hope*. Geneva: World Health Organization. Pg. 20

## World Health Organization. (2001). The world health report 2001 : mental health : new understanding, new hope. Geneva: World Health Organization. Pg. 30

- World Health Organization. (2001). *The world health report 2001 : mental health : new understanding, new hope*. Geneva: World Health Organization. Pg. 30

## Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing native women's health: an "indigenist" stress-coping model. Am J Public Health, 92(4), 520-524.

- Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing native women's health: an "indigenist" stress-coping model. *Am J Public Health, 92*(4), 520-524.

## De Bellis, M. D. (2002). Developmental traumatology: a contributory mechanism for alcohol and substance use disorders. Psychoneuroendocrinology, 27(1-2), 155-170.

**De Bellis, M. D. (2002). Developmental traumatology: a contributory mechanism for alcohol and substance use disorders. *****Psychoneuroendocrinology, 27*****(1-2), 155-170.**

## Slide 18

## Slide 19

## Demographics

## Sample Demographics N = 234

| Demographic Characteristic | Mean | Std Dev |
| --- | --- | --- |
|  Age (range 18-45) | 29.8 | 7.5 |
|  | N | Percent |
|      18-25 | 87 | 37.1 |
|      26-35 | 90 | 38.4 |
|      26-45 | 58 | 24.7 |
| Marital Status |  |  |
|      Married | 45 | 19.2 |
|      Living as married | 98 | 41.8 |
|      Formerly Married | 26 | 11.1 |
|     Single | 65 | 27.7 |
| Educational Level |  |  |
|      < HS | 25 | 10.6 |
|      HS Graduate | 68 | 29.0 |
|      1-3 yrs Vocational | 36 | 15.3 |
|      Some college | 93 | 39.7 |
|      College Graduate | 12 | 5.1 |

- Sample Demographics N = 234

## Sample Demographics   N = 234

| Demographic Characteristic | N | Percent |
| --- | --- | --- |
| Residence |  |  |
|      Urban | 205 | 87.6 |
|      Rural/Reservation | 29 | 12.4 |
| Attended Boarding School | 96 | 41.0 |
| Annual Household Income |  |  |
|      Below Poverty | 82 | 35.0 |
|      100-185% of Poverty | 80 | 34.2 |
|      186-300% of poverty | 47 | 20.1 |
|      More than 300% | 25 | 10.7 |
| Family history of substance abuse problems | 
163 | 
69.6 |
| Tribal Blood Quantum |  |  |
|      Full | 158 | 67.5 |
|      3/4 | 17 | 7.2 |
|      Half | 41 | 17.5 |
|      14 or less | 15 | 6.4 |

- Sample Demographics   N = 234

## Mental Disorders

## Prevalence of Lifetime and Current Substance Disorders: Native American Women in Primary Care 1999

|  | Lifetime |  | Current |  |
| --- | --- | --- | --- | --- |
| 
Diagnosis | Interviewed Sample Prevalence | Estimated prevalence1
(SE) | Interviewed Sample Prevalence | Estimated Prevalence1
(SE) |
| Alcohol Abuse | 28.2 | 28.3 (3.1) | 9.0 | 10.1 (2.2) |
| Alcohol Dependence | 32.5 | 29.3 (3.1) | 4.7 | 3.7 (1.1) |
| Any Drug Abuse | 12.8 | 12.3 (3.1) | 0.9 | 0.9 (0.7) |
| Any Drug Dependence | 19.2 | 17.1 (2.5) | 3.4 | 3.1 (1.1) |
| Any Substance Abuse | 27.8 | 27.9 (3.1) | 9.0 | 9.7 (2.1) |
| Any Substance Dependence | 37.6 | 34.0 (3.2) | 6.4 | 5.6 (1.5) |

**Prevalence of Lifetime and Current Substance Disorders: Native American Women in Primary Care 1999**

- 1 Weighted to the entire sample of 495 using the GHQ

## Prevalence of Lifetime and Current Mood Disorders: Native American Women in Primary Care 1999

|  | Lifetime |  | Current |  |
| --- | --- | --- | --- | --- |
| 
Diagnosis | Interviewed Sample Prevalence | Estimated prevalence1
(SE) | Interviewed Sample Prevalence | Estimated Prevalence1
(SE) |
| Any Major Depression | 41.5 | 38.1 (3.3) | 18.8 | 17.5 (2.6) |
| Dysthymic Disorder | 2.6 | 2.3 (1.0) | 0.9 | 0.6 (0.4) |
| Bipolar I | 6.0 | 4.9 (1.4) | 3.8 | 2.8 (0.9) |
| Any Mood Disorder | 48.3 | 43.7 (3.4) | 23.1 | 20.6 (2.7)  |

**Prevalence of Lifetime and Current Mood Disorders: Native American Women in Primary Care 1999**

- 1 Weighted to the entire sample of 495 using the GHQ

## Prevalence of Lifetime and Current Anxiety Disorders: Native American Women in Primary Care 1999

|  | Lifetime |  | Current |  |
| --- | --- | --- | --- | --- |
| 
Diagnosis | Interviewed Sample Prevalence | Estimated prevalence1
(SE) | Interviewed Sample Prevalence | Estimated Prevalence1
(SE) |
| Obsessive Compulsive Disorder | 7.7 | 6.4 (1.5) | 6.8 | 5.7 (1.5) |
| PTSD | 33.3 | 29.0 (3.0) | 14.5 | 12.6 (2.2) |
| Any Specific Phobia | 32.9 | 30.4 (3.1)  | 29.1 | 26.7 (3.0) |
| Social Phobia | 15.0 | 14.0 (2.3) | 10.7 | 9.4 (1.9) |
| Generalized Anxiety Disorder | 15.0 | 13.7 (2.3) | 10.7 | 9.1 (1.8) |
| Any Anxiety Disorder | 62.8 | 58.0 (3.5) | 50.4 | 46.7 (3.4)  |

**Prevalence of Lifetime and Current Anxiety Disorders: Native American Women in Primary Care 1999**

- 1 Weighted to the entire sample of 495 using the GHQ

## Prevalence of Lifetime and Current Any Disorder and Number of Disorders: Native American Women in Primary Care 1999

|  | Lifetime |  | Current |  |
| --- | --- | --- | --- | --- |
| 
Diagnosis | Interviewed Sample Prevalence | Estimated prevalence1
(SE) | Interviewed Sample Prevalence | Estimated Prevalence1
(SE) |
| Any Disorder | 84.2 | 80.4 (2.9) | 61.5 | 56.6 (3.5) |
| Number of Major Diagnostic Sets with Positive Diagnosis |  |  |  |  |
|           0 | 15.8 | 19.6 (2.9) | 39.3 | 43.3 (3.5) |
|           1 | 23.5 | 25.4 (3.1) | 35.9 | 33.2 (3.2) |
|           2 | 26.1 | 24.0 (2.9) | 18.0 | 16.9 (2.5) |
|           3 or 4 | 34.6 | 31.1 (3.1) | 6.8 | 6.5 (1.6) |

**Prevalence of Lifetime and Current Any Disorder and Number of Disorders: Native American Women in Primary Care 1999**

- 1 Weighted to the entire sample of 495 using the GHQ

## Intimate Partner Violence

## Intimate Partner Violence N = 234

| Violence Activity | Perpetrated on subject | Perpetrated by subject |
| --- | --- | --- |
| Past year Physical Assault |  |  |
|      Minor | 20.51 | 22.22 |
|      Minor and Severe | 22.65 | 23.08 |
| Past Year Injury |  |  |
|      Minor | 14.53 | 15.38 |
|      Minor and Severe | 12.82 | 4.70 |
| Lifetime Physical Assault |  |  |
|      Minor | 19.66 | 27.35 |
|      Minor and Severe | 38.89 | 36.32 |
| Lifetime Injury |  |  |
|      Minor | 22.65 | 23.08 |
|      Minor and Severe | 22.22 | 7.69 |

**Intimate Partner Violence **N = 234

**43.16**

**45.3**

**27.35**

**20.08**

**58.55**

**63.67**

**44.87**

**30.77**

## Child Maltreatment Prevalence

## Prevalence of Child Abuse and Neglect

| Maltreatment Type | N | Percent (%) |
| --- | --- | --- |
| No Maltreatment | 55 | 23.5 |
| Sexual and physical abuse | 65 | 27.8 |
| Other sexual abuse | 39 | 16.7 |
| Other physical abuse | 32 | 13.7 |
| Other emotional abuse | 24 | 10.3 |
| Neglect only | 19 | 8.1 |

## Prevalence of Child Abuse and Neglect

| Number of Maltreatments | N | Percent (%) |
| --- | --- | --- |
| 0 | 55 | 23.5 |
| 1 | 37 | 15.8 |
| 2 | 41 | 17.5 |
| 3 | 47 | 20.1 |
| 4 | 54 | 23.1 |

## Maltreatment Severity

| Maltreatment Severity | N | Percent (%) |
| --- | --- | --- |
| None | 55 | 23.5 |
| Low | 37 | 15.8 |
| Moderate | 45 | 19.2 |
| Severe | 97 | 41.5 |

## Unadjusted and Adjusted Association of Child Maltreatment Severity with Any Diagnosis

|  | Any Diagnosis |  |
| --- | --- | --- |
| Maltreatment Severity | Unadjusted PR 
(95% CI) | Adjusted 
PR (95% CI) |
| None  | 1.00 | 1.00 |
| Low-Moderate | 1.08 (0.88, 1.33) | 1.08 (0.88, 1.33) |
| Severe | 1.38 (1.16, 1.64) | 1.38 (1.16, 1.64) |

## Unadjusted and Adjusted Association of Child Maltreatment Severity with Any Diagnosis

## Child Maltreatment Severity with Two or More Diagnosis

|  | Two or more Diagnosis |  |
| --- | --- | --- |
| Maltreatment Severity | Unadjusted PR (95% CI) | Adjusted 
PR (95% CI) |
|   None  | 1.00 | 1.00 |
|   Low-Moderate | 1.52 (1.00, 2.31) | 1.53 (1.01, 2.32) |
|   Severe | 2.39 (1.64, 3.47) | 2.32 (1.59, 3.38) |
| Debt |  |  |
|   None | -- | 1.00 |
|   Some | -- | 1.00 (0.79, 1.27) |
|   Very Much | -- | 1.22 (0.99, 1.52) |

## Child Maltreatment Severity with Two or More Diagnosis

## Child Maltreatment Severity with Any Substance

|  | Any Substance |  |
| --- | --- | --- |
| Maltreatment Severity |  Unadjusted PR (95% CI) | Adjusted 
PR (95% CI) |
|   None  | 1.00 | 1.00 |
|   Low-Moderate | 1.94 (1.31, 2.88) | 1.92 (1.29, 2.85) |
|   Severe | 2.36 (1.62, 3.43) | 2.28 (1.56, 3.33) |
| Education |  |  |
|   > HS graduate | -- | 1.00 |
|   HS graduate/GED | -- | 1.03 (0.85, 1.24) |
|   < HS graduate | -- | 1.22 (1.03, 1.44) |

## Child Maltreatment Severity with Any Substance

## Child Maltreatment Severity with Mood

|  | Mood |  |
| --- | --- | --- |
| Maltreatment Severity | Unadjusted PR   (95% CI) | Adjusted PR  
(95% CI) |
|   None  | 1.00 | 1.00 |
|   Low-Moderate | 1.22 (0.75, 1.98) | 1.24 (0.76, 2.00) |
|   Severe | 2.17 (1.43, 3.30) | 2.09 (1.37, 3.19) |
| Debt |  |  |
|   None | -- | 1.00 |
|   Some | -- | 1.05 (0.75, 1.47) |
|   Very Much | -- | 1.30 (0.94, 1.80) |

## Child Maltreatment Severity with Mood

## Child Maltreatment Severity with Any Anxiety

|  | Any Anxiety |  |
| --- | --- | --- |
| Maltreatment Severity | Unadjusted PR    (95% CI)   | Adjusted PR         (95% CI) |
|   None  | 1.00 | 1.00 |
|   Low-Moderate | 1.04 (0.74, 1.47) | 1.02 (0.73, 1.43) |
|   Severe | 1.64 (1.23, 2.18) | 1.65 (1.25, 2.19) |
| Age |  |  |
|   18-24 | -- | 1.00 |
|   25-34 | -- | 1.38 (1.09, 1.76) |
|   35-45 | -- | 1.32 (1.03, 1.69) |

## Child Maltreatment Severity with Any Anxiety

## Child Maltreatment Severity with PTSD

|  | PTSD |  |
| --- | --- | --- |
| Maltreatment Severity | Unadjusted 
PR (95% CI) | Adjusted 
PR (95% CI) |
|   None  | 1.00 | 1.00 |
|   Low-Moderate | 1.82 (0.82, 4.04) | 1.68 (0.75, 3.76) |
|   Severe | 4.21 (2.06, 8.62) | 3.91 (1.90, 8.03) |
| Debt |  |  |
|   None | -- | 1.00 |
|   Some | -- | 1.23 (0.77, 1.97) |
|   Very Much | -- | 1.55 (1.00, 2.41) |
| Parental Boarding School |  |  |
|   No | -- | 1.00 |
|   Yes | -- | 1.58 (0.98, 2.53) |

## Child Maltreatment Severity with PTSD

## Child Abuse, Intimate Partner Violence and Mental Disorders

## Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate 

- Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate
- partner violence against Native American women: a cross-sectional study. *BMC Med, 2*(1), 20.

## Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate 

- Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate
- partner violence against Native American women: a cross-sectional study. *BMC Med, 2*(1), 20.

## Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate 

- Malcoe, L. H., Duran, B. M., & Montgomery, J. M. (2004). Socioeconomic disparities in intimate
- partner violence against Native American women: a cross-sectional study. *BMC Med, 2*(1), 20.

## Prevalence Ratios for Past Year Mental Disorders by   CAN, and IPV Variables N=234

|  
 CA and IPV | 
N (%) | Any Substance Abuse/Dep | 
PTSD
  |  |  | 
Any Anxiety Disorder |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Maximum Level of 
Childhood Abuse |  |  |  |  |  |  |  |  |
|      None to Minimal | 74 (32) | 1.0 |  |  | 1.0 |  |  | 1.0 |
|      Low to Moderate | 72 (31) | 1.9 (0.8, 4.5) |  |  | 2.1 (0.6, 6.5) |  |  | 1.5 (1.03, 2.2) |
|      Severe | 88 (37) | 1.9 (0.8, 4.4)
 |  |  | 4.6 (1.7, 12.8) |  |  | 2.0 (1.4, 2.8) |
| Maximum Level of 
Past  Year IPV |  |  |  |  |  |  |  |  |
|      None | 86 (37) | 1.0 |  | 1.0 |  |  | 1.0 |  |
|      Minor | 85 (36) | 0.9 (0.4, 2.0) |  | 1.6 (0.6, 3.9) |  |  | 1.4 (1.03, 2.0) |  |
|      Severe | 63 (27) | 1.5 (0.7, 7.1) |  | 3.1 (1.4, 7.1) |  |  | 1.5 (1.1, 2.1) |  |

## Prevalence Ratios for Past Year Mental Disorders by   CAN, and IPV Variables N=234

|  
 CA and IPV | 
N (%) | 
Mood Disorder | 
Any Disorder | 
2+ Disorders |
| --- | --- | --- | --- | --- |
| Maximum Level of 
Childhood Abuse |  |  |  |  |
|      None to Minimal | 74 (32) | 1.0 | 1.0 | 1.0 |
|      Low to Moderate | 72 (31) | 1.8 (0.9, 3.9) | 1.5 (1.1, 2.1) | 2.3 (1.1, 4.7) |
|      Severe | 88 (37) | 2.7 (1.4, 5.4) | 2.0 (1.5, 2.7) | 2.8 (1.4, 5.5) |
| Maximum Level 
of Past  Year IPV |  |  |  |  |
|      None | 86 (37) | 1.0 | 1.0 | 1.0 |
|      Minor | 85 (36) | 1.3 (0.7, 2.4) | 1.3 (1.04, 1.8) | 1.5 (0.9, 2.6) |
|      Severe | 63 (27) | 1.5 (0.8, 2.6) | 1.5 (1.1, 1.9)) | 1.6 (0.9, 2.9) |

## Prevalence Ratios for Past Year Mental Disorders by Single “Abuse/Violence” Variable

|  Childhood Abuse and Past Year IPV | N | Mood Disorder | Any Disorder | 2+ Disorders |
| --- | --- | --- | --- | --- |
| Neither | 34 | 1.0 | 1.0 | 1.0 |
| Childhood Abuse Only | 52 | 1.4 (0.5, 3.8) | 2.4 (1.3, 4.4) | 2.8 (0.9, 9.2) |
| Past Year IPV only | 40 | 0.7 (0.2, 2.3) | 2.0 (1.1, 3.7) | 1.7 (0.5, 6.3) |
| Both | 105 | 2.1 (0.9, 5.0) | 2.8 (1.6, 5.0) | 3.9 (1.3, 11.8) |

## Cultural Identification

| Cultural Identification | Number  | Percent |
| --- | --- | --- |
| Indian way |  |  |
|      Not at All | 45 | 19 |
|      A Little | 48 | 20 |
|      Some | 64 | 27 |
|      A Lot | 78 | 33 |
| White/American Way |  |  |
|      Not at All | 52 | 22 |
|      A Little | 49 | 21 |
|      Some | 65 | 28 |
|      A Lot | 69 | 29 |
| Bi-Cultural |  |  |
|      Not at All | 41 | 17 |
|      A Little | 60 | 25 |
|      Some | 52 | 22 |
|      A Lot | 82 | 35 |

**39**%

**33**%

**42**%

## Utilization of Traditional Healing Services

| Have you seen a medicine person for physical health, drug or alcohol or mental health problem? | 
Number | 
Percent |
| --- | --- | --- |
|      Never | 106 | 45 |
|       Yes-not past year | 52 | 22 |
|       Yes-past year | 77 | 33 |

## Conclusions

## Native American Women in Primary Care

- Have very high rates of exposure to child maltreatment
- CAN is a general risk factor for mental disorders
- CAN is a specific risk factor for PTSD
- Community and policy level interventions are warranted

## Source: Broken Promises: Evaluating the Native American Health Care System. (Draft)(2004). 

*Source: Broken Promises: Evaluating the Native** **American Health Care System*. (Draft)(2004).
- Washington DC: US Commission on Civil Rights: Office of the General Counsel.

## Slide 59

## Slide 60