RESEARCH ARTI CLE Open Access

Abuse and mental disorders among women at

walk-in clinics in Trinidad: A cross-sectional study
Rohan G Maharaj
1*
, Colanne Alexander
2
, Candace H Bridglal
2
, Aysha Edwards
2
, Hassina Mohammed
2
,
Teri-Ann Rampaul
2
, Sharlene Sanchez
2
, Gina P Tanwing
2
, Kristy Thomas
2
Abstract
Background: To determine the prevalence of abuse by their partners and its association with mental disorders
among female patients at walk-in clinics in Trinidad.
Methods: 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.
Results: 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.
Conclusion: 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.
Background
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% [1,2], among currently pregnant, 9.2%
[3], in the emergency room, 8% [4], and at the fee-for-
service family practices, 27% [5]. 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 disor-
ders associated with such abuse and reports suggest that
there is a greater likelihood of depression [6], multiple
somatic complaints [7] and post-traumatic stress disor-
der symptomatology [8].
Our objective was to determine the prevalence of
woman abuse and the mental disorders associated with
this experience, and further to explore which demo-
graphic factors may predict the likelihood of such abuse
at walk-in clinics in Trinidad.
Methods
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 pro-
blem). 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 knowl-
edge of attendance rates, 16 clinics were chosen
* Correspondence: [email protected]
1
The Unit of Public Health and Primary Care, Faculty of Medical Sciences,
The University of the West Indies, St. Augustine, Trinidad
Maharaj et al. BMC Family Practice 2010, 11:26
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2010 Maharaj et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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.
Persons who presented with an emergency were
excluded.
The WAST-Short (Woman Abuse Screening Tool-
Short Form) was used to determine the presence of
abuse among women. This tool has been shown to
accurately detect 100% of non-abused women and 91.7%
of abused women [9]. Only the 2 questions of the Short
Form were used in an attempt control the number of
questions in the survey instrument and to reduce
respondent fatigue. The WAST-Short was used because
a locally developed and validated scale was longer and
had been found to have a low positive predictive value
[5]. Additionally, the other major instrument in the
questionnaire (see below) had a component for studying
physical and sexual abuse.
The PRIME-MD PHQ (Primary Care Evaluation of
Mental Disorders-Patient Health Questionnaire) has a
specificity of 90%, a sensitivity of 75% and is used for the
screening of minor psychiatric disorders and illnesses
[10,11]. This questionnaire is based on the DSM-IV and
has been used in many populations [12-15] and medical
settings [16-19] and collects mental health, social and
medical information and as noted above assisted in col-
lecting information on physical and sexual abuse.
The WAST-Short scored as positive if a woman gave a
response of a lot of tension, or some tension to the
question: In general, how would you describe your present
intimate relationship? Or if the woman completes the
phrase: Do you and your partner work out arguments
with... with great difficulty or some difficulty. The com-
bined questionnaire was piloted and found to be easily
understood; inter-rater reliability was not tested.
Responses to the PRIME-MD questionnaire were scored
based on the Reference Guideline for Interpreting the
Patient Health Questionnaire and Brief PHQ and the
scores were used to determine the possibility of being at
risk for having a mental disorder [20]. Demographic
characteristics were also collected. Questionnaires were
applied by trained interviewers. All authors except RGM
carried out the interviews. Data were analysed using
SPSS v.12. Associations between independent variables
and the presence of woman abuse were analyzed using
the chi-square test with a statistical significance of 5%.
Regression analysis was carried out to determine which
independent variables predicted the presence of woman
abuse as defined by the WAST-Short.
This study was approved by the Ethics Committee of
the Faculty of the Medical Sciences, The University of
the West Indies (St. Augustine campus) and the relevant
regional health authorities (RHAs) and was coordinated
and supervised by the first author and conducted by
medical students as part of their compulsory year-2
undergraduate research project. Patients were informed
that the study was to understand common psychological
and social problems among patients at the walk-in
clinics and consent was obtained from all participants.
Privacy was maintained by conducting the interviews on
a one-to-one basis in a quiet part of the waiting room.
However total seclusion was not possible because of the
limited space and large volumes of patients at these
clinics.
Results
Four hundred and thirty two women responded (a 92%
response rate), 49.5% were between 18 and 49 years;
37% were married. Indo-Trinidadians made up 44.7%
and 35% were Afro-Trinidadian. Those who had
achieved education up to age 14 only represented 67.8%,
30.3% were employed and 3.0% received more than
TTD $5,001 per month ($1 USD = $6.3 TTD). Table 1
gives further details of the participants demographic
characteristics.
Forty percent (173) of all respondents were positive
for abuse as scored by the WAST-Short scale. Younger
women were more likely to report abuse with those
between the ages 20 - 49 reporting an average of 54.1%
versus those between the ages 50 - 61 who reported an
average of 31.4%. Women who were married (55.6%), in
common-law relationships (40.7%) or single (66.7%)
were more likely to report abuse versus 2% of all other
groups. All major ethnic groups Indo- (37.8%), Afro-Tri-
nidadians (44.4%) and mixed (37.9%) reported abuse.
Higher proportions of women with lower educational
achievements reported abuse (40.7%) versus 34.8% of
women with higher achievements. However women with
employment were more likely to report abuse (50.4%)
versus 35.6% of unemployed. Similarly, among women
who were in the higher income bracket, 53.9% reported
abuse versus 39.6% of women in the lower income
bracket. See Table 2.
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 lit-
tle by thinking or dreaming about something terrible
that happened to them in the past. There was a statisti-
cally significant association between reports of abuse
and PTSD with 48.9% of the women who were both-
ered a lot and 58.5% of the women who were bothered
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a little reporting abuse, compared with 35.1% of respon-
dents who were not bothered.
Alcohol abuse
There was a statistically significant association between
reports of abuse and womens 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. See Table 3.
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.
Additional analysis
Chi-square analysis suggested association (p < 0.05)
between history of abuse and age, employment status,
current relationship, the desire to cut down on alcohol
intake, and the presence of symptoms of depression,
PTSD and somatization. Tables 2 and 3 provide more
details of the chi-square analysis. Logistic regression
showed that statistically significant (p < 0.05) predictors
of woman abuse were age less than 50, wanting to cut
down on alcohol use and being in a relationship. See
Table 4.
Discussion
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 pre-
dictors 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
Table 1 Demographic description of 432 female
participants in a survey of abuse and mental disorders in
Trinidad.
Variable N (%)
Age Group
(years)
18-19 12 (2.8)
20-29 69 (16.0)
30-39 51 (11.8)
40-49 82 (19.0)
50-59 91 (21.1)
60-69 87 (20.1)
70 40 (9.3)
Marital
Status
Married 160 (37.0)
Single 108 (25.0)
Divorced 21 (4.9)
Separated 20 (4.6)
Common law 57 (13.2)
Visiting 64 (14.8)
Widowed 1 (0.2)
Others 1 (0.2)
Ethnicity Indo-Trinidadian* 193 (44.7)
Afro-Trinidadian** 151 (35.0)
Mixed 87 (20.1)
Others 1 (0.2)
Monthly
Income
<$1,000 100 (23.1)
$1,001-$2,500 149 (34.5)
$2,501-$5,000 52 (12.0)
>/= $5001 13 (3.0)
Does Not Know 85 (19.7)
No Response 33 (7.6)
Education Primary school (approximately Grade 5) 55 (12.7)
School Leaving (Approximately Grades 5-6) 52 (12.0)
Secondary School (approximately Grades 6
and above)
83 (19.2)
Higher Education (Certificate/Diploma,
Degree)
41 (9.5)
Others 15 (3.5)
None 186 (43.1)
Employment Yes 131 (30.3)
No 301 (69.7)
* or ** Trinidadians of South Asian or African descent
A long-term relationship where a common home is not shared,
participants may live at their family of origin or independent premises
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Table 2 The association between demographic variables and the presence of a positive response on the Woman
Abuse Screening Tool-Short form (WAST-Short).
Positive response on WAST-Short Positive response on WAST-Short p-value*
Yes N (%) No (%)
Education NS
Lower achievement 157 (40.7) 229 (59.3)
Higher achievement 16 (34.8) 30 (65.2)
Age < 0.001
49 years and less 115 (53.7) 99 (46.4)
50 years and more 58 (26.6) 160 (72.4)
Employment 0.003
Employed 66 (50.4) 65 (49.6)
Un-employed 107 (35.6) 194 (64.4)
Income NS
< $4, 999 TTD 166 (39.6) 253 (60.4)
$5, 000 TTD and more 7 (53.9) 6 (46.1)
Relationship 0.002
Current (e.g. married, common-law) 127 (70.2) 154 (29.8)
None (e.g. widowed, divorced) 46 (30.5) 105 (69.5)
*Fishers exact test
Table 3 The association between mental health symptoms and the presence of a positive response on the Woman
Abuse Screening Tool-Short form (WAST-Short).
Positive response on WAST-Short Positive response on WAST-Short p-value*
Yes
N (%)
No
N (%)
Would like to cut down on alcohol use 0.011
Yes 16 (64.0) 9 (36.0)
No 157 (38.6) 250 (61.4)
Possible depression 0.001**
Major depression 23 (69.7) 10 (30.3)
No depression 117 (31.3) 206 (68.7)
Other depressive disorder 33 (44.0) 42 (58.0)
Suicidal ideation 0.018
Yes 12 (66.7) 6 (33.3)
No 161 (38.9) 253 (61.1)
Possible somatization 0.014
Yes 59 (48.8) 62 (51.2)
No 114 (36.7) 197 (63.3)
Possible anxiety disorder 0.072
Yes 14 (56.0) 11 (44.0)
No 159 (39.1) 248 (60.9)
Possible Post Traumatic Stress Disorder 0.001**
Not Bothered*** 113 (35.1) 209 (64.9)
Bothered a little 38 (58.5) 27 (41.5)
Bothered a lot 22 (48.9) 23 (51.1)
Reported physical or sexual abuse in the past year < 0.001
Yes 25 (71.4) 10 (28.6)
No 148 (37.3) 249 (62.7)
*Fishers exact test
** Pearson Chi-square
*** About something terrible that has happened in the past.
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care populations worldwide. Its results add to the Carib-
bean 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.
These findings are consistent with the recent medical
literature [6-8,21].
Another potentially important finding is the relation-
ship between the symptoms which bothered the partici-
pants 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 con-
sidered 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 com-
fortable 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 sta-
tus. 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 ill-
ness so these results set the scene for further investiga-
tion using prospective studies. Future research should
focus on refining the prevalence of the mental disorders
found and confirming the findings using validated diag-
nostic tests. Additionally we need to document if the
patients quality of life is presently severely enough
affected such that treatment was required and subse-
quently if this treatment was successful over time.
These results have a myriad of implications for pri-
mary care first contact clinics in Trinidad. Firstly these
clinics and similar ones in Trinidad have a history of
very large numbers of patients, and very short consulta-
tion times [22]. Yet results from studies such as this and
those reported above [1-5] support the international
findings [10,12,13,23] of a high level of mental health
morbidity among primary care patients of woman abuse
and other conditions including depression, anxiety, and
posttraumatic stress disorder. Such conditions require a
much longer consultation to recognize and initiate treat-
ment plus sizable resources to support the primary care
worker. It has been well documented that mental health
continues to be under-funded, under-researched and
poorly resourced in the developing world [24]. Papers
such as this one continue to provide advocates with the
evidence to entreat the political powers to provide the
financial and human resources required to address these
issues and educators with the conviction to train their
students with these curricula.
Conclusions
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 Eva-
luation of Mental Disorders (PRIME-MD) scale.
Table 4 Results of Binary Logistic Regression analysis to
determine the independent variables associated with the
presence of a positive response to the Woman Abuse
Screening Tool-Short form (WAST-Short) among female
attendees at walk-in clinics in Trinidad.
Independent Variable Odds Ratio
(95% CI)
p value
Education
Lower vs. Higher achievement 1.57 (0.75-3.26) NS
Age < 0.001
>/= 50 vs. </= 49 y 3.42 (2.18-5.34)
Employment NS
Unemployed vs. Employed 1.48 (0.91-2.39)
Income NS
> $5000 vs. <$4 999 TTD/mo 0.69 (0.195-2.46)
Presently in a relationship < 0.001
No vs. Yes 2.63 (1.62-4.25)
Would like to cut down on alcohol 0.045
No vs. Yes 2.48 (1.02-6.02)
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Author details
1
The Unit of Public Health and Primary Care, Faculty of Medical Sciences,
The University of the West Indies, St. Augustine, Trinidad.
2
Faculty of Medical
Sciences, The University of the West Indies, St. Augustine, Trinidad.
Authors contributions
All authors contributed to the conception and design; all authors except
RGM assisted in the acquisition of data; all authors contributed to the
analysis and interpretation of data and have been involved in the drafting of
the manuscript or revising it critically for important intellectual content; and
have given final approval of the version to be published.
Competing interests
The authors declare that they have no competing interests.
Received: 11 November 2009 Accepted: 30 March 2010
Published: 30 March 2010
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Cite this article as: Maharaj et al.: Abuse and mental disorders among
women at walk-in clinics in Trinidad: A cross-sectional study. BMC Family
Practice 2010 11:26.
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