 RESEARCH AND PRACTICE 
Interpersonal Violence in the Lives of Urban
American Indian and Alaska Native Women:
Implications for Health, Mental Health, and Help-Seeking
| Teresa Evans-Campbell, PhD, Taryn Lindhorst, PhD, Bu Huang, PhD, and Karina L. Walters, PhD
Violence against women is a significant public
health problem. Although a growing body of
literature documents the consequences of in-
terpersonal violence for the health and men-
tal health of women,1–3 very few studies have
examined the relation between interpersonal
violence and health and mental health out-
comes among American Indian/Alaska Native
(AIAN) women. This discrepancy in the litera-
ture 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% report-
ing 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 do-
mestic 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 seri-
ous health problems, such as self-neglect, sex-
ually 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 is-
sues and reduced immunity to illness in gen-
eral,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 re-
sult of victimization. Among samples of non-
Native women, those who have been battered
or who have experienced sexual assault have
1416 | Research and Practice | Peer Reviewed | Evans-Campbell et al.
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 associ-
ated 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 inter-
personal violence, of which 28% reported childhood physical abuse, 48% re-
ported rape, 40% reported a history of domestic violence, and 40% reported mul-
tiple 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 in-
crease 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 im-
plications for health and mental health professionals. (Am J Public Health. 2006;
96:1416–1422. doi:10.2105/AJPH.2004.054213)
higher rates of severe mental disorders, in- based samples typically report high rates of
cluding depression, anxiety, and posttraumatic violence across types of victimization. For in-
stress disorder.1,3 In several categories, the stance, in 1 of the few studies to explore mul-
rates of distress for survivors of violence are tiple experiences of victimization across the
double, and sometimes triple those of women lifespan of AIAN women,15 27% reported
who have not been abused.7 Violence itself childhood physical abuse, 40% reported
has been found to be more predictive of de- child sexual abuse, 40% reported experienc-
pression in battered women than preexisting ing adult sexual assault, and 67% reported
mental disorders, demographics, or develop- physical violence from an adult partner. Yet,
mental characteristics.3 Among AIAN women although there is ample evidence that inter-
specifically, preliminary evidence indicates personal violence among AIAN women is
that violent victimization is related to depres- high, the relation between violence and
sion, posttraumatic stress disorder, suicide at- AIAN women’s health has not been ad-
tempts, and alcohol use.14 dressed, and research exploring interpersonal
Previous studies of AIAN women represent violence among urban AIAN women is al-
an initial investigation of interpersonal vio- most nonexistent.
lence, but most are limited by their use of
tribally specific and/or reservation-based American Indians and Alaska Natives in
samples. The only nationally representative Urban Areas
survey to include AIAN women, the National Contrary to their common stereotype as
Violence Against Women Survey, relied on a rural or reservation-based people, more than
subsample of 88 AIAN women out of a total 60% of AIAN people currently live in urban
sample of 16 000 for its results. Reservation- settings.16 In the past several decades, AIAN
American Journal of Public Health | August 2006, Vol 96, No. 8

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 Na-
tives at risk for a host of biopsychosocial
problems,17,18 including vulnerability to HIV
infection.19 Despite these high rates of urban-
ization, the Indian Health Service, which pro-
vides 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 (do-
mestic 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
The current investigation was part of a
comprehensive assessment of HIV risk behav-
iors 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 popula-
tion of American Indians and Alaska Natives
in the country (98 922 American Indian and
Alaska Native alone or with other races, ac-
cording to the 2000 US Census16 ). In order
to increase item clarity, coherence, and cul-
tural relevance, the survey was piloted and
reviewed by American Indian and Alaska
Native key informants, focus groups, and re-
search consultants before its administration.
Given the difficulty in randomly sampling
urban AIAN populations, and the large sam-
ple needed for random-digit dialing, an alter-
native means for obtaining a representative
sample was devised. The sampling plan used
a multiple-wave sampling approach with
modified respondent-driven sampling, chain
August 2006, Vol 96, No. 8 | American Journal of Public Health
 RESEARCH AND PRACTICE 
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 mem-
bership list for a local AIAN community cen-
ter. 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 strat-
ified random sampling technique and divided
our list into 18 strata by geographic location
and gender (e.g., Brooklyn males and fe-
males). The number of potential nominators
randomly selected was proportionate to the
size of that stratum within the AIAN popula-
tion, as defined by US Census data (5% sam-
ple 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 tar-
geted 20 American Indians and Alaska Na-
tives who did not affiliate with the commu-
nity 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 (de-
fined as someone they would feel comfort-
able calling on the phone) and who lived
within a 70-mile radius of New York City.
Respondent lists varied in size, with some re-
spondents providing only 1 name, and others
providing many more. From these network
lists, network members were randomly se-
lected to enroll in the study using a predeter-
mined, 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
Evans-Campbell et al. | Peer Reviewed | Research and Practice | 1417
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 partici-
pants (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 pro-
tocol. After obtaining informed consent, inter-
viewers read questions from a printed ques-
tionnaire and recorded participants’ responses.
All participants indicated that they spoke flu-
ent English, and all interviews were con-
ducted in English. For sexual behavior items,
the participant could opt to privately record
responses on the interview form. Study partic-
ipants received $35 compensation per inter-
view 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 school-
ing, with a mean of 14 years. Participants’ in-
come levels were quite low compared with
residents of New York City in general. Among
those who provided the information on in-
come, the median household income level
was between $30 000 and $39 999, com-
pared 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 sec-
tions: demographics and family history;
health and health services; stress and mental
health; cultural factors; traumatic event expo-
sure; alcohol and drug use; high–HIV risk
sexual behaviors (HIV sexual risk); and mili-
tary service.

Control variables. We explored a number of
potential control variables for the study. How-
ever, 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 dichoto-
mized as less than $20 000 (32.4%) versus
$20 000 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 Psy-
chiatric 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 be-
fore the age of 18 years. To measure domes-
tic 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 be-
cause 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 out-
come variables. Several areas of health and
mental health were explored—self-rated health,
lifetime depression and dysphoria, current de-
pression 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. Life-
time depression and dysphoria items were
based on the Semi-Structured Assessment for
1418 | Research and Practice | Peer Reviewed | Evans-Campbell et al.
 RESEARCH AND PRACTICE 
the Genetics of Alcoholism measure22 (e.g., Level of trauma in response to interpersonal
“Have you ever had a period of time lasting violence was assessed by asking respondents
at least one week when you were bothered to rate their level of trauma on a 7-point
most of the day, nearly every day, by feeling scale, from 1 (not at all traumatic) to 7 (ex-
depressed, sad, uninterested, or irritable, even tremely traumatic), both at the time of the in-
if you felt OK sometimes?”). This assessment cident and at the time of the interview.
has been adapted for and used successfully
Data Analysis
with urban AIAN populations.23 Current de-
We began our data analysis by examining
pression and current anxiety were measured
the descriptive statistics of study variables.
using the Brief Symptom Inventory subscales
Chi-square tests were then performed to ex-
for depression and anxiety.24 Respondents
amine the bivariate associations among vari-
were asked to rate items on a 5-point scale,
ables. Because of the strong correlations
from 0 (not at all) to 4 (extremely) for the
among the interpersonal abuse variables, 5
previous 7 days (e.g., “In the last 7 days, how
sets of multivariate logistic regression models
much were you bothered by feeling no inter-
were developed for the data: each model in-
est in things?”). HIV sexual risk was assessed
cluded 1 type of abuse history control for age
by asking participants to indicate whether or
and income. Complete case analysis was used
not they had engaged in any of 10 HIV sex-
for modeling, and all variables were retained
ual risk behaviors since 1980 (e.g., sex with
in each model, regardless of statistical signifi-
an HIV-positive person). The HIV sexual risk
cance. All analyses were performed with
questions were developed and piloted specifi-
SPSS Version 11 (SPSS Inc, Chicago, Ill).
cally for AIAN populations in previous stud-
ies,12,25 and have since been successfully used
RESULTS
in other studies.13
Two types of help-seeking were assessed:
Overall, 75.7% of the women rated their
seeking mental health counseling, and seeking
health as good to excellent. A majority of the
traditional Native healing interventions. Seek-
women (64.5%) reported ever having a pe-
ing conventional mental health counseling was
riod of depression, 50.9% reported a history
measured by asking, “Have you ever spoken
of dysphoria, and 86.9% reported having
to a professional about any emotional prob-
engaged in unsafe sex. Most women (60.7%)
lems you might have had?” Questions related
had attended mental health counseling at
to seeking traditional Native healing were
some point, whereas 67.9% had utilized a
adapted from the American Indian Service
traditional Native healing method.
Utilization, Psychiatric Epidemiology, Risk,
and Protective Factors Project study26 (e.g., Interpersonal Violence and Trauma
“In the past year, have you been to see a The majority of women in the sample
medicine man/woman for your health and (65.5%) had experienced at least 1 form of
general well-being?”). interpersonal violence. As shown in Table 1,
TABLE 1—Types of Interpersonal Violence Experienced, by Level of Trauma and Age at Time
of Abuse, by American Indian/Alaska Native Women: New York City, 2000–2003 (n = 112)
Child Touched No
Physical Against Domestic Multiple Abuse
Abuse Rape Will Violence Victimization History
Percentage of women who 28.2 (31) 48.2 (53) 41.7 (45) 40 (44) 41 (46) 34 (38)
experienced (no.)
Mean level of trauma at timea 6.41 6.43 6.07 6.33 ... ...
Mean level of trauma nowa 3.84 3.96 3.88 3.20 ... ...
Mean age at abuse, y 10.83 18.39 11.41 29.58 ... ...
a
Mean of possible response scale ranging from 1 to 7.
American Journal of Public Health | August 2006, Vol 96, No. 8
  RESEARCH AND PRACTICE 

TABLE 2—Types of Childhood Trauma Experienced by American Indian/Alaska Native Women the percentage of women who had ever expe-
(%), by Demographic and Health Characteristics: New York City, 2000–2003 (n = 112) rienced depression was higher among sur-
vivors (ranging from 67.7% to 83%, depend-
Child Touched No ing on the type of violence history) than
Physical Against Domestic Multiple Abuse
among those with no history of interpersonal
Abuse Rape Will Violence Victimization History
violence (44.7%). A history of dysphoria was
Income also higher among women who had experi-
$0–$20 000 44.4 44.9 31.7 33.3 37.2 21.2 enced violence (ranging from 35.6% to
>$20 000 55.6 55.1 68.3 66.7 62.8 78.8 47.2%, depending on type of violence his-
Work full-time 40 30.8 31.8 38.6 37.8 39.5 tory) than among those with no history of vio-
Health and mental health lence (11.8%). Those with a history of inter-
Self-rated health personal violence were more likely to seek
Good—excellent 66.7 69.2 75 76.7 73.3 81.6 help—both conventional counseling services
Poor—fair 33.3 30.8 25 23.3 26.7 18.4 and traditional healing. Although 45% of
Ever depressed 67.7 83.0 77.8 70.5 71.7 44.7 women with no history of violence had ac-
Ever dysphoric 45.2 47.2 35.6 36.4 41.3 11.8 cessed conventional counseling services, be-
HIV sexual risk 96.6 94.0 95.6 95.1 95.3 72.2 tween 58.1% and 71.7% (depending on type
Help-seeking of violence) of survivors had accessed such
Sought counseling 58.1 50.9 60.7 70.5 71.7 45.0 services. Among women who had experi-
Sought traditional 71.0 77.4 82.2 65.9 73.0 57.9 enced interpersonal violence, rates of seeking
Native healinga traditional interventions ranged from 65.9%
a to 82.2%, compared with those with no his-
At least 1 of 5 traditional healing practices.
tory of interpersonal violence (57.9%). Of
particular note were results in the area of
HIV sexual risk behavior. Women who had
28.2% reported a history of childhood physi- to 7 (highest), the average level of trauma re- experienced any type of interpersonal vio-
cal assault, 48.2% reported a history of rape ported at the time of the incident was be- lence had dramatically high rates of engaging
in their lifetime, 41.7% stated that they had tween 6 and 7 for every type of interpersonal in HIV sexual risk behaviors (ranging from
been touched against their will at some point violence. Although current levels of trauma in 94% to 96.6%, depending on type of vio-
in their life, and 40.0% indicated that they response to these incidents were significantly lence history) compared with women with no
had experienced assault from a spouse or lower, women still reported violence-related history of interpersonal violence (72.2%).
romantic partner as an adult. In addition, levels of trauma to be between 3 and 4 at the
41.0% of the women reported experiencing time of the interview. Interpersonal Violence, Mental Health,
multiple victimization, defined as experienc- Table 2 illustrates differences in demo- Help-Seeking, and HIV Risk
ing at least 2 types of the interpersonal vio- graphic characteristics, mental health, HIV Table 3 presents the multivariate analyses
lence explored in the study. Women who had sexual risk behaviors, and help-seeking of types of interpersonal violence and having
experienced any type of interpersonal vio- among women who experienced different a history of mental health problems, using
lence had high levels of traumatization at the types of interpersonal violence. Among sur- conventional mental health or traditional
time of the assault. On a scale from 1 (lowest) vivors of all types of interpersonal violence, healing services, and engaging in HIV sexual

TABLE 3—Interpersonal Violence Experience and Mental Health, Help-Seeking, and HIV Sexual
Risk Behaviorsa (Odds Ratios and 95% Confidence Intervals) Among American Indian/Alaska
Native Women: New York City, 2000–2003 (n = 112)

Ever Depressed Ever Dysphoric Sought Counseling Sought Native Healing HIV Risk

Childhood physical abuse (vs none) 0.63 (0.24, 1.67) 1.51 (0.50, 3.90) 0.89 (0.33, 2.38) 1.26 (0.44, 3.58) 9.94 (0.84, 118.12)
Sexual assault (vs none) 4.44 (1.74, 11.30) 4.76 (1.93, 11.73) 5.27 (2.06, 13.47) 3.10 (1.23, 7.78) 28.44 (3.33, 243.28)
Domestic violence (vs none) 1.85 (0.75, 4.60) 1.93 (0.82, 4.56) 1.76 (0.71, 4.35) 0.49 (0.19, 1.24) 5.60 (0.92, 34.24)
Multiple victimization (vs other) 3.19 (1.87, 5.47) 2.73 (1.14, 6.51) 1.94 (0.80, 4.80) 1.26 (0.50, 3.13) 10.00 (1.36, 73.68)
Never abused (vs ever abused) 0.28 (0.11, 0.73) 0.15 (0.05, 0.42) 0.33 (0.15, 0.75) 0.47 (0.18, 1.20) 0.02 (0.00, 0.24)
a
Controlled for age and income level.

August 2006, Vol 96, No. 8 | American Journal of Public Health Evans-Campbell et al. | Peer Reviewed | Research and Practice | 1419

risk behaviors. Women who had a history of
sexual assault were significantly more likely
than others to report ever having been de-
pressed or dysphoric (odds ratio [OR] = 4.44
and 4.76, respectively), use of mental health
counseling services (OR = 5.27), and use of
traditional healing (OR = 3.10). In addition,
sexual assault was significantly associated
with engaging in HIV sexual risk behaviors
(OR = 28.44). Having experienced multiple
victimization was significantly related to ever
having been depressed or dysphoric (OR =
3.19 and 2.73, respectively) and engaging in
HIV sexual risk behaviors (OR = 10.00). Inter-
estingly, analyses conducted on the effect of
victimization on general self-report of health
and current levels of mental health (depres-
sion or dysphoria in the previous 7 days)
showed no significant relation with any type
of interpersonal violence.
Women who had never experienced child
physical abuse, sexual assault, or domestic
violence were significantly less likely to have
experienced periods of depression (OR =
0.28) or dysphoria (OR = 0.15) than women
who had a history of any type of interper-
sonal violence. Moreover, they were less
likely to use counseling services (OR = 0.33)
or engage in sexual risk behaviors (OR =
0.02) than those who had experienced at
least 1 interpersonal assault.
DISCUSSION
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 out-
comes. 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 trau-
matic 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
1420 | Research and Practice | Peer Reviewed | Evans-Campbell et al.
 RESEARCH AND PRACTICE 
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 fo-
cused specifically on American Indians and
Alaska Natives.30,31 It is important to note how-
ever, that the current sample is community-
based, whereas these reservation-based re-
search 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 phys-
ical abuse, sexual assault, and domestic vio-
lence are higher than those found in a re-
cent community-based study of trauma
exposure in 2 large reservation communi-
ties.6 Community-based research that com-
pares rates of violence among those living on
reservations with that of those in urban set-
tings is needed to determine if there are risk
or protective factors associated with differ-
ences in geographic location or social capital
(e.g., higher level of education).
Although interpersonal violence was associ-
ated with a lifetime experience of depression
and dysphoria, it was not associated with cur-
rent mental health, in contrast to previous re-
search findings.14,15 Two possibilities might ex-
plain 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 pe-
riod, 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 vari-
ous measures of mental health/distress as
well as the developmental trajectories related
to adjustment after abuse.
American Journal of Public Health | August 2006, Vol 96, No. 8
Victimization was also not associated with
the respondents’ general self-assessment of
health. However, having ever been victim-
ized, having had multiple experiences of vic-
timization, and particularly having been sexu-
ally assaulted were all associated with a
substantial increase in sexual risk behaviors.
Notably, 6% of the women in the sample re-
ported being HIV-positive, a rate that is signif-
icantly 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 sta-
tus. However, previous research has found
that various forms of violence against women
increase the risk of HIV infection,13,32 suggest-
ing 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 sex-
ual assault were significantly more likely than
others to access both forms of help. One pos-
sible explanation for this finding is that there
are an increasing number of services avail-
able 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, con-
sequently, sexual assault victims may have
been more driven to seek out help.
Implications
Our findings have several important impli-
cations for research and practice with AIAN
women. First, the overwhelming frequency of
AIAN women reporting some form of trau-
matic victimization highlights the need for
strong violence prevention efforts targeted at
urban communities. Scholars and practition-
ers should promote culturally responsive
standards of training for violence prevention
efforts aimed specifically at urban AIAN
women. For women who have already experi-
enced violence, providers should focus on the

prevention of related health and mental
health issues. To assist in this regard, it is in-
cumbent upon service providers to complete
an in-depth assessment of interpersonal vio-
lence, exploring the types and frequency of
interpersonal violence experiences, current
levels of trauma associated with these experi-
ences, and the possibility of ongoing health/
mental health sequelae.
Second, our results show that AIAN
women are likely to seek out help after expe-
riencing 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 profession-
als have unique opportunities in terms of pre-
vention, assessment, and intervention. Receiv-
ing 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 stan-
dard mental health services, or as an alterna-
tive. 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 inter-
ventions, we do not have information regard-
ing access to and quality of these interven-
tions. 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 satis-
faction 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 net-
work 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 typi-
cally the norm in studies of American Indians
August 2006, Vol 96, No. 8 | American Journal of Public Health
 RESEARCH AND PRACTICE 
and Alaska Natives. Because the sample was
generated in New York City, these levels may
reflect differences that are unique to that geo-
graphic location. In addition, the research de-
sign is cross-sectional, and so cannot offer in-
sight into the causal relationships among the
constructs studied or the developmental cor-
relates for violence and its health/mental
health outcomes, suggesting that longitudinal
research related to these factors is needed.
Notwithstanding these limitations, our find-
ings highlight the significance of the problem
of interpersonal violence in urban AIAN com-
munities, and underscore the need for ad-
vanced statistical models that identify media-
tional pathways to various health and mental
health outcomes.
About the Authors
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 Well-
ness Center of the School of Social Work, University of
Washington.
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@u.washington.edu).
This article was accepted October 25, 2005.
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 con-
tributed to writing. K. L. Walters was principal investiga-
tor of the project upon which this study was based, and
assisted in editing the article.
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
The protocol was approved by the institutional review
boards of Columbia University, New York, NY, and the
University of Washington, Seattle, WA.
References
1. Golding JM. Intimate partner violence as a risk
factor for mental disorders: a meta-analysis. J Fam Vio-
lence. 1999;14:99–132.
2. Campbell JC, Lewandowski LA. Anger, aggression
and violence: mental and physical health effects of inti-
mate partner violence on women and children. Psychi-
atr Clin North Am. 1997;20:353–374.
Evans-Campbell et al. | Peer Reviewed | Research and Practice | 1421
3. Resnick HS, Aciemo R, Kilpatrick DG. Health im-
pact of interpersonal violence 2: Medical and mental
health outcomes. Behav Med. 1997;23:65–79.
4. Tjaden P, Thoennes N. Full Report on the Preva-
lence, Incidence and Consequences of Violence Against
Women. Washington, DC: National Institutes of Justice;
2000. Publication NCJ 183781.
5. Greenfield LA, Smith SK. American Indians and
Crime. Washington, DC: Department of Justice; 1999.
Publication NCJ 173386.
6. Manson S, Beals J, Klein S, Croy C, and the
AI-SUPERPFP Team. Social Epidemiology of Trauma
Among 2 American Indian Reservation Populations.
Am J Public Health. 2005;95:851–859.
7. Arbuckle J, Olson L, Howard M, Brillman J, Anctil C,
Sklar D. Safe at home? Domestic homicides among
women in New Mexico. Ann Emerg Med. 1996;27:
210–215.
8. Tjaden P, Thoennes N. Extent, Nature and Conse-
quences of Intimate Partner Violence: Findings from the
National Violence Against Women Survey. Washington,
DC: National Institute of Justice and Centers for Dis-
ease Control; 2000. Publication NCJ 181867.
9. Coker A, Smith P, Bethea L, King M, McKeown R.
Physical health consequences of physical and psycho-
logical intimate partner violence. Arch Fam Med. 2000;
9:451–457.
10. Sutherland CA, Sullivan CM, Bybee DI. Effects of
intimate partner violence versus poverty on women’s
health. Violence Against Women. 2001;7:1122–1143.
11. Campbell J, Jones A, Dienemann J, et al. Intimate
partner violence and physical health consequences.
Arch Intern Med. 2002;162:1157–1163.
12. Walters K, Simoni J. Trauma, substance use, and
HIV risk among urban American Indian women. Cultur
Divers Ethnic Minor Psychol. 1999;5:236–248.
13. Simoni J, Sehgal S, Walters K. Triangle of risk:
urban American Indian women’s sexual trauma, injec-
tion drug use, and HIV sexual risk behaviors. AIDS
Behav. 2004;8:33–45.
14. Hamby SL, Skupien MB. Domestic violence on
the San Carlos Apache reservation: rates, associated
psychological symptoms and current beliefs. IHS Prim
Care Provid. 1998;23:103–106.
15. Robin RW, Chester B, Rasmussen JK, Jaranson JM,
Goldman JK. Prevalence and characteristics of trauma
and posttraumatic stress disorder in a southwestern
American Indian community. Am J Psychiatry. 1997;
154:1582–1588.
16. US Bureau of the Census. 2000 Census Counts of
American Indians, Eskimos, Aleuts, and American Indian
and Alaska Native Areas. Washington, DC: Racial Statis-
tics Branch, Population Division; 2001.
17. Evans-Campbell T, Walters KL. Indigenist practice
competencies in child welfare practice: a decoloniza-
tion framework to address family violence and sub-
stance abuse among First Nations peoples. In: Fong R,
McRoy R, Ortiz Hendricks C, eds. Intersecting Child
Welfare, Substance Abuse, and Family Violence: Cultur-
ally Competent Approaches. Alexandria, VA: CSWE
Press; In press.
18. LaFromboise TD, Berman JS, Sohi BK. American
Indian women. In: Comas-Diaz L, Green B, eds.
Women of Color: Integrating Ethnic and Gender Identities
  RESEARCH AND PRACTICE 

in Psychotherapy. New York, NY: Guilford Press; 1994:

30–71.
19. Walters K, Simoni J, Evans-Campbell T. Substance
use among American Indians and Alaska Natives: in-
corporating culture in an “indigenist” stress-coping
paradigm. Public Health Rep. 2002;117(suppl 1):
S104–S117.
20. A Quiet Crisis: Federal Funding and Unmet Needs
in Indian Country. Washington, DC: US Commission on
Behind the Mask
How the World Survived SARS,
the First Epidemic of the Twenty–First Century
By Timothy J. Brookes, in collaboration with Omar A. Khan, MD, MHS.
Foreword by David L. Heymann, MD, World Health Organization

T
his exciting new book tells the story of the recent
Civil Rights; 2003. outbreak of SARS—Severe Acute Respiratory
21. Heckathorn DD. Respondent-driven sampling: a Syndrome, the first true epidemic of the 21st cen-
new approach to the study of hidden populations. Soc tury. It follows the beginnings of this epidemic from the
Probl. 1997;44:174–199. point of view of the virus–hunters as well as of those
22. Bucholz K, Cadoret R, Cloninger C, et al. A new, most affected.
semi-structured psychiatric interview for use in genetic Follow the SARS trail from rural China as it
linkage studies: a report on the reliability of the spreads to various places in the world. See how seem-
SSAGA. J Stud Alcohol. 1994;55:149–158. ingly casual contacts help the disease spread like wild-
23. Walker R, Lambert M, Walker P, Kivlahan D, fire. Work alongside the many infectious disease spe-
Donovan D, Howard M. Alcohol abuse in urban Indian cialists as they trace the disease to its origin all the
adolescents and women: a longitudinal study for as- time knowing that each hour of delay allows the dis-
sessment and risk evaluation. Am Indian Alsk Native ease to spread even further.
Ment Health Res. 1996;7:1–47.
24. Derogatis LR, Melisaratos N. The Brief Symptom ISBN 0-87553-046-X • Softcover • 2004 • 262 pages
$21.00 APHA Members • $25.00 Nonmembers
Inventory: an introductory report. Psychol Med. 1983;
13:595–605.
American Public Health ORDER TODAY!
25. Walters K, Simoni J, Harris C. Patterns and predic- Association
tors of HIV risk among urban American Indians. Am American Public Health Association
800 I Street, NW,
Indian Alsk Native Ment Health Res. 2000;9:1–25. Washington, DC 20001 Publication Sales
www.apha.org
Web: www.apha.org
26. Novins D, Beals J, Moore L, Spicer P, Manson S E-mail: APHA@pbd.com
and the AI-SUPERPFP Team. Use of biomedical ser- Tel: 888-320-APHA
vices and traditional healing options among American FAX: 888-361-APHA
Indians: sociodemographic correlates, spirituality, and
ethnic identity. Med Care. 2004;42:670–679.
27. Bohn DK. Lifetime physical and sexual abuse,
substance abuse, depression and suicide attempts
among Native American women. Issues Ment Health
Nurs. 2003;24:333–352.
28. Fairchild DG, Fairchild MW, Stoner S. Prevalence
of adult domestic violence among women seeking rou-
tine care in a Native American health care facility. Am
J Public Health. 1998;88:1515–1517.
29. Segal B. Responding to victimized Alaska Native
women in treatment for substance use. Subst Use Mis-
use. 2001;36:845–865.
30. Fischler R. Child abuse and neglect in American
Indian communities. Child Abuse Negl. 1995;9:
95–106.
31. Kunitz SJ, Levy JE, McCloskey J, Gabriel KR. Al-
cohol dependence and domestic violence as a sequalae
of abuse and conduct disorder in childhood. Child
Abuse Negl. 1998;22:1079–1091.
32. Cohen M, Deamant C, Barkan S, et al. Domestic
violence and childhood sexual abuse in HIV-infected
women and women at risk for HIV. Am J Public Health.
2000;90:560–565.
33. Gerbert B, Abercrombie P, Caspers N, Lowe C,
Bronstone A. How health care providers can help bat-
tered women: the survivor’s perspective. Womens
Health. 1999;29:115–135.
34. Bates L, Hancock L, Peterkin D. “A little encour-
agement”: health services and domestic violence. Int
J Health Care Qual Assur Inc Leadersh Health Serv.
2001;14:49–56.

1422 | Research and Practice | Peer Reviewed | Evans-Campbell et al. American Journal of Public Health | August 2006, Vol 96, No. 8