For women included in this study, the effects of violence perpetrated by an intimate partner were concentrated in the emotional and psychological domains of health despite the apparent physical effects of abuse. Fear, control and power played significant roles in women's negative outcomes from IPV. Furthermore, children's experience of witnessing IPV had a significant impact on their mothers' HRQOL, beyond the effect on the children themselves. Existing preference-based measures of HRQOL focus more on the physical domains of health than the emotional and psychological domains, contrary to those which were most severely affected among the women in our study. The importance of children's quality of life to these mothers' HRQOL suggests the need for a wider conception or definition of HRQOL, possibly focusing on the family unit as a whole[23, 24]. Measures of HRQOL developed for physical illnesses may underestimate the effect of IPV for some women, and resource decisions made on this basis may possibly be misguided. To adequately capture the HRQOL impact of IPV for these women, HRQOL measures may need to include greater and broader focus on psychological outcomes, or possibly focus on holistic measures that include all aspects of self-perceived quality of life.
Generic HRQOL instruments are extremely valuable because of their ease of use and adaptation to many varying conditions. Preference-based measures of HRQOL are particularly important because of their role in economic evaluations upon which resource allocation decisions are often based. The benefit attributed to particular interventions is oftentimes measured with preference-based measures of HRQOL, meaning that accurate assessment of benefits is dependent upon accurate measurement instruments. In this context, the decision to allocate resources to IPV prevention or intervention efforts may hinge upon accurate measurement of the impact of IPV on quality of life and hence the benefit that would accrue from preventing or intervening in violence. While many of the existing preference-based HRQOL instruments were originally designed to measure the effect of medical conditions (e.g., ), they have been adopted for more general use because of their ease of use and comparability across conditions. The prevalent use of these measures requires that they be considered for a broader range of uses than may have been originally intended, including non-medical conditions such as IPV, and that they be adapted accordingly.
Researchers measuring HRQOL for any purpose should take care to choose measures that encapsulate the entirely of impact of a condition on health, and define health in an appropriate way for the condition under consideration. The domains specified by each instrument define the aspects of life that are included and excluded in that assessment of HRQOL. When choosing among instruments, researchers should consider the aspects of health and life that are expected be affected by a condition. Notice should also be taken of the more general or holistic elements included in some instruments, such as the visual analog scale in the EuroQol and the general health measure in the SF-36, which may capture aspects of health not otherwise included in specified domains. These general measures may also be considered as a validity check of other domains included in a composite measure, or to inform the more subjective aspects of HRQOL. Our results suggest that for at least some women, measuring the effect of IPV on HRQOL may require a broader definition of health than is included in commonly-used, preference-based measures of HRQOL in order to adequately capture the entirely of their experience. Other health conditions may have similar impacts on aspects of life and health that are not included in generic HRQOL measures, and should be explored to obtain unbiased estimates of the burden of the condition/disease on those affected.
Of particular note are the effects of health conditions on individuals surrounding the index person or patient, including family members and caretakers[23, 27]. Such effects are often difficult to measure, yet may make a significant contribution to the overall impact of a disease or condition. The "spillover" effect of children's health on their parents' quality of life is occasionally considered, as well as the effect of illness on siblings[23, 29]. Measurement of the indirect connection between parent and child HRQOL that we observed in our sample, in which the health of the woman affects the child which in turn further affects the woman, is unprecedented in HRQOL measures. Our observation of the significant impact of children's distress on their mother's HRQOL suggests the need for the inclusion of a new domain in the measurement of HRQOL in this context, and potentially in others as well.
It is important to acknowledge that the data on which this research is based has extraordinary richness but accordingly limited generalizability. We spoke with 40 women, mostly African American, from one urban area. It is not known whether the emotional and psychological impact of violence differs by race or geographic location, so our results must be considered in context and with caution. And though our data are self-reported and unconfirmed by objective measures, we believe that self-report bias would tend toward underreporting of abuse and the impact thereof, so our results might be considered a lower bound of the effect. The qualitative reports of HRQOL by women in our focus groups are consistent with their CTS and WEB scores, providing some internal consistency in our data. Nevertheless, further research on abused women and the range of effects of violence on their lives would be a welcome addition to the sparse literature on outcomes of IPV.