# Associations of Violence Against Women With Comorbid Symptoms of Depression and Anxiety Among Left-Behind Women in Rural China: Cross-Sectional Study

## TL;DR

This study finds that violence against women in rural China is linked to higher rates of depression and anxiety, with low resilience and social support playing a mediating role.

## Contribution

The study identifies specific forms of violence against women and their mental health impacts, with mediation analysis on resilience and social support in a rural Chinese population.

## Key findings

- Lifetime violence against women increases the risk of comorbid depression and anxiety by 84%.
- Remote intimate partner violence is associated with a 279% higher likelihood of comorbid symptoms.
- Low resilience and social support mediate 28.2% and 18.6% of the association between violence and mental health outcomes.

## Abstract

Violence against women (VAW) is a major public health and human rights concern with profound mental health consequences. However, the association between specific VAW forms and mental health, particularly among left-behind women in rural China, remains unclear.

This study aimed to identify the associations of VAW with depression, anxiety, and comorbid symptoms and to explore the potential roles of resilience and social support.

The cross-sectional survey was conducted in Y City, Henan Province, China, in July 2023. A multistage stratified random sampling method was used to recruit left-behind women, resulting in a final sample of 1503 participants. Data on participants and their VAW were collected through a face-to-face questionnaire survey. The forms of VAW assessed were nonpartner violence (NPV) and intimate partner violence (IPV; including remote IPV). Depressive symptoms were evaluated using the 10-item Center for Epidemiological Studies Depression Scale, while anxiety symptoms were assessed with the Generalized Anxiety Disorder-7. The comorbid symptoms of depression and anxiety (CDA) were ascertained as the simultaneous presence of depressive and anxiety symptoms. A multivariable logistic regression model was used to estimate the odds ratio and 95% CIs. A 4-way decomposition analysis was conducted to test the mediation roles and interactions of resilience and social support between VAW and mental health outcomes. Population attributable fractions and pathway-specific population attributable fractions were calculated to estimate the burden of mental health outcomes attributable to VAW.

Lifetime VAW (adjusted odds ratio [aOR] 1.84, 95% CI 1.32‐2.54) was associated with an increased risk of CDA. Women who were exposed to lifetime IPV (aOR 1.84, 95% CI 1.32‐2.56), remote IPV (aOR 2.79, 95% CI 1.60‐4.74), and NPV (aOR 2.63, 95% CI 1.58‐4.26) had an increased likelihood of reporting CDA. Similar associations could also be found for depressive symptoms and anxiety symptoms. In the 4-way decomposition analysis for VAW and CDA, mediation effects of low resilience and social support were statistically significant (P<.05), whereas none of the interactions reached significance (P>.05). The pure mediation proportion was 28.2% for the low resilience and 18.6% for the social support between VAW and CDA. A total of 20.8% of CDA cases, 15.1% of depressive symptoms cases, and 22.7% of anxiety symptoms cases were attributable to VAW. Among these, low resilience accounted for 7.2% and low social support accounted for 4.7% of CDA cases as mediators.

Lifetime VAW, including IPV (and remote IPV) and NPV, shows significant associations with CDA and depressive and anxiety symptoms among rural left-behind women in China. The associations are partly mediated by low resilience and social support. Targeted strategies, including efforts to reduce violence against rural left-behind women, enhance their resilience and strengthen their social support networks, are urgently needed.