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

Background: 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. Objective: 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. Methods: 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. Results: 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. Conclusions: 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.