Predictive validity of a screen for partner violence against women.

BACKGROUND: While public health leaders recommend screening for partner violence, the predictive value of this practice is unknown. The purpose of this study was to test the ability of a brief three-question violence screen to predict violence against women in the ensuing months. METHODS: We conducted a prospective cohort study of adult women participating in the Colorado Behavioral Risk Factor Surveillance System (BRFSS), a population-based, random-digit-dialing telephone survey. During 8 monthly cohorts, 695 women participated in the BRFSS; 409 women participated in follow-up telephone interviews approximately 4 months later. Violent events during the follow-up period, measured using a modified 28-item Conflict Tactics Scale, were compared between women who initially screened positive and those who screened negative. RESULTS: Among BRFSS respondents, 8.4% (95% confidence interval [CI]=6.3%-10.5%) had an initial positive screen. During the follow-up period, women who screened positive were 46.5 times (5.4-405) more likely to experience severe physical violence, 11.7 times (5.0- 27.3) more likely to experience physical violence, 3.6 (2.4-5.2) times more likely to experience verbal aggression, and 2.5 times (1.2-5.1) more likely to experience sexual coercion. In a multivariate model, separation from one's spouse and a positive screen were significant independent predictors of physical violence. CONCLUSIONS: A brief violence screen identifies a subset of women at high risk for verbal, physical, and sexual partner abuse over the following 4 months. Women with a positive screen who are separated from their spouse are at highest risk.     

Provider barriers and facilitators to screening for intimate partner violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.     

Physicians' Screening Practices for Female Partner Abuse During Prenatal Visits

Objective: Our purpose was to examine physicians' screening practices for female partner abuse during prenatal visits and to identify barriers to screening. Methods: A self-administered questionnaire was developed to collect data on physicians' screening practices and their beliefs about screening for female partner abuse. The survey was mailed to all primary care physicians practicing in Alaska. The response rate was 80% (305/383). These analyses were limited to physicians who indicated that they provided prenatal care (n = 157). Results: More than one-half of respondents providing prenatal care estimated that 10% or more of their female patients had experienced abuse. Less than one-half of respondents had recent training on partner abuse. Only 17% of respondents routinely screened at the first prenatal visit and 5% at follow-up visits. Respondents were more likely to screen at the first prenatal visit compared to follow-up visits. Multivariate analyses failed to support any associations between physicians' characteristics and screening practices. Physicians' perception that abuse was prevalent among their patients and physicians' belief that they have a responsibility to deal with abuse were the only variables that were independently associated with screening at prenatal visits. Other barriers frequently cited in the literature were not predictive of screening. Conclusion: Most Alaskan physicians do not routinely screen for abuse during prenatal visits. Medical education should increase physicians' index of suspicion for abuse, emphasize physicians' responsibility to address partner abuse, and reinforce the importance of routine screening throughout the pregnancy. More research is needed to identify barriers to screening and strategies for integrating routine screening into prenatal care.     

Provider Barriers and Facilitators to Screening for Intimate Partner Violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.     

Training internal medicine residents to screen for domestic violence

Internal medicine residency programs will need to train residents about domestic violence to comply with the Residency Review Commission standards. To assess the effectiveness of an educational intervention intended to increase screening of patients for domestic violence by internal medicine resident physicians and identify characteristics associated with increased screening, we used a quasi-experimental, pretest/posttest trial. This was conducted in an internal medicine residency program and its affiliated primary care clinic with categorical internal medicine and combined medicine/pediatrics resident physicians. Exit interview surveys of patients were conducted at baseline and following the educational program. Patients were questioned about demographics and if they were asked about domestic violence during the current visit. Physicians were questioned about demographics and attitudes and beliefs related to domestic violence. Prior to the intervention, only 0.8% (1 of 122) of patients reported being asked about domestic violence. After the intervention, the percentage asked rose to 17% (20 of 116). The odds ratio (OR) for being asked about domestic violence after training was 25.2 (6.1-104). Patients who were younger than 50 years were more likely to be asked (OR 2.5, 1.5-4.6). Caucasian physicians were more likely to ask (OR 2.8, 1.1-7.6). Patients reporting they were taught breast self-examination at that day's visit were also more likely to be screened (OR 2.9, 1.1-7.9). We found evidence that moderately intense training and focusing on results can increase resident physician screening rates for domestic violence. To do so effectively, we recommend a training session similar to this one and continued monitoring of outcome in the clinical setting.     

Barriers to screening for intimate partner violence

Background: Health care providers play a vital role in the detection of intimate partner violence among their patients. Despite the recommendations for routine intimate partner violence screening in various medical settings, health care providers do not routinely screen for intimate partner violence. The authors wanted to identify barriers to intimate partner violence screening and improve the understanding of intimate partner violence screening barriers among different health care providers. Methods: The authors conducted a systematic review to examine health care providers' perceived barriers to screening for intimate partner violence. By grouping the studies into two time periods, based on date of publication, they examined differences in the reported barriers to intimate partner violence screening over time. Results: The authors included a total of 22 studies in this review from all examined sources. Five categories of intimate partner violence screening barriers were identified: personal barriers, resource barriers, perceptions and attitudes, fears, and patient-related barriers. The most frequently reported barriers included personal discomfort with the issue, lack of knowledge, and time constraints. Provider-related barriers were reported more often than patient-related barriers. Conclusions: Barriers to screening for intimate partner violence are numerous among health care providers of various medical specialties. Increased education and training regarding intimate partner violence is necessary to address perceptions and attitudes to remove barriers that hinder intimate partner violence screening by health care providers.     

Physicians taught as residents to conduct smoking cessation intervention: a follow-up study

BACKGROUND: The influence of residency training on use of smoking cessation intervention (SCI) in future practice is unexamined. METHODS: We surveyed 291 physicians who participated in SCI research during residency between 1986 and 1996. Half received SCI training; half did not. Best practice included: (1) identifying smokers; (2) advising cessation; (3) assisting with a plan; (4) arranging follow-up. RESULTS: Forty-two percent of respondents were using best practices. Training per se was not associated with current use of best practices (relative risk = 1.04; adjusted relative risk [ARR] = 0.91). However, those who reported use of best practices in residency were twice as likely to currently use best practices [ARR = 2.0; 95% confidence interval (CI) 1.3, 2.9]. Resources associated with use of best practices included patient education materials (ARR = 1.8; CI 1.1, 2.7), staff familiar with SCI (ARR = 1.8; CI 1.2, 2.6), and opportunity for referral to cessation counselors/programs (ARR = 1.3; CI 1.0, 1.9). Resources related in a dose-response fashion to best practices: 24% of those without resources provide best SCI, 32% with any one resource, 51% with any two, and 74% with all three. CONCLUSIONS: To expand use of best SCI, residencies must ensure physicians use SCI skills, and health care systems must provide resources to facilitate intervention.     

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.     

Barriers to Screening for Intimate Partner Violence

Background: Health care providers play a vital role in the detection of intimate partner violence among their patients. Despite the recommendations for routine intimate partner violence screening in various medical settings, health care providers do not routinely screen for intimate partner violence. The authors wanted to identify barriers to intimate partner violence screening and improve the understanding of intimate partner violence screening barriers among different health care providers. Methods: The authors conducted a systematic review to examine health care providers' perceived barriers to screening for intimate partner violence. By grouping the studies into two time periods, based on date of publication, they examined differences in the reported barriers to intimate partner violence screening over time. Results: The authors included a total of 22 studies in this review from all examined sources. Five categories of intimate partner violence screening barriers were identified: personal barriers, resource barriers, perceptions and attitudes, fears, and patient-related barriers. The most frequently reported barriers included personal discomfort with the issue, lack of knowledge, and time constraints. Provider-related barriers were reported more often than patient-related barriers. Conclusions: Barriers to screening for intimate partner violence are numerous among health care providers of various medical specialties. Increased education and training regarding intimate partner violence is necessary to address perceptions and attitudes to remove barriers that hinder intimate partner violence screening by health care providers.     

Partner violence victimization and unintended pregnancy in Latina and Asian American women: Analysis using structural equation modeling

Intimate partner violence (IPV) is a pervasive public health problem in the U.S., affecting nearly one in every three women over their lifetimes. Using structural equation modeling, we evaluated the association between IPV and unintended pregnancy, mediated by condom use and perceived spousal/partner support among Latina and Asian women. Data came from the 2002–2003 National Latino and Asian American Study (NLAAS). The analysis was restricted to married or cohabiting female respondents aged 18+ years (n = 1,595). Dependent variables included unintended pregnancy, condom use, and perceived partner support. Independent variables included physical abuse or threats by current partner and primary decision-maker. Weighted least squares was used to fit path models to data comprising dichotomous and ordinal variables. More than 13% of women reported IPV during their relationship with their partner/spouse. Abused women were twice as likely as non-abused women to have had an unintended pregnancy. This association was partially mediated by perceived partner support. Condom use had a positive, but non-significant association with unintended pregnancy, and IPV had a negative, but non-significant association with condom use. Results highlight the importance of IPV screening for minority women. Efforts to combine family planning and violence prevention services may help reduce unintended pregnancy.     

Who gets screened during pregnancy for partner violence?

CONTEXT: Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown. OBJECTIVES: To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened. DESIGN, SETTING, AND PARTICIPANTS: This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998. MAIN OUTCOME MEASURES: Self-reports of violence, health service factors, and sociodemographic characteristics. ANALYSIS: The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors. RESULTS: Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source. CONCLUSIONS: These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care. Arch Fam Med. 2000;9:1093-1099     

The role of rural communities in the recruitment and retention of women physicians

ABSTRACT

Rural communities in the United States have a shortage of primary care physicians. Women physicians are more likely than male physicians to choose primary care specialties but less likely to locate in rural areas. With an increasing proportion of women physicians, it is important to understand community characteristics that encourage their recruitment and retention. This qualitative study explored community characteristics that influenced successful rural practice. We conducted telephone interviews with 25 women family physicians in rural practice in the United States in 2012. Interviews continued until saturation of themes was reached. Data were analyzed using immersion and crystallization. Community themes associated with successful rural practice included: fit with the community; spouse/partner fit with the community; relationships with individuals; and relationships with the community. Family ties, training experience within the community, social networks, and investment in the community were positive factors, while political/cultural differences were negative. Community integration arose from compatibility between the physicians’ goals and community characteristics, opportunities for a spouse/partner, friendships, and a feeling of community purpose. This information can be used by rural communities to recruit and retain physicians, and by physicians, medical students, and those who advise them to promote successful rural practice.     

Missed opportunities: intimate partner violence in family practice settings

BACKGROUND: For women experiencing partner violence, women health care visits represent opportunities for physicians and patients to address intimate partner violence (IPV), a significant health threat for women. OBJECTIVES: The objectives were to estimate rates of physician documentation of IPV in medical records; characterize IPV+ women most likely to have IPV documented; and determine whether IPV screening increased IPV documentation. METHODS: Subjects were women ages 18-65 receiving primary care in two large family practice clinics. All were screened for IPV by study staff using a modified Index of Spouse Abuse and the Women's Experience with Battering scales. We selected and abstracted medical records for all women experiencing current IPV (N = 144) and a random sample of women never experiencing IPV (N = 147). RESULTS: Of 144 women screened as currently experiencing IPV, 14.7% were documented. Women most likely to have IPV documented were Caucasian, with higher WEB scores, and more likely to have an event that could trigger posttraumatic stress syndrome. Although the majority (41/56) of women currently in physically violent relationships did not plan to disclose IPV, those disclosing were significantly more likely to have IPV documented and documentation occurred after screening for 60% of women experiencing IPV. CONCLUSION: IPV screening increased documentation. IPV screening can provide the opportunity for patients to disclose IPV. Physicians then have the opportunity to compassionately connect patients with appropriate resources.     

Contractual arrangements between residency programs and HMOs.

BACKGROUND. Although one out of seven health maintenance organizations (HMOs) is directly involved in graduate medical education (GME), either as an accredited sponsoring organization or through a contractual agreement with an academic medical center or teaching hospital to serve as an ambulatory rotation site, relatively little is known about the extent to which HMOs have provider contracts with faculty or residents of GME programs. Such provider contracts are not agreements to collaborate on the education of residents, but rather contractual arrangements under which individual physicians or groups (who happen to be residents or faculty) agree to provide services to HMO enrollees in return for some form of compensation. METHODS. In 1990, the Group Health Association of America conducted a survey of a sample of residency training programs in family medicine, internal medicine, and pediatrics to ascertain the extent to which (1) residents and faculty of residency training programs are participating physicians in HMOs; and (2) HMO enrollees are serving as the patient base for GME in ambulatory settings. RESULTS. Overall, 42% of the residency program respondents indicated that they contract with HMOs to provide services to enrollees. Nearly two thirds (64%) of family practice programs have provider contracts as compared with 28% of pediatrics programs and 24% of internal medicine programs. Provider contracts with independent practice associations are by far the most common, followed by group, network, and staff model contracts, in that order. CONCLUSIONS. It is apparent that provider contractual arrangements between HMOs and primary care residency programs are quite common, especially in the area of family practice. These contractual arrangements have probably resulted in a more predictable and stable patient revenue base for residency programs. The long-term effects on provider practice styles and the financing of graduate medical education are less clear.     

The impact of perceived barriers on primary care physicians' screening practices for female partner abuse

OBJECTIVES: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices. METHODS: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice. RESULTS: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse. CONCLUSION: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.     

The Impact of Perceived Barriers on Primary Care Physicians' Screening Practices for Female Partner Abuse

ABSTRACT

Objectives: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices.

Methods: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice.

Results: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse.

Conclusion: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.     

Population surveillance for physical violence among adult men and women, Montana 1998

BACKGROUND: Few epidemiologic studies of physical violence or intimate partner violence provide population-based surveillance data. OBJECTIVES: To estimate the prevalence and describe the characteristics associated with physical violence among adult men and women in the past year. METHODS: A random sample of Montana households was contacted via the Behavioral Risk Factor Surveillance System telephone survey in 1998 (N=1804). RESULTS: Five percent of men (39/787) and 3% of women (33/1017) reported experiencing physical violence in the past year. Among respondents reporting physical violence in the past year, women were more likely than men to report that the perpetrator was a current/former partner (58% vs 10%, p/=0.05). Men who reported experiencing physical violence in the past year were more likely to be younger and not to be living with a current partner. Women who reported experiencing physical violence in the past year were more likely to be younger, not currently living with a partner, have no health insurance, and have more days with mental health problems in the past month. CONCLUSIONS: Recent physical violence is common for both men and women; however, the perpetrators, locations, and demographic characteristics differ. Further study is needed to better understand the factors associated with physical violence among men and women in the context of designing and implementing appropriate interventions to reduce violence.     

Frequency and correlates of intimate partner violence by type: physical, sexual, and psychological battering

OBJECTIVES: This study estimated the frequency and correlates of intimate partner violence by type (physical, sexual, battering, or emotional abuse) among women seeking primary health care. METHODS: Women aged 18 to 65 years who attended family practice clinics in 1997 and 1998 took part. Participation included a brief in-clinic survey assessing intimate partner violence. Multiple polytomous logistic regression was used to assess correlates of partner violence by type. RESULTS: Of 1401 eligible women surveyed, 772 (55.1%) had experienced some type of intimate partner violence in a current, most recent, or past intimate relationship with a male partner; 20.2% were currently experiencing intimate partner violence. Among those who had experienced partner violence in any relationship, 77.3% experienced physical or sexual violence, and 22.7% experienced nonphysical abuse. Alcohol and/or drug abuse by the male partner was the strongest correlate of violence. CONCLUSIONS: Partner substance abuse and intimate partner violence in the woman's family of origin were strong risk factors for experiencing violence. Efforts to universally screen for partner violence and to effectively intervene to reduce the impact of such violence on women's lives must be a public health priority.