SCREENING FOR ABUSE: BARRIERS AND OPPORTUNITIES

Domestic abuse is the leading cause of injuries and death among women of childbearing age in the United States. The broad purpose of this research is to discover how pregnant women's psychological and behavioral responses to abuse affect birth outcomes. To select a diverse sample of women, we identified 8 prenatal care sites and completed the human subjects approval process with each. Rates of screening for abuse range from all but 12 women over a 2-1/2-year period at one site to no screening for abuse at another site. In this article, we will review pertinent literature and discuss the supports and barriers we observed when implementing an abuse screening program using the Abuse Assessment Screen, a well-tested and valid clinical instrument. Suggestions will be made for improving the screening rates at those sites where screening is absent or inconsistent.     

Domestic violence: a life-span approach to assessment and intervention

Domestic violence affects millions of Americans, many of whom deny or refuse to admit that that they are victims of abuse. Assessing patients at risk for domestic violence is a critical aspect of providing comprehensive primary care. As social agents, with moral and ethical responsibility, primary care providers must advocate for clients in the fight against domestic violence. Primary health care agencies must adopt uniform policies that assure that all women, children, and elders at risk for abuse are screened using a simple tool that becomes part of the primary care record. Screening for abuse should become part of an annual screening process, not unlike screening patients for high blood pressure or high cholesterol. If patients are suspected of being abused, document this on the problem list so subsequent providers will know to explore the possibility of abuse with patients. Multiple forms of abuse occur in families, and signs of abuse are usually subtle in nature. Abuse may be the reason for failed office visits, noncompliance with medications, depression, and other unexplained physical and psychological signs and symptoms. If we fail to ask, we will never know how many of our patients are victims of abuse and in need of our help.     

Providers of primary care to homeless women in Los Angeles County

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as "major providers"). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.     

Partner violence intervention in the busy primary care environment

BACKGROUND: Few studies of intimate partner violence (IPV) interventions have been conducted in primary care settings. Based on recommendations, we implemented a multifaceted IPV intervention that included a sticker placed in medical charts listing screening questions, routine IPV screening by nursing staff, clinician follow-up for women screening positive, and referral to on-site services. METHODS: A prospective cohort study compared multiple measures collected at the intervention site and a center providing usual care. Measures included self-reported IPV, documented IPV screening and IPV experiences, and quantity of IPV materials taken from the centers. RESULTS: Of 746 charts reviewed in a random chart review conducted at the intervention site, 36.6% were tagged for IPV screening, and of those tagged, 86.1% had documentation of screening. Approximately 5% (11 of 235) of women screened positive for IPV; about half had documented clinician follow-up and referral to on-site services. Comparison of survey responses and medical record reviews (intervention site) indicated that the screening protocol primarily identified severely abused women (sensitivity 80%, specificity 98%), but rarely identified women experiencing low to moderate levels of abuse. IPV brochures were taken from the intervention site at a rate of 51 per 1000 visits versus 29 per 1000 visits taken from the control site. CONCLUSIONS: Utilizing screening as the only gateway to on-site services limited access for many IPV victims. The removal of IPV brochures from examination rooms suggests that providing contact information for self-referral to on-site services may improve access.     

Screening women for gonorrhea: demographic screening criteria for general clinical use.

OBJECTIVES: The purpose of this analysis was to derive potential gonorrhea screening criteria for women. METHODS: Data corresponding to 44,366 gonorrhea cultures from women 15 through 44 years of age in Columbus, Ohio, were analyzed. RESULTS: Characteristics that were associated with gonococcal infection and were suitable for screening decisions included patient's age and marital status and previous prevalence of gonorrhea at provider site. Probabilities of infection ranged from .001 for married women 25 through 44 years of age at low-prevalence provider sites to .078 for unmarried women 15 through 19 years of age at high-prevalence sites. CONCLUSIONS: Patient's age and marital status and prevalence of gonorrhea at provider site can be used as indicators to ensure testing of high-prevalence groups.     

Simultaneous alcohol and cannabis expectancies predict simultaneous use

Background

Despite the importance of identifying co-occurring psychiatric disorders in substance abuse treatment programs, there are few appropriate and validated instruments available to substance abuse treatment staff to conduct brief screen for these conditions. This paper describes the development, implementation and validation of a brief screening instrument for mental health diagnoses and trauma among a diverse sample of Black, Hispanic and White women in substance abuse treatment. With input from clinicians and consumers, we adapted longer existing validated instruments into a 14 question screen covering demographics, mental health symptoms and physical and sexual violence exposure. All women entering treatment (methadone, residential and out-patient) at five treatment sites were screened at intake (N = 374).

Results

Eighty nine percent reported a history of interpersonal violence, and 70% reported a history of sexual assault. Eighty-eight percent reported mental health symptoms in the last 30 days. The screening questions administered to 88 female clients were validated against in-depth psychiatric diagnostic assessments by trained mental health clinicians. We estimated measures of predictive validity, including sensitivity, specificity and predictive values positive and negative. Screening items were examined multiple ways to assess utility. The screen is a useful and valid proxy for PTSD but not for other mental illness.

Conclusion

Substance abuse treatment programs should incorporate violence exposure questions into clinical use as a matter of policy. More work is needed to develop brief screening tools measures for front-line treatment staff to accurately assess other mental health needs of women entering substance abuse treatment     

Feasibility study of family planning services screening as clinical decision support at an urban Federally Qualified Health Center network

Objective

The objective was to assess the feasibility of an intervention introducing family planning services screening clinical decision support to improve provision of contraception and/or preconception services for women of reproductive age in our primary care Federally Qualified Health Center (FQHC) network.

The health visitor's role in the identification of domestic abuse

Internationally, domestic abuse is a significant public health issue in terms of imposing physical and psychological distress upon victims, having a detrimental impact upon parenting and causing psychological problems for victim's children. Figures identify that one in four UK women experience domestic abuse. However, it is acknowledged that reported rates are gross underestimates of true figures and that multiple barriers exist that inhibit domestic abuse identification. This paper reviews the literature to explore these barriers and ascertain evidence-based strategies that will help practitioners to identify domestic abuse more effectively. Particular attention is paid to domestic abuse screening tools, as research suggests their use increases disclosure rates. The paper concludes that routine and recurrent enquiry using a screening tool, information giving to all women, knowledgeable staff and supportive environments, are all potential facilitators to identification.     

Barriers to disclosure of abuse among rural women

The purposes of this study were to examine the prevalence of abuse (physical, emotional, and sexual) in women seeking care in rural medical clinics and WIC voucher pick-up sites, and to discover ways of improving the response of health care providers to violence. Data were collected in 8 medical clinics and 17 WIC supplemental food program sites in 9 counties of west central Minnesota during January and February 1997. Fifteen percent of respondents reported having had a discussion about abuse with a health care provider. Six of the 8 symptoms and injuries most associated with abuse indicate diminished emotional health. A series of barriers are identified as substantial obstacles to obtaining help and revealing abuse to health care providers. The most frequently reported barriers were self-reliance, reliance on God, and reliance on friends and family. These findings show that a large percentage of rural women experience abuse and that their health is adversely affected. The barriers to disclosure of abuse reported in this study illustrate the complexity of disclosing abusive relationships in rural and other settings. Low screening levels suggest that rural health care providers can develop additional opportunities to discuss abuse with their patients.     

Preferences of rural Victorian women for screening mammography services

Abstract: The aim of this study was to examine rural women's access to regional fixed-site screening mammography services and their preferences for either a mobile service or a fixed-site centre. One hundred and thirty-seven women aged 49 to 69 from rural Victoria were interviewed in June 1991. Eighty-five per cent of women normally go to major towns which are possible screening sites at least once every six months, spending an average of five hours each visit. Around 77% of women said they would be likely to go to a fixed site while 86% said they would be likely to go to a mobile service. If the fixed-site centre was at a major town not usually frequented, this would be a deterrent to 58% of women. A decision to widely implement mobile screening in rural areas of Victoria is not justified at this time, but pilot mobile services should be considered.     

Who tells and what happens: disclosure and health service responses to screening for intimate partner violence

Routine screening of women for intimate partner violence (IPV) has been introduced in many health settings to improve identification and responsiveness to hidden abuse. This cross‐sectional study aimed to understand more about how women use screening programmes to disclose and access information and services. It follows women screened in ten Australian health care settings, covering antenatal, drug and alcohol and mental health services. Two samples of women were surveyed between March 2007 and July 2008; those who reported abuse during screening 6 months previously (122) and those who did not report abuse at that time (241). Twenty‐three per cent (27/120) of women who reported abuse on screening were revealing this for the first time to any other person. Of those who screened negative, 14% (34/240) had experienced recent or current abuse, but chose not to disclose this when screened. The main reasons for not telling were: not considering the abuse serious enough, fear of the offender finding out and not feeling comfortable with the health worker. Just over half of both the positive and negative screened groups received written information about IPV and 35% of the positive group accessed further services. The findings highlight the fact that much abuse remains hidden and that active efforts are required to make it possible for women to talk about their experiences and seek help. Screening programmes, particularly those with established protocols for asking and referral, offer opportunities for women to disclose abuse and receive further intervention.     

Predictors of Sexual Coercion Against Women and Men: A Multilevel,Multinational Study of University Students

Several explanations have been forwarded to account for sexual coercion in romantic relationships. Feminist theory states that sexual coercion is the result of male dominance over women and the need to maintain that dominance; however, studies showing that women sexually coerce men point towards weaknesses in that theory. Some researchers have, therefore, suggested that it is the extent to which people view the other gender as hostile that influences these rates. Furthermore, much research suggests that a history of childhood sexual abuse is a strong risk factor for later sexual victimization in relationships. Few researchers have empirically evaluated the first two explanations and little is known about whether sexual revictimization operates for men or across cultures. In this study, hierarchical linear modeling was used to investigate whether the status of women and adversarial sexual beliefs predicted differences in sexual coercion across 38 sites from around the world, and whether sexual revictimization operated across genders and cultures. Participants included 7,667 university students from 38 sites. Results showed that the relative status of women at each site predicted significant differences in levels of sexual victimization for men, in that the greater the status of women, the higher the level of forced sex against men. In addition, differences in adversarial sexual beliefs across sites significantly predicted both forced and verbal sexual coercion for both genders, such that greater levels of hostility towards women at a site predicted higher levels of forced and verbal coercion against women and greater levels of hostility towards men at a site predicted higher levels of forced and verbal coercion against men. Finally, sexual revictimization occurred for both genders and across all sites, suggesting that sexual revictimization is a cross-gender, cross-cultural phenomenon. Results are discussed in terms of their contributions to the literature, limitations of the current study, and suggestions for future research.     

Opportunities for intervention: discussing physical abuse during prenatal care visits

BACKGROUND: The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that screening for physical abuse during prenatal care visits becomes routine. Although prenatal care visits offer a unique intervention opportunity, screening is not yet standard practice. DATA AND METHODS: We used data from the 1996 and 1997 Pregnancy Risk Assessment Monitoring System (PRAMS) to assess the prevalence of and the factors associated with health care providers' discussion of physical abuse with pregnant women in 14 states. PRAMS is a state-specific, population-based surveillance system that collects information from women on maternal behaviors before and during pregnancy, and at 2 to 6 months postpartum. RESULTS: Between 22% and 39% of the women surveyed reported that health care providers talked with them about physical abuse during prenatal care visits. Health care providers were more likely to discuss physical abuse with women who were black, Hispanic, young (aged <20 and 20 to 29), had a high school education or less, or paid for prenatal care with Medicaid. CONCLUSIONS: Our results indicate that most pregnant women do not report that their prenatal care providers discussed physical abuse with them. Logistic regression analyses identified consistent associations across the 14 states between discussion of abuse and demographic and pregnancy-related factors. A better understanding of the factors associated with whether a health care provider discusses physical abuse with a pregnant woman could increase intervention opportunities.     

Development of a screening instrument to detect physical abuse and its use in a cohort of pregnant women in Sri Lanka

The objective of this study was to develop and validate a screening instrument (Abuse Assessment Questionnaire) to estimate the prevalence of physical abuse in a cohort of pregnant women in a district of Sri Lanka. The samples of 1200 pregnant women were identified by using a cluster sampling technique. Public health midwives (primary healthcare workers) were selected as interviewers and the antenatal clinic was identified as the setting to identify physical abuse. The reliability and validity (sensitivity 85.7%; specificity 89.7%) of the screening instrument proved to be high. The prevalence of physical abuse in categories 'ever-abuse', 'current abuse' and 'current pregnancy'were 18.3%, 10.6% and 4.7% respectively. In addition, 'current sexual abuse' was reported by 2.7% of women. The prevalence rates indicate that the physical abuse of women is a significant public health problem. The Abuse Assessment Questionnaire, administered by public health midwives, proved valuable in detecting physical abuse in pregnant women. If this instrument is used universally to screen Lankan women for physical abuse in antenatal clinics, it has good potential for early detection and intervention.     

Screening for abuse in Spanish-speaking women

BACKGROUND: Domestic violence is a major personal and public health concern affecting women of all walks of life. Physicians have reported the need for screening instruments to help recognize abuse; several have been validated in English. No screening tools thus far have been validated in other languages. METHODS: We translated a previously validated tool, the Woman Abuse Screening Tool (WAST), into Spanish. To assess for validity, we compared responses of Spanish-speaking abused and nonabused respondents drawn from a community health center and a battered women's shelter. There were 27 women in the abused group and 34 women in the nonabused comparison group. RESULTS: The scale was found to be reliable with a Cronbach alpha of 0.91. The mean WAST Spanish scores were significantly different between the two groups, indicating this tool would be a valid screening instrument. A short form using the two most reliable questions was developed as a more rapid screening tool for office use, achieving a specificity of 94% and a sensitivity of 89%. CONCLUSIONS: The Spanish version of the WAST successfully discriminated between Spanish-speaking nonabused and abused women. The short form might help physicians reliably screen for abuse in Spanish-speaking women.     

Women's evaluation of abuse and violence care in general practice: a cluster randomised controlled trial (weave)

Background  

Intimate partner abuse (IPA) is a major public health problem with serious implications for the physical and psychosocial wellbeing of women, particularly women of child-bearing age. It is a common, hidden problem in general practice and has been under-researched in this setting. Opportunities for early intervention and support in primary care need to be investigated given the frequency of contact women have with general practice. Despite the high prevalence and health consequences of abuse, there is insufficient evidence for screening in primary care settings. Furthermore, there is little rigorous evidence to guide general practitioners (GPs) in responding to women identified as experiencing partner abuse. This paper describes the design of a trial of a general practice-based intervention consisting of screening for fear of partner with feedback to GPs, training for GPs, brief counselling for women and minimal practice organisational change. It examines the effect on women's quality of life, mental health and safety behaviours.     

Women’s opinions about domestic violence screening and mandatory reporting

Background: The purpose of this paper is to describe women’s opinions and policy preferences concerning domestic violence screening and mandatory reporting.Methods: This case–control study included 202 abused women and 240 randomly selected non-abused women recruited from a large metropolitan health maintenance organization who were interviewed by telephone. Of these women, 46.6% had a college degree, 53.4% were white, and 60% had a household income of $50,000 or more.Results: Forty-eight percent of the sample agreed that health care providers should routinely screen all women, with abused women 1.5 times more likely than non-abused women to support this policy. For mandatory reporting, 48% preferred that it be the woman’s decision to report abuse to the police. Women thought it would be easier for abused women to get help with routine screening (86%) and mandatory reporting (73%), although concerns were raised about increased risk of abuse with both screening (43%) and reporting (52%) policies. Two thirds of the sample thought women would be less likely to tell their health care providers about abuse under a mandatory reporting policy. Interventions offered in managed care settings that would be well received, according to the women in this study, include counseling services, shelters, and confidential hotlines.Conclusions: Women expressed fears and concerns about negative consequences of routine screening and, even more so, for mandatory reporting. Domestic violence policies and protocols need to address the safety, autonomy, and confidentiality issues that concern women.     

Women's opinions about domestic violence screening and mandatory reporting

BACKGROUND: The purpose of this paper is to describe women's opinions and policy preferences concerning domestic violence screening and mandatory reporting. METHODS: This case-control study included 202 abused women and 240 randomly selected non-abused women recruited from a large metropolitan health maintenance organization who were interviewed by telephone. Of these women, 46.6% had a college degree, 53.4% were white, and 60% had a household income of $50,000 or more. RESULTS: Forty-eight percent of the sample agreed that health care providers should routinely screen all women, with abused women 1.5 times more likely than non-abused women to support this policy. For mandatory reporting, 48% preferred that it be the woman's decision to report abuse to the police. Women thought it would be easier for abused women to get help with routine screening (86%) and mandatory reporting (73%), although concerns were raised about increased risk of abuse with both screening (43%) and reporting (52%) policies. Two thirds of the sample thought women would be less likely to tell their health care providers about abuse under a mandatory reporting policy. Interventions offered in managed care settings that would be well received, according to the women in this study, include counseling services, shelters, and confidential hotlines. CONCLUSIONS: Women expressed fears and concerns about negative consequences of routine screening and, even more so, for mandatory reporting. Domestic violence policies and protocols need to address the safety, autonomy, and confidentiality issues that concern women.     

Effect of appointment scheduling and reminder postcards on adherence to mammography recommendations

A brief, simple intervention designed to increase the adherence of female patients to their physicians' recommendations for screening mammograms was tested in several midwestern sites. Compared with a control group in which women were examined, told about mammography, and instructed to make an appointment for themselves, an intervention that scheduled appointments for women on the spot and followed up with a reminder postcard increased adherence at every site. Such an intervention, if implemented on a wide scale, would augment the value of screening mammography in controlling breast cancer.