Factors that influence clinicians' assessment and management of family violence.

OBJECTIVES. High rates of family violence and low rates of detection, report, and therapeutic intervention by health professionals are well documented. This study was undertaken to determine what factors influence clinicians' decision making about identifying abuse and intervening with victims. METHODS. Survey data about clinicians' experiences with and attitudes toward family violence were gathered by mailed questionnaire from a random sample of practicing clinicians in six disciplines (n = 1521). RESULTS. Data showed similarities within and wide differences among three groups of subjects: dentists/dental hygienists, nurses/physicians, and psychologists/social workers. Overall, a third of subjects reported having received no educational content on child, spouse, or elder abuse in their professional training programs. Subjects with education on the topic more commonly suspected abuse in their patients than those without; among all subjects, spouse abuse was suspected more often than child abuse while elder abuse was suspected infrequently. Significant numbers of subjects did not view themselves as responsible for dealing with problems of family violence. Subjects indicated low confidence in and low compliance with mandatory reporting laws. CONCLUSIONS. There is a need for educators to expand curricula on family violence and for legislators to reexamine mandatory reporting laws.     

Interventions that help victims of domestic violence. A qualitative analysis of physicians' experiences

BACKGROUND: The barriers physicians face when providing care to victims of domestic violence are well detailed in the literature, but few studies provide insight into how physicians overcome these barriers. Our goal was to describe the domestic violence interventions used by physicians who are committed to providing quality health care to battered women. METHODS: We conducted 6 focus groups with 45 San Francisco Bay Area physicians who had intervened with victims of domestic violence. The sessions were audiotaped and transcribed. We constructed, through constant comparison, a template of open codes to identify themes that emerged from the data. RESULTS: Our analysis revealed that physicians viewed validation (ie, providing messages to the patients that they are worth caring about) as the foundation of intervention. Other interventions included labeling the abuse as abuse; listening and being nonjudgmental; documenting, referring, and safety planning; using a team approach; and prioritizing domestic violence in the health care environment. Physicians described a range of rewards for intervening with victims, from seeing a patient change her entire life to subtle shifts in the way a woman thinks of her relationship and herself. CONCLUSIONS: Our study offers insight into how physicians can intervene to help victims of domestic violence. Recent interview and survey studies of battered women support the physician interventions described.     

Physicians' response to victims of domestic violence: toward a model of care

Even though current domestic violence guidelines, such as those published by the AMA in 1992, attempt to relieve physicians of the "full burden of intervention," they continue to call upon physicians to play a large role in identifying, intervening in, and following up on case of partner abuse. In this paper, we define a limited domestic violence role for physicians which furthers the direction recommended by the AMA and which complements exemplary programs. We propose simplifying and limiting physicians' tasks to Asking patients about abuse; providing Validating messages, acknowledging that battering is wrong and confirming patient worth; Documenting presenting signs, symptoms, and disclosures; and Referring victims to domestic violence specialists (AVDR). By drawing on the literature and our own experience, we show how focusing the physician's role on these four taks is consistent with exemplary programs and expands on ideas put forth by experts for addressing domestic violence in health care settings; reduces barriers for physician interventions with victims; offers a realistic approach for physicians, reducing unrealistic educational demands; and complements managed care trends in contemporary health care.     

Injuries from domestic violence in the Autonomous Community of Valencia (Spain)

The lack of homogeneous and reliable epidemiological data on domestic violence greatly limits public decision making on the help that should be provided to victims of this form of abuse. Health professionals are obliged to report cases of domestic violence in adults to the judicial authorities and a unified, easily completed model for reporting injuries from domestic violence has been established in the Autonomous Community of Valencia. From June to October 2005, 500 cases of domestic violence were received and processed, most of which were reported by primary care physicians (68%). Cases of domestic violence occurred mainly in young women (aged, 20-39 years), either married or cohabiting, and with primary or secondary level education. The most frequent findings were physical injury or psychological damage (62%). Eighty-three percent of victims had at least one antecedent of abuse.     

A population-based survey assessing support for mandatory domestic violence reporting by health care personnel

BACKGROUND: State laws mandating health care personnel to contact police when treating patients injured as a result of domestic violence are controversial. Attitudes toward these laws have been studied in select groups, but never in a large population-based sample. METHODS: We measured support for mandatory reporting (MR) among 845 women in 11 cities who participated in a telephone survey assessing risk factors for intimate partner violence. Abused women were oversampled to create equal groups (427 abused and 418 non-abused); results are presented stratified by abuse status or weighted based on prevalence of abuse among women who were screened. RESULTS: The estimated prevalence of physical violence or threat of physical violence from an intimate partner during the past two years was 11.7%; 72% (95% CI = 69%-75%) of women supported MR. Abused women were significantly less likely to support MR compared to non-abused women (59% versus 73%, p < 0.01). Reasons that endorsed support included: victims would find it easier to get help (81%) and would like health care personnel to call the police (68%). Reasons that endorsed opposition included: victims would be less likely to disclose abuse (77%), would resent someone else having control (61%), and reporting would increase the risk of perpetrator retaliation (44%). CONCLUSIONS: Most women support mandatory reporting by health care personnel. However, abused women were significantly less supportive than those not abused.     

Voluntary abortion and domestic violence among women attended at a public maternity hospital of Salvador-BA

Quantitative study in order to study domestic violence in women with induced abortion. Interviews were conducted with 147 women hospitalized for induced abortion in a public maternity hospital in Salvador, Bahia. The subjects are characterized by mostly women, black, poorly educated, economically dependent on spouses, experienced psychological abuse, physical and sexual abuse committed by their spouses. Almost half of the women were victims of domestic violence during the current pregnancy, and that was the reason for inducing abortion for 67% of them. The study reveals an association between experience of domestic violence and induced abortion. As mental health consequences, they developed symptoms of post trauma stress disorder. It is necessary that the health professionals consider the cues to identify domestic violence as a health problem associated with induced abortion, which requires a transformation on the training model, including domestic violence as a health issue.     

Domestic violence compared to other health risks: a survey of physicians' beliefs and behaviors

BACKGROUND: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD-risk behavior. We compared physicians' behaviors and beliefs on screening and intervention for domestic violence with each other risk. METHODS: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. RESULTS: Fewer primary care physicians screened for domestic violence than for other risks (p <0.001); once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p<0.001). CONCLUSIONS: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.     

Health care professionals' skills, beliefs, and expectations about screening for domestic violence in a border community

This article describes domestic violence education of health professionals and determines association between screening behavior and preparedness, outcome expectations, and beliefs about how and when to screen. A survey was mailed to all primary care physicians, dentists, and nurse practitioners in El Paso, Texas (n = 561). Return rate was 34.4%. Using linear regression, differences (p < 0.05) were found between dentists and others in percentage of patients screened, education, preparedness, and beliefs. Education had a positive association (p < 0.001) with preparedness, beliefs about when to screen, and outcome expectations, and a negative association with beliefs about how to screen. Preparedness, beliefs, and realistic outcome expectations had a positive association (p < 0.02) with percentage of female patients screened. Education about domestic violence is important in increasing preparedness and influencing beliefs about when to screen and what outcomes can be expected. Educational programs should include not only information, but also skills training to increase perceptions of preparedness.     

A Population-Based Survey Assessing Support for Mandatory Domestic Violence Reporting by Health Care Personnel

SUMMARY

Background: State laws mandating health care personnel to contact police when treating patients injured as a result of domestic violence are controversial. Attitudes toward these laws have been studied in select groups, but never in a large population-based sample.

Methods: We measured support for mandatory reporting (MR) among 845 women in 11 cities who participated in a telephone survey assessing risk factors for intimate partner violence. Abused women were over-sampled to create equal groups (427 abused and 418 non-abused); results are presented stratified by abuse status or weighted based on prevalence of abuse among women who were screened.

Results: The estimated prevalence of physical violence or threat of physical violence from an intimate partner during the past two years was 11.7%; 72% (95% CI = 69%–75%) of women supported MR. Abused women were significantly less likely to support MR compared to non-abused women (59% versus 73%, p < 0.01). Reasons that endorsed support included: victims would find it easier to get help (81%) and would like health care personnel to call the police (68%). Reasons that endorsed opposition included: victims would be less likely to disclose abuse (77%), would resent someone else having control (61%), and reporting would increase the risk of perpetrator retaliation (44%).

Conclusions: Most women support mandatory reporting by health care personnel. However, abused women were significantly less supportive than those not abused.     

Domestic violence and abuse, health status, and social functioning

BACKGROUND: Current and past history of domestic violence (DV), including physical, sexual, and emotional abuse is common among women patients seen in health care settings and is associated with a higher frequency of many health problems. However, the association of DV with self-assessed social functioning is less well known. METHODS: We administered a telephone survey to a random sample of 391 women HMO members seen for a routine annual check-up. The survey included questions about current and past physical, sexual, and emotional violence and self-assessed social functioning and health status from the SF-36. We included questions about attitudes toward routine DV screening, likelihood of disclosure, and the health care setting as a resource. RESULTS: Seven percent of the women reported recent DV and 34% reported lifetime abuse. Abuse was related to limitations in social functioning (adjusted OR = 2.26). Among women with no recent history of abuse, those with a history of past physical (adjusted OR = 1.90), sexual (adjusted OR = 2.04), or emotional (adjusted OR = 2.20) abuse reported significantly poorer social functioning. Emotional abuse, even in the absence of a history of physical or sexual abuse, was strongly associated with limitations in social functioning (adjusted OR = 4.95). Most women believed it appropriate for clinicians to inquire routinely about DV (87%) and 83% believed that the health care setting was a source of help. CONCLUSIONS: Current and past DV, including emotional abuse, adversely affect social functioning. Therefore, clinicians in the health care setting have a unique and important opportunity to assist women victims of DV and abuse.     

Workplace violence in a large correctional health service in New South Wales, Australia: a retrospective review of incident management records

ABSTRACT: BACKGROUND: Little is known about workplace violence among correctional health professionals. This study aimed to describe the patterns, severity and outcomes of incidents of workplace violence among employees of a large correctional health service, and to explore the help-seeking behaviours of staff following an incident. METHODS: The study setting was Justice Health, a statutory health corporation established to provide health care to people who come into contact with the criminal justice system in New South Wales, Australia. We reviewed incident management records describing workplace violence among Justice Health staff. The three-year study period was 1/7/2007-30/6/2010. RESULTS: During the period under review, 208 incidents of workplace violence were recorded. Verbal abuse (71%) was more common than physical abuse (29%). The most (44%) incidents of workplace violence (including both verbal and physical abuse) occurred in adult male prisons, although the most (50%) incidents of physical abuse occurred in a forensic hospital. Most (90%) of the victims were nurses and two-thirds were females. Younger employees and males were most likely to be a victim of physical abuse. Preparing or dispensing medication and attempting to calm and/or restrain an aggressive patient were identified as 'high risk' work duties for verbal abuse and physical abuse, respectively. Most (93%) of the incidents of workplace violence were initiated by a prisoner/patient. Almost all of the incidents received either a medium (46%) or low (52%) Severity Assessment Code. Few victims of workplace violence incurred a serious physical injury - there were no workplace deaths during the study period. However, mental stress was common, especially among the victims of verbal abuse (85%). Few (6%) victims of verbal abuse sought help from a health professional. CONCLUSIONS: Among employees of a large correctional health service, verbal abuse in the workplace was substantially more common than physical abuse. The most incidents of workplace violence occurred in adult male prisons. Review of the types of adverse health outcomes experienced by the victims of workplace violence and the assessments of severity assigned to violent incidents suggests that, compared with health care settings in the community, correctional settings are fairly safe places in which to practice.     

Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research

Domestic violence victims are in frequent contact with the healthcare service yet rarely disclose. Therefore, it is critical to understand victims' experiences and perceptions regarding disclosure in healthcare settings. The goal of this review is to provide an updated synthesis of qualitative research identifying barriers and facilitators, advice, and positive and negative outcomes of adult victims' disclosure of domestic violence to healthcare professionals (HCPs). A systematic search of PsychINFO, CINAHL and Web of Science was conducted in January 2018. Thirty-four eligible studies were identified, including 783 domestic violence victims (781 females). Formal quality assessment indicated variable study quality. Barriers of disclosure included negative HCPs attitudes, victims' perceptions of safety and concerns about the consequences of disclosing. Facilitators of disclosing included a positive relationship with the HCP, HCPs directly asking victims about abuse, and HCPs ensuring that the environment is safe and disclosure is confidential. Victims advised increased awareness of HCPs reactions to disclosure and avoiding mirroring their perpetrators minimization. HCPs were encouraged to engage in direct questioning and maintain a supportive and secure environment. Positive and negative outcomes of abuse were identified, such as being able to leave the abuser or, on the other hand, the victims' situation not changing. Our results indicate that barriers for disclosure of domestic violence in healthcare settings persist despite the widespread implementation of policies and guidelines to counter them. Based on these findings, we provide recommendations for clinical practice and future research to help improve disclosure in healthcare settings.     

Attitudes and practices of doctors toward domestic violence victims in South Africa

Our study intended to ascertain doctors' attitudes and practices toward domestic violence in a sample of 402 doctors randomly chosen for a mail survey from a list of registered medical practitioners in South Africa. We found that the mean number of patients treated for domestic violence per month was 11.4 (SD = 13.4); for White doctors 15.8, African Black 6.2, and for Asian doctors 5.3. The high frequency of domestic violence detected in this sample seems to reflect national surveys on domestic violence. Most doctors believed that they should play a role in prevention and treatment, and their attitudes toward victims of domestic violence were generally sympathetic and supportive. Male doctors and long-serving practitioners tended to have more conservative views of the causes and attitudes of spousal assault and of the doctors' role in prevention. Only 9.7% of the doctors had received any training on domestic violence. Further research is needed to establish the prevalence of domestic violence in women presenting to medical practitioners and to investigate how the problem currently is being addressed.     

Rates of domestic violence against adult women by men partners

This study examines the rate of domestic violence against adult women by men partners. Two hundred eighteen women at two primary care clinics responded anonymously to a questionnaire. Forty-eight percent reported verbal abuse, 44 percent minor physical abuse, and 28 percent severe physical abuse. Abuse was common (16 percent) before marriage. Respondents whose partners were reported to be chemically dependent or sexually abusive were at greater risk for verbal and physical abuse. Respondents with lower socioeconomic status were at increased risk for verbal and physical abuse, as were women whose partners had less formal education. Ages of respondents and partners were not significant factors in abuse. Boyfriends not cohabitating were the least abusive, while couples together for 4 to 6 years had more domestic violence than other couples. Because spouse abuse is common and the consequences are devastating, it is important that family physicians become astute in making this diagnosis and initiate early treatment.     

Unsafe sex,substance abuse,and domestic violence: how do recently trained obstetricians-gynecologists fare at lifestyle risk assessment and counseling on STD prevention?

BACKGROUND: Unsafe sexual practices, substance abuse, and domestic violence impact women's health. This study examined whether lifestyle risk assessment during a general medical examination and counseling about sexually transmitted disease during consultations for adolescent contraception and treatment of a sexually transmitted disease were more frequently done by recently trained obstetricians-gynecologists compared to those of obstetrician-gynecologists licensed before 1990. It also documented obstetrician-gynecologists' evaluations of their medical training in that area. METHODS: A pretested anonymous mail survey was conducted in 1995 with all 241 obstetrician-gynecologists practicing in Quebec, Canada; 66% responded (N = 158). RESULTS: Compared to less recently trained obstetrician-gynecologists, recently trained obstetrician-gynecologists reported routinely assessing tobacco use (77 vs 51%, P = 0.01), alcohol use (50 vs 23%, P = 0.004), and illicit drug use (33 vs 17%, P = 0.05) more frequently during a patient's general medical evaluation. However, they did not assess condom use (50%), number of sexual partners, sexual partners' sexually transmitted disease risk (30%), or experiences of sexual abuse or domestic violence (3%) more frequently than less recently trained obstetrician-gynecologists. They were also not more likely to counsel teenagers about sexually transmitted disease prevention during a contraceptive consultation (30-60%) or to discuss human immunodeficiency virus infection (29%) and hepatitis B immunization (13%) during a sexually transmitted disease consultation. CONCLUSION: Although evaluation of substance use was better among recently trained OB-Gyn physicians, little or no improvement has been noted regarding STD prevention or the evaluation of sexual abuse or domestic violence, all important lifestyle risks that directly affect women's health and well-being.     

Interpersonal violence in a "normal" low-income control group

This paper examines the rates of interpersonal violence and trauma reported in a sample of 98 urban, low-income women, predominantly Latina or African-American descent constituting a "normal" control group for a larger study on drug abuse and violence. This sample was recruited from the obstetrics-gynecology outpatient clinic at St. Luke's-Roosevelt Hospital Center in New York City and carefully screened for the absence of any DSM-IV Axis I psychopathology including major mood disorders, anxiety, psychotic, alcohol and substance use disorders. Consistent with the literature, our sample exhibited rates of interpersonal violence and trauma markedly above estimates for women nationwide; compared to such national figures, our sample was at higher risk for experiencing childhood sexual abuse, childhood physical abuse, and partner violence. Almost one-quarter of our sample met diagnostic criteria for lifetime post-traumatic stress disorder. Ten to twenty percent of our sample reported other kinds of trauma, such as witnessing a murder, seeing violence between her parents, or being homeless. Interestingly, women in our sample were more likely than women nationwide to tell someone else of their abuse or trauma; it may be that disclosure of such events to a supportive person has protected these women to a certain extent from some of the longer-term potential effects of such negative experiences. The data collected in this study underscore the need for mental health and medical professionals to be sensitive to the high prevalence of certain kinds of traumatic and violent experiences in the lives of inner-city, low-income, minority women.     

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.