How and why community hospital clinicians document a positive screen for intimate partner violence: a cross-sectional study

BACKGROUND: This two-part study examines primary care clinicians' chart documentation and attitudes when confronted by a positive waiting room screen for intimate partner violence (IPV). METHODS: Patients at community hospital-affiliated health centers completed a screening questionnaire in waiting rooms that primary care providers (PCPs) were subsequently given at the time of the visit. We first reviewed the medical records of patients who screened positive for IPV, evaluating the presence and quality of documentation. Next we administered a survey to PCPs that measured their knowledge, attitudes and practice regarding IPV. RESULTS: Seventy-two percent of charts contained some documentation of IPV, however only 10% contained both a referral and safety plan. PCPs were more likely to refer patients (p < .05) who screened positively for mood or anxiety disorders, disclosed that they feared for their safety or were economically disadvantaged. Those that feared for their safety or endorsed mood or anxiety disorders were more likely to have notation of a safety plan in their records. When surveyed, 81.6% of clinicians strongly agreed that it is their role to inquire about IPV, but only 68% expressed confidence in their ability to manage it. In contrast, 93% expressed confidence in managing depression. Sixty-seven percent identified time constraints as a barrier to care. Predictors of PCP confidence in treating patients who have experienced IPV (p < .05) included hours of recent training and clinical experience with IPV. CONCLUSION: Mandatory waiting room screening for IPV does not result in high levels of referral or safety planning by PCPs. Despite the implementation of a screening process, clinicians lack confidence and time to address IPV in their patient populations suggesting that alternative methods of training and supporting PCPs need to be developed

Prevalence of Domestic Violence in an Inpatient Female Population

Studies have evaluated the prevalence of domestic violence in populations of patients in emergency and primary care settings, but there are little data on patients admitted to hospitals. We undertook a study to evaluate the prevalence of domestic violence among female inpatients. Of 131 consecutive female patients between the ages of 18 and 60 admitted to a nontrauma urban teaching hospital asked to complete a self-administered survey about domestic violence, 101 completed the questionnaire. Twenty-six percent of the respondents reported being in an abusive relationship at one time. Two patients felt that domestic violence contributed to their current reason for admission. No respondents were asked about domestic violence by health care providers. Domestic violence is an uncommon but important precipitant to nontrauma hospital admissions. Physicians should query all female inpatients about domestic assault

Relation of Low-Severity Violence to Women's Health

OBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history.Low-severity violence patientshad been “pushed or grabbed” or had someone “threaten to hurt them or someone they love” in the year prior to presentation.High-severity violence patientshad been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p < .0001). Psychological distress also increased with increasing severity of violence (mean total SCL-22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p < .0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress

Inside “Pandora's Box”: Abused Women's Experiences with Clinicians and Health Services

OBJECTIVE: To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting. DESIGN: Focus group data conducted and analyzed with qualitative methodology. SETTING: Three community-based mental health centers and one women's shelter. PARTICIPANTS: Twenty-one women in group therapy for domestic violence. MAIN RESULTS: Eighteen (86%) of the 21 women had seen their “regular doctor” in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse. CONCLUSIONS: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences

Prevalence and Determinants of Intimate Partner Abuse Among Public Hospital Primary Care Patients

OBJECTIVE: To determine the prevalence, sociodemographic determinants, and depression correlates of intimate partner abuse among an ethnically diverse population of women patients. DESIGN: Cross-sectional telephone survey in English and Spanish of a random sample of women patients aged 18 to 46 years. SETTING: Three public hospital primary care clinics (general internal medicine, family medicine, and obstetrics/gynecology) in San Francisco, Calif. PARTICIPANTS: We interviewed 734 (74%) of the 992 eligible participants. Thirty-one percent were non-Latina white, 31% African American, and 36% Latina. MEASUREMENTS AND MAIN RESULTS: Using questions adapted from the Abuse Assessment Screen, we determined recent and lifetime history of physical, sexual, and psychological abuse. Overall, 15% reported recent abuse by an intimate partner (in the preceding 12 months); lifetime prevalence was 51%. Recent abuse was more common among women aged 18 to 29 years (adjusted odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2 to 3.7), non-Latinas (adjusted OR, 1.7; 95% CI, 1.0 to 2.9), and unmarried women (adjusted OR, 1.65; 95% CI, 1.0 to 2.7). The prevalence of abuse did not differ by education, employment, or medical insurance status of the women. Compared with women with no history of abuse, a greater proportion of recently abused women reported symptoms of depression (adjusted OR, 3.5; 95% CI, 2.2 to 5.5). CONCLUSIONS: Because a substantial proportion of women patients in primary care settings are abused, screening for partner abuse and depression is indicated. In contrast to other studies, lower socioeconomic status was not associated with partner abuse history

Physical Abuse Among Depressed Women

OBJECTIVE: To provide estimates of physical abuse and use of health services among depressed women in order to inform efforts to increase detection and treatment of physical abuse. DESIGN: Retrospective assessment of abuse and health services use over 1 year in a cohort of depressed women. SETTING: Statewide community sample from Arkansas. PARTICIPANTS: We recruited 303 depressed women through random-digit-dial screening. MEASUREMENTS AND MAIN RESULTS: Exposure to physical abuse based on the Conflict Tactics Scale, multi-informant estimate of health and mental health services. Over half of the depressed women (55.2%) reported experiencing physical abuse as adults, with 14.5% reporting abuse during the study year. Women abused as adults had significantly more severe depressive symptoms, more psychiatric comorbidity, and more physical illnesses than nonabused women. After controlling for sociodemographic and severity-of-illness factors, recently abused, depressed women were much less likely to receive outpatient care for mental health problems as compared to other depressed women (odds ratio [OR] 0.3;p = .013), though they were more likely to receive health care for physical problems (OR 5.7, p = .021). CONCLUSIONS: Because nearly all depressed women experiencing abuse sought general medical rather than mental health care during the year of the study, primary care screening for physical abuse appears to be a critical link to professional help for abused, depressed women. Research is needed to inform primary care guidelines about methods for detecting abuse in depressed women