|
 |
|
|||||||
|
|||||||||
© 2003 American Public Health Association
RESEARCH AND PRACTICE |
Sarah Hudson Scholle is with the Department of Psychiatry, University of Pittsburgh, Pa. Raquel Buranosky and Barbara H. Hanusa are with the Division of General Internal Medicine, University of Pittsburgh, Pa. At the time of the study, LeeAnn Ranieri, Kate Dowd, and Benita Valappil were with Magee-Womens Hospital, Pittsburgh, Pa.
Correspondence: Requests for reprints should be sent to Sarah Hudson Scholle, DrPH, University of Pittsburgh, 3811 O’Hara St, Suite 430, Pittsburgh, PA, 15213 (e-mail: schollesh{at}msx.upmc.edu).
 |
INTRODUCTION |
|---|
 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
|---|
Intimate partner violence affects 5% to 22% of women seen in primary care settings.1–4 Routine screening of all adult women is recommended by advocacy and medical organizations.5–7 However, implementation of screening has not been studied outside of a research intervention. Physician barriers to screening include concerns about time, training, and lack of available treatments.8,9 Women report barriers to disclosure, such as confidentiality concerns, shame, and fear of escalating violence or loss of child custody.10,11
Our goal was to examine the frequency of intimate partner violence screening and disclosure in an outpatient obstetrics and gynecology clinic with a policy calling for routine screening at every visit.
|
METHODS |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Design and Setting
Charts from all patients seen during 1 week in March 2000 at a university-based obstetrics and gynecology clinic were reviewed for notations of screening for and detection of intimate partner violence. All physicians and clinic staff receive ongoing education in intimate partner violence screening and counseling. Screening questions, or prompts, are found on most standardized clinic forms, although the exact wording varies by form.
Data Collection
The clinic schedule was used to identify patients who completed visits in physician-led clinics. A standard chart review form was used to record demographic characteristics of the patients, type of visit, forms completed, and intimate partner violence documentation. Any mention of an intimate partner violence discussion, completion of an intimate partner violence prompt, or indication of presence or absence of intimate partner violence was considered evidence of an intimate partner violence screen. Because hospital policy states that screening should not be done in the presence of the partner, charts were excluded if they had documentation that the partner was present.
|
RESULTS |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
A total of 469 patients attended 473 visits during the study period. For the 4 patients with 2 visits, only the first visit of the week was included. Charts for 45 patients could not be located, and 6 patients were excluded because they were seen only for a research protocol. We excluded 26 women (with 27 forms) because they had been seen with a partner present. The analyses focused on 392 patients who had 733 forms completed.
Women in the study group were young (mean age = 26.4; SD = 8.4), had public insurance (75%), and were evenly split between African Americans and Whites. Of the patients, 51% were seen for prenatal care, and the remainder were seen for family planning (20%), gynecology (16%), and colposcopy visits (7%).
The rate of completion of intimate partner violence prompts was generally high in prenatal visits, with documentation found in 97% of the prenatal history, 82% of the prenatal flow, and 82% of the prenatal assessment forms (Table 1
). The exception was the prenatal progress note (6%), which usually accompanies the other 3 structured prenatal visit forms. Among nonprenatal visits, intimate partner violence documentation occurred on 57% of the forms, and there was more variation. For example, 74% of the gynecology visit structured forms had a record of intimate partner violence screening compared with 33% of the gynecology notes forms (Table 1). The structured form is used by nurses or clinicians to document an annual gynecologic examination, whereas the gynecology notes form is used by physicians and nurse practitioners to document an interim or problem visit. Social work forms also had less frequent documentation of intimate partner violence (38%).
|
Because women often had several forms per visit, there were usually several opportunities for documenting intimate partner violence (Table 2
). Overall, 72% of the women seen in the clinic had documentation that intimate partner violence was discussed in the visit, with a significantly higher screening rate among women seen for prenatal care (84%) compared with other women (60%) (P < .01).
|
Only 9 women of the 392 (2%) had recent intimate partner violence documented as present, and the rate was somewhat higher for prenatal care patients (4%) than for other patients (1%) (P = .17). For 8 of the 9 women with documented intimate partner violence, at least 1 other form at the same visit had a negative response to a screening prompt.
|
DISCUSSION |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
This chart review study showed that an intimate partner violence screening program can be successfully implemented in routine practice; nearly three quarters of the patients in our clinic were screened in a given week. This compares favorably with an 88% screening rate obtained under a research protocol in a prenatal clinic setting12 and with other studies that improved screening through specific protocols.13 Screening was more frequently documented during prenatal visits, possibly because of heightened awareness of risk or safety concerns for pregnant women4,14 or because prenatal visits generally involve multiple providers, thus allowing more opportunities for screening. More variation in screening occurred during nonprenatal visits. The context of the visit may be important. For example, better intimate partner violence screening documentation was evident on the form used for longer annual gynecology visits, which may allow more time to address sensitive issues such as intimate partner violence.
Given the good compliance with the screening procedures, the rate of documented intimate partner violence was lower than expected, given prior studies1–4 and the young study group.4,15 The question used to screen may have affected disclosure because most prompts emphasize current abuse by a current partner. Women may be victimized by ex-partners and may have different interpretations of whether abuse is "currently" occurring.5,11 In addition, there is probably more variability in how clinicians working in this real-life setting approach intimate partner violence screening compared with how specially trained interviewers in research projects screen for intimate partner violence.
Still, the lack of disclosure is consistent with reports from abused women who stated that they often refused to disclose abuse in health care settings.16 Interestingly, the same women advise health care professionals to ask about intimate partner violence because it gives abused women support and information.17 Further research is needed to understand whether aspects of the patient-provider relationship affect women’s disclosure of intimate partner violence and whether intimate partner violence screening in the health care setting leads women to seek help in other settings or to make safety improvements on their own, without disclosing abuse to health care providers.
|
Acknowledgments |
|---|
This study was supported by the Center of Excellence in Women’s Health (Principal Investigator: Hillier), The Scaife Family Foundation (Principal Investigator: Ranieri), and the Mental Health Intervention Research Center (MH 30915; Principal Investigator: Kupfer).
Human Participant Protection
This study was approved by the institutional review board of the Magee-Womens Hospital.
|
Footnotes |
|---|
Contributors
S. H. Scholle and R. Buranosky planned the study and wrote the brief. L. Ranieri and K. Dowd assisted with study design and interpretation of the data and contributed to the writing of the brief. B. H. Hanusa and B. Valappil analyzed the data and contributed to the writing of the brief.
Accepted for publication November 25, 2002.
|
References |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
1. McGrath ME, Hogan JW, Peipert JF. A prevalence survey of abuse and screening for abuse in urgent care patients.Obstet Gynecol.1998;91:511–514.[Web of Science][Medline]
2. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med. 1992;24:283–287.[Medline]
3. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA.1996;275:1915–1920.
4. Gin NE, Rucker L, Frayne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med. 1991;6:317–322.[Web of Science][Medline]
5. Preventing Domestic Family Violence: Clinical Guidelines on Routine Screening. San Francisco, Calif: The Family Violence Prevention Fund; 1999.
6. Physicians and domestic violence. Ethical considerations. Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 1992;267(23):3190–3193.
7. Jones RF, Horan DL. The American College of Obstetricians and Gynecologists: responding to violence against women.Int J Gynecol Obstet. 78(suppl 1):S75–S77, 2002.
8. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol.1995;173:381–386.[Web of Science][Medline]
9. Sugg NK, Inui T. Primary care physicians’ response to domestic violence: opening Pandora’s box. JAMA.1992;267:3157–3160.
10. McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside "Pandora’s Box": abused women’s experiences with clinicians and health services. J Gen Intern Med. 1998;13:549–555.[Web of Science][Medline]
11. Rodriguez M, Quiroga S, Bauer H. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med. 1996;5:153–158.
12. Wiist WH, McFarlane J. The effectiveness of an abuse assessment protocol in public health prenatal clinics. Am J Public Health. 1999;89:1217–1221.
13. Waalen J, Goodwin MM, Spitz AM, Petersen R, Saltzman LE. Screening for intimate partner violence by health care providers: barriers and interventions. Am J Prev Med. 2000;19:230–237.[Web of Science][Medline]
14. Mayer L, Liebschutz J. Domestic violence in the pregnant patient: obstetric and behavioral interventions. Obstet Gynecol Surv.1998;53:627–635.[Medline]
15. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med.1995;123:737–746.
16. Rodriguez MA, Sheldon WR, Baver HM, Perez-Stable, EJ. The factors associated with disclosure of intimate partner abuse to clinicians. J Fam Pract. 2001;50(4):338–344.[Web of Science][Medline]
17. Chang JC, Decker M, Moracco KE, Martin SL, Peterson R, Frasier PY. What happens when health care providers ask about intimate partner violence? A description of consequences from the perspectives of female survivors. J Am Med Womens Assoc. In press.
This article has been cited by other articles:
|
|
 |
|
  M. Oschwald, P. Renker, R. B. Hughes, A. Arthur, L. E. Powers, and M. A. Curry Development of an Accessible Audio Computer-Assisted Self-Interview (A-CASI) to Screen for Abuse and Provide Safety Strategies for Women With Disabilities J Interpers Violence, May 1, 2009; 24(5): 795 - 818. [Abstract] [PDF]
|
|
|
|
 |
|
 J. Spangaro, A. B. Zwi, and R. Poulos The Elusive Search for Definitive Evidence on Routine Screening for Intimate Partner Violence Trauma Violence Abuse, January 1, 2009; 10(1): 55 - 68. [Abstract] [PDF]
|
|
|
|
 |
|
 T. Zink, S. Regan, L. Goldenhar, S. Pabst, and B. Rinto Intimate Partner Violence: What Are Physicians' Perceptions? J Am Board Fam Med, September 1, 2004; 17(5): 332 - 340. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |