Identification of Victims of Spouse Abuse by Family Practitioners

Ramani Rangavajhula, M.D., Ph.D. 1; Stacey Plichta, Sc.D. 2; Clare Houseman, Ph.D. 3; & Laurel Garzon, D.N.Sc4.

1 San Jose State University, Department of Health Science, San Jose, CA 95192-0052.
2,3 Old Dominion University, College of Health Science, Norfolk, VA 23504
4 College of Nursing, Old Dominion University, Norfolk, VA 23508

Author for reprints
Ramani Rangavajhula
514 Mac Quarrie Hall
San Jose State University
San Jose, CA 95192-0052
Phone: (408) 924-2984
Fax: (408) 924-2979

Objectives: This study seeks to describe the behaviors of family practitioners toward victims of spouse abuse. It examines the frequency with which physicians ask their patients about experiences of spouse abuse, and the criteria by which they decide women may be at risk. The study also explores the relationship of demographic and training characteristics to the frequency of screening, amount of identification, and screening criteria.
Study design: Cross-sectional, self-answered questionnaire.
Population: Family practitioners attending a family medicine refresher course in a southern state.
Outcomes measured: Self-reported behavior, as measured by verbal statements of behavior, estimates of the number of victims identified, and the types of symptoms that may lead physicians to suspect abuse.
Results: Family practitioners are most likely to score positively on verbal statements of behavior and least likely to suspect and actually ask about abuse when victims present with various symptoms. About 25% of family practitioners surveyed do not even ask about abuse when the patients present with injuries. Women and those who had known a victim of spouse abuse are most likely to have positive behaviors.
Conclusions: By not identifying victims of spouse abuse family practitioners may be missing a critical opportunity to help the victims. This may lead to further entrapment of the victim. Domestic violence prevention courses that include resources to help identify and assist victims of spouse abuse are needed for family practitioners.

Key words: Family practitioners, spouse abuse, measurement of behavior, intimate partner violence, physicians

Intimate partner violence is an epidemic in the United States. Approximately 25% of all adult women in the United States are at risk of being abused by a male intimate partner during their lifetime (http://ncjrs.org/pdffiles1/nij/181867.pdf). Each year an estimated 8% to 11% of all married women (4-6 million) in the United States are physically abused by their current or former intimate partners (Plichta, 1996; Schulman, 1979; Stark et al, 1991; Straus et al, 1986). Battering may be the single major cause of injury to women, more frequent than auto accidents, mugging and rape combined (Stark et al, 1992). Each year more than 1.5 million women nation-wide seek medical treatment for injuries related to abuse (American Medical Association, 1992). Victims of spouse abuse are much more likely to use health care facilities than are other women. In one study criminal victimization severity was the most powerful predictor of physician visits (Koss et al, 1991). It is estimated that 22%-35% of women seeking care in the emergency departments are victims of spouse abuse (Abbot et al, 1995; Roberts et al, 1996; Kurz, 1987; Stark et al, 1979). It is also estimated that about 25% of women seeking care in ambulatory and family medicine clinics are victims of spouse abuse (Gin et al, 1991; Rath et al, 1990; Stark et al, 1988). The current research estimates for spouse abuse victims among women seeking prenatal care are close to 25% (Helton et al, 1987; McFarlane et al, 1992). Over 60% of women hospitalized in psychiatric facilities are also believed to be victims of spouse abuse (Carmen et al, 1984).

Despite their poorer health status and higher utilization of health services, the vast majority of abused women are not detected by health care providers even when the injury they presented with was directly due to abuse (Plichta, 1992). In fact, without active screening, fewer than 10% -15% of victims of spouse abuse are identified in medical practice (Chamberlain et al, 2002; Coker et al, 2002; Flitcraft, 1990; Freund et al, 1996; Hamberger et al, 1992; McLeer et al, 1987; Rodriguez et al, 1999; Warshaw, 1989). Victims often encounter blame, misinformed advice, and punitive responses when they seek help. A failure to identify victims of spouse abuse is likely to lead to a failure to refer appropriately. Neglect, denial, isolation, mistreatment and punitive interventions and referrals characterize the ongoing care of women who present with abusive injury (Stark et al, 1992). In a survey that asked 1000 abused women to rate the effectiveness of various professionals in addressing their abuse, health care professionals had the lowest rating, ranking behind shelter staff, lawyers, social service workers, police and clergy (Bowker et al, 1987).
Little is known about physician behaviors towards spouse abuse victims in the primary care setting. The frequency of screening for abuse, the criteria by which providers come to suspect spouse abuse, and the extent to which primary care providers actually detect spouse abuse is not well documented. Therefore, the purpose of this study is to describe the frequency of asking about the possibility of spouse abuse in patients, by family practitioners.

This survey instrument is a modified version of the instrument developed by the Group Health Cooperative of Puget Sound and Harborview Injury Prevention and Research Center. The survey consists of three attitude scales, a knowledge assessment, socio-demographic measures, a question about whether or not they personally knew a victim, and measures of practice and training characteristics. Attitude was measured as a composite of beliefs, behavior and affect. The attitude scales have been empirically tested and found to be valid and reliable (Maiuro et al, 2000).

Physician behavior toward victims of spouse abuse are measured by three items: a scale measuring behavioral intent through a series of verbal statements, a self-estimated number of victims identified, and a measure of the extent to which the physician would suspect abuse when patients present with a variety of symptoms (ranging from injuries to headache). The behavioral intent scale is comprised of four items, measured on a five point Likert scale, where responses range from strongly disagree to strongly agree. Note that negative items have been reverse coded in the analyses so that higher scale scores always mean a more positive behavior (verbal statement). Number of victims identified in the past year was measured as interval level variable where 1 = (0); 2 = (1-5); 3 = (6-10); 4 = (11-20); 5 = (>20). Suspecting a possibility of abuse was measured by giving the respondents a series of symptoms, and asking, on a five point scale (never to always), how often they would suspect spouse abuse in a patient presenting with that symptom. Not applicable was a valid answer choice if they had not seen a patient with that symptom in the last three months.
The demographic variables examined in this study are physician gender, age, ethnicity, and marital status. Age was dichotomized into under 35 and 35 or older. Medical training characteristics are measured by years in the profession (less than ten years vs. ten or more years), having received training about domestic violence while in medical school (none vs. any) and having received any post-graduate domestic violence training (none vs. any). Respondents were also asked about their personal exposure to domestic violence, through either their own or an acquaintances' experience.

The survey was administered to about 150 family practitioners attending a family medicine review course, 48 surveys were completed and returned (RR = 32%). Table 1 shows the demographic characteristics of the respondents. The majority of the sample is White (94%), most are married (77%), nearly half are female, and almost two-thirds (64%) are age 35 and over. Half (50%) have worked for more than 10 years in the profession, almost one-third received no domestic violence training in graduate school, and 79% have received no post-graduate domestic violence training.

One of the main limitations of this study is lack of response-bias analysis, as we do not have information from the non-respondents about their demographic or training characteristics. The external validity could be increased by employing a larger sample with known demographic characteristics, so we could compare respondents and non-respondents. Training was measured by a single item, and did not examine the quality or quantity of training. Also this is an indirect measure of self-reported behavior and may be different from the actual behavior. A more direct measure of behavior may be by observers in a clinic, and may help to make more realistic conclusions about identification rates.

Almost all physicians (92%) had identified a victim of spouse abuse at some point in their practice, though over 20% had not identified even a single victim of spouse abuse in the past year. Of those that had identified a victim in the past year, 79% had identified fewer than five victims. Only one physician identified (2%) more than 20 victims in the past year. About 20% identified 6-20 victims in the past year.
Most of the respondents had positive verbal statements about their ability to enquire about abuse (Table 2). However, a quarter of the physicians agreed to the statement "If I find a patient who is a victim, I don't know what to do."
The third measure of behavior was asking the patient about the possibility of spouse abuse when patients present with certain symptoms. Even when the patient presented with injuries about 25% never or seldom asked about abuse, and only 8% always asked about abuse (Table 3). Of all the symptoms asked about, family practitioners were most likely to ask about abuse while seeing patients with depression (67%) and injuries (65%).
With the exception of being female, and being a victim of abuse, none of the physician characteristics predicted physician behavior. None of the training characteristics significantly affected any of the measures of behavior.

Contrary to previous research, family practitioners in this study said that they had time to ask about abuse in their practice. A majority also agreed that they are not afraid of offending their patients if they asked about abuse. Most of them also agreed that they know what to do if they find a patient and also know how to ask about the possibility of abuse. But, when the question was framed differently and physicians were asked about enquiring about the possibility of abuse with various symptoms, the results were very different.
The findings in this study with regard to enquiring about abuse are similar to the results of earlier studies that suggested only a small percentage of victims of spouse abuse are being recognized in the health care system. It is very important to note that even when patients present with injury only half of the physicians are enquiring about abuse. Training and graduate curricula on domestic violence do not seem to be improving the identification rates or even asking about the possibility of abuse in this study contrary to a few other studies (Sitterding et al, 2003).
Domestic violence screening as a part of history taking should be made mandatory, so it helps to improve the rates of identification. If physicians routinely started to screen all patients for domestic violence (spouse abuse or intimate partner violence, child abuse or elder abuse) it may take away the burden of constant reminder. It may also ease stereotyping and selective enquiry about spouse abuse, it can also ease the minds of those physicians who may be worried about offending a patient who may not be a victim.
Since training did not seem to influence spouse abuse identification rates, it may be important to improve these programs. Training sessions which have standardized patients or use direct observation techniques may be more helpful in improving the physicians ability and comfort with screening for abuse.

In conclusion, it may be important to train the physicians in ways of identifying victims of spouse abuse. When a patient of abuse realizes that the physician had recognized that they are a victim of abuse but do not acknowledge it or talk about it, it may magnify the patients' anxiety and hopelessness. So even though the physicians alone cannot end spouse abuse, they may be a primary source of identification and treatment for the victims and a first contact to the outside world.

Key points for clinicians:

About 25% of all patients seen in ambulatory clinics may be victims of spouse abuse.

Almost 80% of the physicians identified fewer than five victims in the past year.

Even when the patient presented with injuries about 25% never or seldom asked about abuse.

Family practitioners may be missing a key opportunity to help victims of spouse abuse by not identifying them.

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Table 1. Demographic and Training Characteristics of Respondents

Table 3. Frequency of Suspecting Abuse:
Frequency of Enquiry About The Possibility of Abuse When Seeing a Patient With The Following Conditions

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Psychiatry On-Line	Dentistry On-Line	Vet On-Line	Chest Medicine On-Line	GP On-Line	Pharmacy On-Line	Anaesthesia On-Line	Medicine On-Line	Family Medical Practice On-Line

We thank the Dean's Office of the College of Health Sciences, Old Dominion University, and Office of Research, Economic Development and Graduate Studies, Old Dominion University for the funding that supported much of this research. We are also thankful to the Department of Family and Community Medicine, Eastern Virginia Medical School for all the support extended for conducting the survey. Additionally, we are grateful to Dr. Nancy Sugg and to the Harbor View Medical Center and Group Health Cooperative of Puget Sound for sharing their questionnaire (Health Care Provider Survey on Domestic Violence) and their expertise with us.

Characteristic	Percentage (n)
Gender Female Male	48 (23) 52 (25)
Age	Mean 42.53 (SD =10.22) 64% >35 years
Race White Others	94 (44) 6 (4)
Marital Status Married Divorced/separated Single Single, living with an intimate partner	77 (37) 6 (3) 10 (5) 6 (3)
Years in the profession	12.79 (SD = 10.30) 50% > 10 years
Amount of course content in graduate curricula None Little Moderate amount Great deal	30 (14) 53 (25) 15 (7) 2 (1)
Ever been trained in spouse abuse prevention since graduation? Yes No	21 (10) 79 (38)

Item	% Positive
OVERALL BEHAVIOR SCALE SCORE
I don't have the time to ask about spouse abuse in my practice	83
I am afraid of offending the patient if I ask about spouse abuse in my practice	88
If I find a patient who is a victim, I don't know what to do	75
I don't know how to ask about the possibility of spouse abuse	83

Condition	Never	Seldom	Sometimes	Nearly Always	Always
Injuries	8	17	29	27	8
Chronic Pelvic Pain	15	25	29	13	4
Irritable Bowel Syndrome	21	31	27	10	6
Headaches	23	23	33	10	6
Depression/anxiety	17	13	25	29	13
Hypertension/coronary artery disease	52	23	19	2	0