The Factors Associated with Disclosure of Intimate Partner Abuse to Clinicians

,

Original Research

The Factors Associated with Disclosure of Intimate Partner Abuse to Clinicians

J Fam Pract. 2001 April;50(4):338-344

References

1. Straus M, Gelles R. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. J Marriage Fam 1986;48:465-79.

2. Plichta SB, Duncan MM, Plichta L. Spouse abuse, patient-physician communication, and patient satisfaction. Am J Prev Med 1996;12:297-303.

3. 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;123:737-46.

4. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.

5. Council on Scientific Affairs. American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-89.

6. Friedman LS, Sarnet JH, Roberts MS, et al. Inquiry about victimization experiences: a survey of patient p and physician practices. Arch Intern Med 1992;152:1186-90.

7. Caralis PV, Musialowski R. Women’s experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 1997;90:1075-80.

8. Gin NE, Rucker L, Frayne S, et al. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.

9. Straus MA, Smith C. Family patterns and primary prevention of family violence. Trends in health care, law & ethics 1993;8:17-26.

10. Rodríguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282:468-74.

11. Bauer HM, Rodríguez MA, Pérez-Stable EJ. Prevalence and determinants of intimate partner abuse among public hospital primary care patients JGIM In press.

12. Brislin RW. Back-translation for cross-cultural research. J Cross-Cultural Psych 1970;1:185-216.

13. Soeken K, Parker B, McFarlane J, et al. The abuse assessment screen: a clinical instrument to measure frequency, severity, and perpetrator of abuse against women. In: Campbell JC, ed. Empowering survivors of abuse: health care for battered women and their children. Thousand Oaks, Calif: Sage Publications; 1998.

14. SPSS. Version 8.0 for Windows. Chicago, Ill: SPSS, Inc; 1998.

15. West CM, Kantor GK, Jasinski JL. Sociodemographic predictors and cultural barriers to help-seeking behavior by Latina and Anglo American battered women. Violence Victims 1998;13:361-75.

16. Bauer HM, Rodríguez MA, Quiroga SS, Flores-Ortiz YG. Barriers to health care for abused Latina and Asian immigrant women. J Health Care Poor Underserved 1999;11:33-44.

17. Morales LS, Cunningham WE, Brown JA, et al. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med 1999;14:409-17.

18. Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA 1996;275:783-88.

19. Rodríguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-58.

20. Sugg NK, Inui T. Primary care physicians’ response to domestic violence: opening Pandora’s box. JAMA 1992;267:3157-60.

21. Rodríguez MA, McLoughlin E, Bauer HM, et al. Mandatory reporting of intimate partner violence to police: views of physicians in California. Am J Public Health 1999;89:575-78.

22. Gerbert B, Caspers N, Bronstone A, et al. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131:578-84.

23. 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;173:381-87.

24. Tilden VP, Schmidt TA, Limandri BJ, et al. Factors that influence clinicians’ assessment and management of family violence. Am J Public Health 1994;84:628-33.

25. Harwell TS, Casten RJ, Armstrong KA, et al. Results of a domestic violence training program offered to the staff of urban community health centers. Am J Prev Med 1998;15:235-41.

Patients were considered eligible if they met all the selection criteria, spoke English or Spanish, had verifiable phone numbers, and were mentally and physically capable of completing the survey.

Survey Instrument

We developed the survey instrument through a review of the literature, including the results from some of the authors’ previous qualitative research, consultation with domestic violence researchers and advocates, and discussions with a focus group of 6 abused women. Final survey modifications were made following expert review and pilot testing with 75 women, 25 from each target ethnic group. The instrument included questions about patients’ social, health, and demographic characteristics; clinic and medical clinician utilization; and IPA experiences. Women who indicated histories of IPA were questioned about their experiences in obtaining abuse-related help in the medical system, the barriers to IPA communication with medical clinicians, and clinician demographics. The questionnaire was prepared in English and translated to Spanish using standard translation methods.¹²

Questions about abuse were adapted from the 4-question Abuse Assessment Screen, which has been validated in multiethnic populations.¹³ These questions asked whether the participants had ever experienced physical, sexual, or psychological abuse. For each positive response, women indicated whether the abuse had occurred in the past 12 months (recent abuse) or in the more distant past.

Prevalence of communication with clinicians about abuse was assessed by asking participants if they had ever mentioned or discussed abuse with a physician: (1) in response to direct clinician questioning or (2) in the absence of direct clinician questioning.

Data Collection

The survey was administered to the sample by computer-assisted telephone interview between October 1997 and March 1998. An introductory letter was mailed to the homes of all potential participants (to ensure safety the topic of abuse was not mentioned in this letter). Following this, trained women interviewers contacted potential participants by telephone. After confirming eligibility, privacy, and safety and obtaining verbal consent, interviews lasting approximately 25 minutes were conducted in English or Spanish. The study protocol was approved by the Committee for Human Research at the University of California, San Francisco.

Data Analyses

We analyzed the data using SPSS statistical software.14 IPA was defined as having ever been exposed as an adult to physical abuse, sexual abuse, or threats/fear of abuse. The principal outcome variable was previous communication with a medical clinician about IPA experiences. Predictor variables included age, ethnicity, birthplace, language, employment and medical insurance status, and education, as well as clinician sex and ethnicity, direct clinician questioning about abuse, and presence of an established relationship with a clinician (regular clinician). Additional predictor variables included patients’ perceived barriers to communication.

We used multiple logistic regression analysis to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the factors associated with clinician-patient communication about abuse. Our final model includes variables of primary interest to our study (patient age, ethnicity, education, and presence of a regular clinician), as well as those variables that significantly influenced abuse-related communication (birthplace, direct questioning by a clinician, perceptions that clinicians lack time and interest in discussing abuse, and concerns about confidentiality). For cross tabulations, statistical significance was determined using the Pearson chi-square test. Statistical significance was defined as P less than .05.

Results

Sample Description

Of the 1390 patients selected from the database, 992 (71%) met the eligibility criteria. Of the 398 ineligible women, 315 (23%) did not have verifiable phone numbers, and 83 (6%) either did not speak English or Spanish, were incapable of completing the survey, or did not meet the original selection criteria. The overall collaboration rate was 74% (734/992) of the available eligible participants. Of the women interviewed, 51% (375) reported having ever been abused by an intimate partner as an adult. Further descriptive analyses are reported elsewhere.¹¹ Among the 375 participants who reported a history of abuse: 88% (328) reported having experienced physical abuse; 33% (122) reported having experienced sexual abuse; and 66% (246) reported having experienced threats or fear of IPA. There was substantial overlap between abuse categories for most participants, and almost all women reporting a history of sexual abuse also reported a history of physical abuse. However, 7% (28) of the participants reported previous threats or fear of IPA in the absence of physical or sexual abuse.

Sample characteristics of all study participants with histories of abuse are summarized in Table 1. The mean age was 34.3 years (standard deviation [SD]=7.3 years). The study participants were primarily of lower socioeconomic status. Years of education ranged from none to postgraduate, with a mean of 11.9 years (SD=3.5 years).