BACKGROUND: Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse.
METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N=13) and functional limitations (n=6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse.
RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P <.001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P <.001). They had twice as many bothersome symptoms (3.1 vs 1.7; P <.001) and functional problems (1.6 vs 0.8; P <.001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n=64) reported abusive relationships than in the high-risk group (n=36).
CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.
The prevalence of domestic abuse in 3 primary care studies ranged from 6% to 22%. In these studies domestic abuse was measured as physical abuse1-4 or a combination of both physical and verbal abuse.1,2,4 In these and many other studies, an abusive relationship was associated with psychological problems,3-14 drug and alcohol abuse,3,6,7,9-11 and many other different symptoms.3,5,7-13,15-19 Detection of abusive relationships in clinical settings is assumed to improve outcomes.3,20,21 Guidelines for detection and management are well described.22
Despite its prevalence and importance, a woman’s abusive relationship often goes unnoticed in primary care practice.1-3,23 We used the results of a comprehensive written health survey of 1526 women aged 19 to 69 from 31 practices across the United States to reemphasize why specific inquiry about an abusive relationship is important and how it might be accomplished in a busy office setting.
Methods
Settings and Patients
We used data from 31 sites participating in a 3-year quality improvement project.24 In 1999, at 2 times separated by 6 months, all sites asked 2 sequential samples of adults aged 19 to 69 years to complete an anonymous health survey. Each site determined when and how the sample would be obtained. A total of 2528 patients responded. The number of responses by practice ranged from 19 to 156, and the median was 64. Of these patients, 1584 were women.
Measures
The Screening Tool for an Abusive Relationship. To develop the single-item screening tool,9 primary care physicians and nurses examined several methods for detection of abuse identified in the published literature.25-27 They developed 2 word-and-picture charts based on previously tested methods.28,29 Two groups of women who had recently experienced domestic abuse (total N=13) reviewed these charts, and their suggestions were incorporated.
For our investigation, the word-and-picture Relationships Chart was used (Figure 1). To validate the Relationships Chart we administered it to 51 women volunteers in urban and rural domestic abuse support groups. The control group consisted of 48 randomly selected patients in 2 obstetric and gynecology clinics. These women were also asked to complete 41 items about spouse or partner abuse.25 The items were scored on a 5-point scale so the maximum score would be 205 and the minimum score 41.
Women seeking help from a support group because of their current or previous involvement in an abusive relationship scored much worse than women in the control group on both the single-item chart and the multi-item score (P <.001). Based on the chart, when women reported potential abuse “none or a little of the time,” their average score on the multi-item questionnaire was 62; when their response was “some of the time” their average score was 86; and when they reported “often or always” experiencing potential abuse during the previous 4 weeks their average score was 114.
Eighty-eight of the women completed the Relationship Chart a second time within 10 days after the initial administration. The average test-retest correlation was 0.60; on the 5-point scale 88.4% of the responses stayed the same or shifted by only 1 scale point.
Thus, the Relationship Chart had reasonable face and criterion validity and more than met minimum standards for reliability.30