Routine, Single-Item Screening to Identify Abusive Relationships in Women

,

Original Research

Routine, Single-Item Screening to Identify Abusive Relationships in Women

J Fam Pract. 2000 November;49(11):1017-1022

References

1. Gin NE, Rucker L, Fryne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.

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

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. Johnson M, Elliott BA. Domestic violence among family practice patients in midsized and rural communities. J Fam Pract 1997;4:391-400.

5. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-31.

6. Bergman B, Brismar B. A 5-year follow-up study of 117 battered women. Am J Pub Health 1991;81:1486-89.

7. Briere J, Zaidi LY. Sexual abuse histories and sequalae in female psychiatric emergency room patients. Am J Psychiatry 1989;146:1602-06.

8. Pribor EF, Yutzy SH, Dean T, Wetzel RD. Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993;150:1507-11.

9. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75-80.

10. Walker EA, Katon WJ, Hansom J, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658-64.

11. Walker EA, Katon WJ, Roy-Byrne PP, Jemelka RP, Russo J. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatry 1993;150:1502-06.

12. Jaffe P, Wolfe DA, Wilson S, Zak L. Emotional and physical health problems of battered women. Can J Psychiatry 1986;31:625-29.

13. Briere J, Runtz M. Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 1988;12:51-59.

14. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women’s mental health. Lancet 1988;1:841-45.

15. Drossman DA, Talley NJ, Leserman J, Olden KW, Barreiro MA. Sexual and physical abuse and gastrointestinal illness. Ann Intern Med 1995;123:782-94.

16. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 1987;27:310-14.

17. Haber JD, Roos C. Effects of spouse abuse in the development and maintenance of chronic pain in women. Adv Pain Res 1985;9:339-95.

18. Reiter RC, Shakerin LR, Gambone DO, Milburn AK. Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 1991;165:104-09.

19. Schei B, Bakketeig LS. Gynaecological impact and sexual and physical abuse by spouse: a study of a random sample of Norwegian women. Br J Obstet Gynaecol 1989;96:1379-83.

20. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-92.

21. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800-02.

22. Alpert EJ. Violence in intimate relationships and the practicing internist: new “disease” or new agenda? Ann Intern Med 1995;123:774-81.

23. Sugg NK, Inui T. Primary care physicians’ responses to domestic violence. JAMA 1992;267:3157-60.

24. Hess AMR, Nelson EC, Johnson DJ, Wasson JH. Building an idealized measurement system to improve clinical office practice performance. Managed Care Q 1999;7:22-34.

25. Shepard MF, Campbell JA. The abusive behavior inventory: a measure of psychological and physical abuse. J Interpersonal Violence 1992;7:291-305.

26. Hudson WW, McIntosh SR. The assessment of spouse abuse: two quantifiable dimensions. J Marriage Fam 1981;873-88.

27. Fieldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.

28. Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP functional health assessment charts: brief measures for clinical practice. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia, Pa: Lippincott-Raven Press; 1996;161-68.

29. Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patients: how can it be measured in physicians’ offices? Med Care 1990;28:1111-26.

30. Nunnally JC. Psychometric theory. New York, NY: McGraw-Hill; 1978.

31. Wasson JH, Jette AJ, Johnson DJ, Mohr JJ, Nelson EC. A replicable and customizable approach to improve ambulatory care and research. J Ambulatory Care Management 1997;20:17-27.

32. Wasson JH, Stukel TA, Weiss JE, Hays RD, Jette AM, Nelson EC. A randomized trial of using patient self-assessment data to improve community practices. Effective Clin Pract 1999;2:1-10.

33. Wasson JH, Keller A, Rubenstein LV, Hays RD, Nelson EC, Johnson D. and the Dartmouth Primary Care COOP. Benefits and obstacles of health status assessment in ambulatory settings: the clinician’s point of view. Med Care 1992;30(suppl):MS42-49.

34. Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau P. A short survey for assessing health and social problems of adolescents. J Fam Pract 1994;38:489-94.

35. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and health experiences. Fam Med 1998;30:122-26.

36. Magari ES, Hamel MB, Wasson JH. An easy way to measure quality of physician-patient interactions. J Ambulatory Care Management 1998;21:27-33.

37. Larson CO, Hays RD, Nelson EC. Do the pictures influence scores on the Dartmouth COOP charts? Qual Life Res 1992;1:247-49.

The Patient Health Survey. The Relationships Chart was included as part of a patient health survey called “Improve Your Medical Care.” This survey was used as part of a quality improvement system that has been shown to improve care for different populations.^31,32 However, in our study it was used only to sample patients’ needs and characteristics in the participant practices. The patient health survey contains questions about demographics and diagnoses (8 items), function (6 items), symptoms and bothers (22 items), habits and prevention (13 items), and utilization (4 items). A complete copy of this survey is available on request.

All practices received computer-scored reports for each respondent within 1 week of completion.

Analysis

To compare scores on the Relationships Chart with measures of functional status using the Dartmouth Primary Care Cooperative Information and Research Network (COOP) charts, we used a score of 4 or 5 on a 5-point Likert scale as the threshold for significant limitation in function.³³ For bothersome symptoms we used a response of “often” or “always” in the previous 4 weeks. We used the chi-square test to assess the statistical significance of the comparisons.

We used prevalence ratios to compare the prevalence of abusive relationships for women with and without functional limits and symptoms.

Results

Clinical and Functional Impacts of an Abusive Relationship Ninety-six percent of the women completed the chart (1526/1584). Possible domestic abuse (as assessed by this chart) was reported by 13% (201) of the women visiting these 31 outpatient practices. The range of positive responses was 0% to 50%; the median was 11%.

The Table lists several factors highly associated with an abusive relationship. Women in an abusive relationship were more likely to be young and poor. They more often had multiple problems with function and many bothersome symptoms. They less often engaged in good personal health habits. More of these women smoked cigarettes: 24% vs 15%, P=.002; more of them drank more than 6 alcoholic beverages a week: 12% vs 7%, P=.001). They more often reported that they had been confined to bed in the previous 3 months than women who were not abused.

Despite a higher frequency of clinic use, women in an abusive relationship more often reported problems with access and slightly less often completed necessary preventive actions. However, they had the same number of chronic diagnoses and used the hospital and chronic medications at the same rate as other women (data not shown).

The most common functional limitations reported by all women were pain (24%), physical (21%), and feelings (18%). Figure 2 illustrates the probability of an abusive relationship for women with or without a particular functional limitation. Pain and feelings were most often associated with an abusive relationship. Almost a third of the women who are limited by feelings are at risk for domestic abuse. The prevalence ratio for feelings was 3.0.

The most common symptoms reported were eating/weight (26%), dizziness/fatigue (24%), joint pains (23%), back pains (22%), sleep problems (22%), and headaches (21%). Figure 3 illustrates the probability of an abusive relationship for women with or without a particular symptom. Among the 6 most prevalent symptoms, headache was most strongly associated with domestic abuse (24%). Among women who reported abusive relationships “most or all of the time” the chance of significant problems with feelings, dizziness/fatigue, headache, or sleep was greater than 50% (data not shown).

Identifying Women at Risk

Although a combination of demographic characteristics and clinical problems can be used to identify a group of women at high risk for abuse,³ such an approach makes little practical sense. For example, among women who have inadequate money and significant problems with feelings, 41% (36/89) were likely to have an abusive relationship. However, among the 1025 women with neither financial difficulties nor emotional problems, 64 were at risk for abuse (6%).

Discussion

We found that approximately 13% of women aged 19 to 69 years in 31 practices were identified as being in an abusive relationship by a single written measure. These women had significant psychosocial issues, poor health habits, and many somatic complaints.

Our descriptive study of screening for an abusive relationship in women has 4 important implications for clinical practice:

It reaffirms the prevalence of abuse in office practice settings. In these 31 practices, the median rate of possible abuse was 11%.
It provides a detailed illustration of the burden of clinical and social illness borne by women in abusive relationships. One other study³ has provided a similar level of detail. Where measures of symptoms were comparable, both studies found similar prevalence ratios for abuse.
It reminds clinicians that direct inquiry about possible abuse is likely to be much more effective than using a combination of demographic and clinical factors.^3,15 Clinical intuition used to select an at-risk woman from a group will be less effective than asking her directly about possible abuse.
These results add to the growing body of literature that single-item word-and-picture charts that query patients about complex issues are very useful in clinical practice. Such charts have been shown to be valid and reliable for identifying important functional limitations in adults,^28,29 depression,³³ health and social problems in adolescents,³⁴ and spirituality.³⁵ Because they are single-item they are good for screening, can be easily adapted to other languages, and serve as the foundation for deeper inquiry about physician-patient interaction.^33,36 For example, more than one third of the women in these practices felt that their clinician was unaware of important functional limitations or provided poor education about them.