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

By

Michael A Rodríguez, MD, MPH

References

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OBJECTIVE: Our goal was to identify the prevalence, determinants of, and barriers to clinician-patient communication about intimate partner abuse.

STUDY DESIGN: We conducted telephone interviews with a random sample of ethnically diverse abused women.

POPULATION: We included a total of 375 African American, Latina, and non-Latina white women aged 18 to 46 years with histories of intimate partner abuse who attended 1 of 3 public primary care clinics in San Francisco, California, in 1997.

OUTCOMES MEASURED: We measured the relevance and determinants of past communication with clinicians about abuse and barriers to communication.

RESULTS: Forty-two percent (159) of the patients reported having communicated with a clinician about abuse. Significant independent predictors of communication were direct clinician questioning about abuse (odds ratio [OR] =4.6; 95% confidence interval [CI], 3.2-6.6), and African American ethnicity (OR=1.8; 95% CI, 1.1-2.9). Factors associated with lack of communication about abuse included immigrant status (OR=0.6; 95% CI, 0.3-1.0) and patient concerns about confidentiality (OR=0.7; 95% CI, 0.5-0.9). Barriers significantly associated with lack of communication were patients’ perceptions that clinicians did not ask directly about abuse, beliefs that clinicians lack time and interest in discussing abuse, fears about involving police and courts, and concerns about confidentiality.

CONCLUSIONS: Clinician inquiry appears to be one of the strongest determinants of communication with patients about partner abuse. Other factors that need to be addressed include patient perceptions regarding clinicians’ time and interest in discussing abuse, fear of police or court involvement, and patient concerns about confidentiality.

It is estimated that intimate partner abuse (IPA) occurs in 4 to 6 million relationships each year in the United States^1,2 and that many health care interactions involve abused patients in primary care settings.^3,4 Clinicians are therefore well placed to identify IPA and to provide appropriate care and referrals. However, in spite of its high prevalence and the existence of published guidelines and recommendations for routine clinician screening,⁵ the majority of abused women patients are not identified in the medical system and do not receive needed assistance.^6,7 Estimates of the prevalence of clinician-patient communication about IPA range from 10% to slightly less than one third of all abused women.^2,8

Previous studies have shown that the low rates of clinician-patient communication about IPA result in part from a lack of direct questioning by many clinicians and because women rarely volunteer information about abuse without being asked. Less than 15% of women patients in primary care settings report being asked about abuse by health care professionals.^2,4,6,7,9 A recent statewide study of primary care clinicians in California found that only 10% reported routine screening for abuse among new patients, and 9% reported such screening at periodic checkups.¹⁰ Yet the majority of women patients report that they favor direct questioning by clinicians about IPA and would reveal abuse histories if asked directly.^6,7

Despite these studies there is much that remains unknown about abuse-related communication patterns and patient attitudes about communication in the medical setting. We examined the prevalence and determinants of clinician-patient communication about intimate partner abuse by interviewing an ethnically diverse group of abused women primary care patients to determine whether differences in disclosure of abuse were related to any of the following: age, ethnicity, education, language, and immigrant status of the patient, as well as clinician sex and ethnicity and the presence of an established clinician-patient relationship. We also looked into patients’ perceived barriers to communication about IPA, including lack of direct clinician questioning about abuse, perceptions about clinicians’ lack of time or interest in discussing abuse, fears about involving the police and courts, embarrassment, concerns about confidentiality, fear of shaming the family, and fear that the patient’s partner might hurt or kill her.

Methods

Study Population

Our sample consisted of women seen at 3 primary care outpatient clinics at San Francisco General Hospital in California.¹¹ Each year these family medicine, general internal medicine, and obstetrics/gynecology clinics serve nearly 100,000 ethnically and socioeconomically diverse women aged 18 to 45 years. During the 3-year period preceding our study, many staff members at the 3 clinics received training to encourage identification and management of IPA in the medical setting. The training incorporated lectures and continuing medical education.

We selected the sample from a computerized patient utilization database for the 3 clinics during 1997. Selection criteria included: (1) female sex; (2) race/ethnicity African American, non-Latina white, or Latina; (3) age 18 to 45 years; and (4) receipt of care in 1 of the 3 primary care clinics in the previous 6 months. Women were selected for participation in this study because they are much more likely to have been abused by an intimate partner than are men. Only women who reported histories of abuse were included in this analysis.