1. Screening by Physicians for Intimate Partner Violence
Joseph Frank Trujillo III
University of California, Davis, San Joaquin Valley PRIME in collaboration with University of California, San Francisco - Fresno
Abstract
According to World Health Organization, one in three women are victims of intimate partner violence (IPV) in the world. Currently IPV is a global health concern because of the growing effects IPV has on women and the public health system. Victims are more likely to be at risk for reproductive health issues, depression, alcohol use, and death. It is imperative for physicians to screen women with risk factors for IPV. The scope of this research is to focus on physician screening for IPV and improvement of screening tools.
Introduction
Intimate partner violence is defined by the the National Institute of Injury (NIJ) and Division of Violence Prevention (DPV) as physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner). In current media and society today IPV has made its way to being a well-known and increasingly discussed topic because it has become significantly rampant and prevalent throughout the world. The usual scenarios of IPV are those involving men as the assaulters and women being the victims. Not all IPV cases bring attention to the media/public but those that do display men serving reduced or no legal consequences at all for their acts of IPV. Data from the CDC shows 1 in 5 women have been physically, sexually, and emotionally abused and are 2 times more likely than men to be abused. The disparity of violence we see amongst women compared to men has proven why the CDC has recognized IPV as a public health concern.
Since IPV is a public health concern, I wanted to learn more about the physician and patient relationship regarding the topic. This projects primary focus is to grasp an idea of physicians screening for patients, particularly women, involved in intimate partner violence (IPV). As already mentioned, IPV is common but we tend to see it more amongst certain populations. Risk factors involved with IPV are young age, low academic achievement, low income, economic stress, poverty, traditional gender norms, male dominance in the family, drinking, and witnessing or experiencing violence in the family . These risk factors I listed are only a few, but they exist and are commonly found in families of Fresno county. Knowing risk factors of IPV is as important for knowing the risk factors for other common disease such as stroke. If we know the risk factors, we can potentially educate and prevent dangerous outcomes of IPV among women.
Hypothesis
Physicians do not screen for Intimate Partner Violence (IPV)
Methods
I focused my work with Marjoree Mason Center (MMC) in downtown Fresno. The MMC provides safe houses for women and men that are victims of IPV. They also provide legal assistance, counseling, group therapy, child services, education and training so they can return to the community. Focusing attention on women at MMC for this project would help me understand how well physicians screened women who have already been victims of IPV.
I formed a survey (Figure 1) that consisted of three sections and handed it out to women living at the Marjoree Mason Center in Downtown Fresno that serves the needs of individuals who have experienced IPV.
Results
The first section of the survey addressed questions of general health which looked into how many times women visited a doctor, whether they shared the same doctor as their spouse, and if they have a doctor in general. The results were women saw a doctor on average of 2 times per year, only 14 % share the same doctor as their spouse, and 57% do have a primary care doctor.
The second section questioned how physicians screen for IPV amongst women who have already experienced IPV. The questions consisted of physicians asking about relationship safety, history of abuse, showing concern for home safety, and child abuse. The response showed only 29% asked about relationship safety, 29% asked about ever being abused, 43% asked about safety at home, and there were zero inquiries into safety of their children.
The final section of my survey asked about victim’s comfort level regarding questions about IPV. The survey asked if they thought questions from physicians on IPV were appropriate, whether they would disclose information to a doctor about IPV if they were asked, would they tell their doctor if their child was being abused by their spouse, if they would seek help from a physician if they were being abused, and then lastly they were able to list their comfort level on scale of not comfortable to very comfortable. The results revealed victims of IPV think it is 100% appropriate for physicians to ask about IPV in their homes, 57% said they would tell their doctor if they asked about abuse, 100% said they would tell their doctor if their child was being abused by their spouse, 43% said they would seek help from a doctor, and the average comfort level discussing relationship safety was shown to be neutral on the subject.
Discussion
The data shines light into the fact that physicians do not screen as much as they probably should. Although my study lacked the power of large sample size, it focused on only victims of surviving IPV and of these victims there were low rates of doctors inquiring about their safety in their homes and relationships. Something worrisome and warrants future investigation is the lack of questioning parents of IPV received regarding their children’s safety. This is concerning because children are at greater risk of being abused in their home if their parents are already victims of abuse.
In a brief report from the Journal of Midwifery & Womens Health on screening for IPV they suggested that asking if a women feels safe at home is not sensitive enough for identifying IPV victims. In fact the sensitivity is 8.8%. They suggested asking more specific questions of physical abuse. They also provided screening tools with examples of appropriate dialogue with patients. One screening tool worthy of mentioning is HARK by Hardip Sohal. In a paper published by BMC Family Practice on The sensitivity and specificity of HARK, they found that the screening tool had a sensitivity of 81% and a specificity of 95% – by far the strongest screening modality. Their paper calls-out its own reliability asking others to use it more because it has limited research since it is new, but it doesn’t take away from the fact it is easy to use and asks only 4 questions.
Conclusion
The most important lesson physicians can take away from this experience is to learn to ask specific questions regarding IPV during patient encounters. This is especially important when encountering patients with obvious risk factors. Implementing comprehensive screening policies and procedures into clinics can also help reduce the public health burden of IPV and improve overall family well-being and safety.
Part I: General Health
PERCENT YES
1) Do you have a primary care physician/family doctor/clinic you visit?
57%
2) Do you and your spouse share the same primary care physician/family doctor/clinic?
14%
3) How often do you visit a primary care physician/family doctor/clinic? ____2_____ times per year
Part II: Screening for IPV
1) Has a doctor ever asked if you feel safe in your relationship?
29%
2) Has a doctor ever asked if you have been abused (physically/sexually/emotionally)?
3) Does your doctor ever show concern for your safety a home?
4) Has your doctor asked about child abuse (physically/sexually/emotionally)? 0%
Part III: Patient Comfort Level with Screening for IPV
1) Do you think it is appropriate for doctors to ask about IPV in your home?
100%
2) Would you tell a doctor you were being physically/sexually/emotionally abused if they asked?
3) Would you tell your doctor if your child was being abused by your spouse?
4) Would you seek help from a doctor if you were being physically/sexually/emotionally abused?
43%
5) How comfortable are you discussing your relationship safety with a doctor? (Circle one)
Not comfortable
Somewhat comfortable
Neutral
Comfortable
Very comfortable
Figure 1. This is a survey comprised of three sections to assess how well physicians screen for intimate partner violence. Surveys were anonymous and used solely for educational purposes.