1. The Epidemiology of Domestic Violence Thomas Songer, PhD Cristie Glasheen, MPH University of Pittsburgh

2. Key Points 1.What is being measured? 2.What is NOT being measured? 3.How does this affect the results?

3. Definition of Violence How would you define domestic violence? …...To understand violence, you need to define violence

4. Defining Domestic Violence domestic violence noun: violence committed by one member of a family or household against anotherdomestic violence noun: violence committed by one member of a family or household against another The National Research Council defines violence as:The National Research Council defines violence as: - behaviour by individuals that intentionally threaten, attempt, or inflict physical harm on others

5. Who is Affected by Domestic Violence? ChildrenChildren Intimate Partners (IP)Intimate Partners (IP) EldersElders

6. Data Sources You are planning to do a study of domestic violence using pre-existing data. You are planning to do a study of domestic violence using pre-existing data. Where would you look? Medical sourcesMedical sources State sourcesState sources Government surveysGovernment surveys

7. Which surveillance system is likely to provide the best estimates for domestic violence?

8. Surveillance in Domestic Violence Hospital Admissions Trauma Center Admissions Emergency Department Admissions State-based Reporting Systems Government Surveys –National Criminal Victimization Survey –National Incidence Survey –Behavioral Risk Factor Survey –National Violence Against Women Survey

9. Medical Sources Hospital RecordsHospital Records Trauma Center RecordsTrauma Center Records Emergency DepartmentEmergency Department Recommended: Rudman WJ. Coding and Documentation of Domestic Violence. December, 2000. Available at: http://endabuse.org/programs/healthcare/files/codingpaper.pdf

10. Definition of Health Care Events Related to Domestic Violence Based on N-codes and E-codes –995.80 to 995.85 adult physical abuse –995.50 child abuse –E coding to distinguish domestic violence is relatively poor –E967.x

11. State Based Reporting State-based ReportingState-based Reporting –Child Protective Services –Uniform Crime Reports –National Incident-Based Reporting System (NIBRS) –Supplementary Homicide Report (SHR)

12. State-based Programs Related to Domestic Violence Based on reporting to state agencies –most frequently for child maltreatment –definition of violence is not standard across the states –reporting is subject to knowledge of the issues to medical, educational, and legal personnel

13. Government Surveys Government SurveysGovernment Surveys –National Crime Victimization Survey (NCVS) –National Violence Against Women Survey (NVAW)

14. Surveys Related to Domestic Violence Self-report of violence based upon interviews –Aside from the NCVS, these surveys are not regularly collected –Definition of violence in surveys is not standard –There may be extensive under-reporting of violence

15. What do we know about Child Maltreatment?

16. Epidemiology of Child Abuse MaltreatmentMaltreatment –“behavior towards another person, which a) is outside the norms of conduct, and b) entails a substantial risk of causing physical or emotional harm” »Physical Abuse »Sexual Abuse »Emotional & Psychological Abuse »Neglect

17. Types of Maltreatment Physical abuse: physical acts by a parent, guardian or caretaker that caused physical injury to the child. Neglect (including medical neglect): the failure by the caretaker to provide needed, age- appropriate care (or provide for the health care) of the child. Sexual abuse: the involvement of a child in incest, or sexual assault by a relative or caretaker, includes fondling and exposure to indecent acts.

18. Substantiated Cases of Child Maltreatment, Pennsylvania, 1976-1994

19. The Pyramid of Child Maltreatment in Pennsylvania, 1994 53 deaths 33 head injuries 56 trauma center admissions 177 hospital admissions 2115 ED visits 7,038 substantiated cases 64,560 maltreatment events

20. What do we know about Violence Against Women?

21. Terminology of IPV Intimate Partner Violence (IPV) – relatively new term Also called: domestic violence, domestic abuse, spousal abuse, battery, violence against women

22. Who is an intimate? NCVSSHRNVAWS SpouseHusband/wifeSpouse Ex-spouseEx-husband/ex-wifeEx-spouse Common-law husband or wife Cohabitating partner Boyfriend/girlfriend Ex-boyfriend/ex- girlfriend Same sex relationship Date

23. Study Sample Size Definition and Method Trauma from Abuse One year Prevalence Lifetime Prevalence McCauley1952 Physical and sexual abuse reported in physician practices 5.5%33% Gin453 Physical and sexual abuse and threats by current partner reported in internal medicine clinics 14%28% Goldberg492 Physical abuse reported in an urban emergency department 22% Dearwater3455 Physical or sexual abuse reported in community hospital emergency departments 2.2%14.4%36.9% McLeer412 Physical abuse identified in trauma patients in urban emergency department 30% Abbott648 Physical abuse or threats reported in urban, acute care emergency departments and clinics 2.7%15.3%54.2% Muelleman9057 Physical trauma identified in ten emergency departments 3.1% Estimates of the Frequency of Domestic Violence Against Women seen in Medical Settings

24. IPV Source: American Journal of Preventive Medicine Volume 34, Issue 2, February 2008, Pages 112-118American Journal of Preventive Medicine Volume 34, Issue 2

25. WHO Multi-country Study on Women’s Health and Domestic Violence against Women

26. 960,000 women victimized 1992-96 NCVS 50% reported to police 51% had physical injuries 10% sought medical care 7% treated in emergency department 1418 murders 32% not treated for injury The Pyramid of Violence Against Women, U. S.

27. Trends in the rates of violent victimizations by intimates *, United States, 1992 - 1996

28. Possible Risk Factors Gender Ethnicity Socio-Economic Status Age ? Alcohol ? Pregnancy ? Psychiatric problems ? Intimate Partner Violence

29. What do we know about Elder Abuse?

30. Research Methods You have decided that existing data sources are not adequate to answer your research question. You want to design a new study. What do you need to consider?

31. Who Who are you going to measure?Who are you going to measure? –Victims? –Perpetrators?

32. What is Your Outcome? Physical Injury?Physical Injury? Psychological Injury?Psychological Injury?

33. Physical Injury Easiest to identify Severity of injury What are you missing? –Exposed with no injury

34. Psychological Injury What is the threshold? When is it a psychological “bruise” and when is it a “trauma”? What does this mean for prevention –Primary –Secondary –Tertiary

35. What is your exposure? Experienced or potential for abuse? Officially reported, unreported, or both Suspected or confirmed Attempts or completions Type of exposure –Physical and/or Neglect –Sexual –Emotional

36. How are You Going to Measure It? Domestic Violence is wrought with ethical considerations unique to this field of research

37. Key Lecture Points Surveillance for the frequency of domestic violence is not at the same level of development as for other unintentional injuries and for criminal violence Several limitations, including differing definitions, poor coding, and under-reporting influence our knowledge of the frequency of domestic violence Risk factor analysis in this area is just starting