II. violence prevention and intervention in health care and community settings
Identification and management of domestic violence: A randomized trial1

https://doi.org/10.1016/S0749-3797(00)00231-2Get rights and content

Abstract

Background: Diagnosis of domestic violence (DV) in primary care is low compared to its prevalence. Care for patients is deficient. Over a 1-year period, we tested the effectiveness of an intensive intervention to improve asking about DV, case finding, and management in primary care. The intervention included skill training for providers, environmental orchestration (posters in clinical areas, DV questions on health questionnaires), and measurement and feedback.

Methods: We conducted a group-randomized controlled trial in five primary care clinics of a large health maintenance organization (HMO). Outcomes were assessed at baseline and follow-up by survey, medical record review, and qualitative means.

Results: Improved provider self-efficacy, decreased fear of offense and safety concerns, and increased perceived asking about DV were documented at 9 months, and also at 21 months (except for perceived asking) after intervention initiation. Documented asking about DV was increased by 14.3% with a 3.9-fold relative increase at 9 months in intervention clinics compared to controls. Case finding increased 1.3-fold (95%, confidence interval 0.67–2.7).

Conclusions: The intervention improved documented asking about DV in practice up to 9 months later. This was mainly because of the routine use of health questionnaires containing DV questions at physical examination visits and the placement of DV posters in clinical areas. A small increase in case finding also resulted. System changes appear to be a cost-effective method to increase DV asking and identification.

Introduction

Domestic violence (DV) affects up to16% of U.S. couples per year.1 The spectrum of DV manifestations, as encountered in primary care settings, is broad and includes injury; gastrointestinal, gynecologic, and somatic symptoms; sexually transmitted diseases; and psychological problems.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 Estimated prevalence of domestic violence (physical and/or sexual abuse) within the last year is between 3.9% and 23%3, 17, 18, 19 in medical practice.

Reportedly, only 7% to 25% of DV presenting in practice is identified,6, 20, 21, 22, 23 and queries occur in only 1% to 15% of encounters.3, 17, 18, 24, 25, 26 Interventions are inadequate in 60% to 90% of cases.17, 18, 27, 28, 29

Barriers to action in primary care have been described for United States, Canadian, and Australian physicians. These include fear of offending patients, a sense of futility, and lack of training and time.30, 31, 32, 33

Increased pressure for improved identification and management of DV22, 23, 34, 35, 36, 37, 38 has resulted in protocol development and use in emergency departments,20, 21, 39, 40, 41, 42, 43, 44, 45, 46 prenatal care settings,47, 48, 49, 50, 51, 52, 53, 54 and some hospital settings,55, 56 as well as mandatory reporting requirements in some states.57, 58 Reports of primary care efforts are more limited.59 Practice improvements in most settings have tended to be short-lived.1, 46, 59

We conducted a group-randomized trial of an intensive intervention directed to primary care practice teams to improve identification of, and assistance for, DV victims. We assessed provider knowledge, attitudes, and beliefs; rates of asking; case finding; and quality of assistance provided as outcomes.

Section snippets

Definition

We defined DV as violence between current or former intimate partners, or between a parent and an adult child. Individuals aged ≥18, both genders, and heterosexual or homosexual couples were included. Physical or sexual abuse, threats of violence, or clear-cut controlling behavior were included.

Setting

Five primary care clinics from the Group Health Cooperative (GHC) of Puget Sound, a large HMO, volunteered to participate. The patient population served is demographically comparable to the metropolitan

Characteristics of clinics at baseline

Characteristics of clinic personnel responding (N=179) and clinic membership at baseline are displayed in Table 1. There were 66 physicians, 13 physician assistants, 4 nurse practitioners, 44 nurses, and 52 other members of the health care teams. Over 30% of team members had been at GHC for ≥15 years. Intervention and control groups at baseline did not differ by gender, length of service, or job type. Provider survey nonrespondents did not differ from respondents by clinic, gender, or job type.

Discussion

This effectiveness trial tested an intervention to improve DV identification and care in primary care practice. We documented positive provider KAB outcomes up to 21 months after program initiation, and process of care (asking) outcomes at 9 months. In prior work, effects usually dissipated within 3 to 6 months of program initiation.21, 46, 59

Sustained positive impacts on provider self-efficacy, which generally correlates with action,87, 88 were documented as were effects on fear of offense,

Acknowledgements

Our project was funded by the Agency for Health Care Policy & Research (grant #HS07568-03) and The Group Health Foundation. We are grateful to Eve Adams for manuscript preparation; the DV project study team, comprised of Barbara Meyer, Kathy Smith-DiJulio, Madlen Caplow, Ben Givens, Michael Shafer, Colleen McBride, Lori Fleming, and Delores Meyer; and the five Group Health Cooperative study clinics for their dedication and willingness to participate.

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