II. violence prevention and intervention in health care and community settingsIdentification and management of domestic violence: A randomized trial1
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.
References (94)
- et al.
Gastrointestinal tract symptoms and self-reported abusea population-based study
Gastroenterology
(1994) - et al.
Education is not enougha systems failure in protecting battered women
Ann Emerg Med
(1989) - et al.
Recognition of nonaccidental injury
Ped Clin North Am
(1985) - et al.
Emergency department response to battered women in Massachusetts
Ann Emerg Med
(1994) - et al.
Development and validation of an emergency department screening and referral protocol for victims of domestic violence
Ann Intern Med
(1996) - et al.
Outcome evaluation of an emergency department protocol of care on partner abuse
Aust NZ J Public Health
(1998) - et al.
Safety behaviors of abused women after an intervention during pregnancy
J Obstet Gynecol Neonatal Nurs
(1998) - et al.
WomanKindan innovative model of health care response to domestic abuse
Womens Health Issues
(1995) - et al.
Results of a domestic violence training program offered to the staff of urban community health centers
Am J Prev Med
(1998) - et al.
The development of a health care provider survey for domestic violencepsychometric properties
Am J Prev Med
(2000)
Comparison of domestic violence screening methodsa pilot study
Ann Emerg Med
Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys
J Marr Fam
The “battering syndrome”prevalence and clinical characteristics of domestic violence in primary care internal medicine practices
Ann Intern Med
Prior physical and sexual abuse in women with chronic headacheclinical correlates
Headache
Sexual and physical abuse in women with functional or organic gastrointestinal disorders
Ann Intern Med
Sexual and physical abuse and gastrointestinal illness
Ann Intern Med
Costs of health care use by women HMO members with a history of childhood abuse and neglect
Arch Gen Psychiatry
A preliminary report on the prevalence of domestic violence among psychiatric inpatients
Am J Psychiatry
Violence among intimatesan epidemiological review
Gynaecological impact of sexual and physical abuse by spousea study of a random sample of Norwegian women
Br J Obstet Gynaecol
Psycho-social factors in pelvic paina controlled study of women living in physically abusive relationships
Acta Obstet Gynecol Scand
Assault experiences of 100 psychiatric inpatientsevidence of the need for routine inquiry
Am J Psychiatry
Irritable bowel-type symptoms in HMO examinees
Dig Dis Sci
Clinical characteristics of women with a history of childhood abuseunhealed wounds
JAMA
Health effects of experiences of sexual violence for women with abusive partners
Health Care Women Int
Primary caredomestic violence
New Engl J Med
Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics
J Gen Intern Med
Prevalence of domestic violence in community practice and rate of physician inquiry
Fam Med
Prevalence of violence against pregnant women
JAMA
A study of battered women presenting in an emergency department
Am J Public Health
Domestic violence begets other problems of which physicians must be aware to be effective
JAMA
Domestic violence intervention calls for more than treating injuries
JAMA
Intimate violence
Behind closed doorsviolence in the American family
Family patterns and primary prevention of family violence
Trends Health Care Law Ethics
AMA, Joint Commission urges physicians to become part of solution to family violence epidemic
JAMA
Emergency department responses to battered womenresistance to medicalization
Soc Probl
Limitations of the medical model in the care of battered women
Gender Soc
Primary care physicians’ response to domestic violenceopening Pandora’s box
JAMA
Family physicians’ approach to wife abusea study of Ontario, Canada, practices
Fam Med
Attitudes and practices of doctors toward spouse assault victimsan Australian study
Violence Vict
Domestic violence and primary careattitudes, practices and beliefs
Arch Fam Med
From public health to personal healthviolence against women across the life span
Ann Int Med
Violence in intimate relationships and the practicing internistnew “disease” or new agenda?
Ann Int Med
Learning from the paradoxes of domestic violence
JAMA
Violence against womenrelevance for medical practitioners
JAMA
Physicians and domestic violencechallenges for prevention
Health Aff
Cited by (139)
Interprofessional Education in Radiation Oncology
2019, Journal of the American College of RadiologyCitation Excerpt :Prior studies have demonstrated that IPE initiatives lead to improved patient outcomes in a variety of health care fields and clinical settings [2]. These include diabetes care [3,4], emergency department culture and patient satisfaction [5], emergency department collaborative team behavior and reduction of clinical error rates [6], collaborative team behavior in operating rooms [7], management of care delivered in cases of domestic violence [8], and mental health practitioner competencies related to the delivery of patient care [9]. Graduate medical education accreditation bodies have begun to include interprofessional collaboration in their lists of core competencies [10,11], and IPE initiatives are increasingly included in medical residency programs.
Birth Outcomes in Relation to Intimate Partner Violence
2017, Journal of the National Medical AssociationInterprofessional education in primary health care for entry level students - A systematic literature review
2015, Nurse Education TodayIntimate Partner Violence. The Role of Nurses in Protection of Patients.
2015, Critical Care Nursing Clinics of North AmericaCaring For Kids Where They Live: Interprofessional collaboration in teaching and learning in school settings
2014, Nurse Education in PracticeOrganization-Based Factors Bearing on Provider Screening and Referral Practices for Women Exposed to Intimate Partner Violence
2022, Journal of Interpersonal Violence
- 1
The full text of this article is available via AJPM Online at http://www.elsevier.comlocate/ajpmonline.