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

References

1. Straus M, Gelles R. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. J Marriage Fam 1986;48:465-79.

2. Plichta SB, Duncan MM, Plichta L. Spouse abuse, patient-physician communication, and patient satisfaction. Am J Prev Med 1996;12:297-303.

3. McCauley J, Kern DE, Kolodner K, et al. The ‘battering syndrome’: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123:737-46.

4. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.

5. Council on Scientific Affairs. American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-89.

6. Friedman LS, Sarnet JH, Roberts MS, et al. Inquiry about victimization experiences: a survey of patient p and physician practices. Arch Intern Med 1992;152:1186-90.

7. Caralis PV, Musialowski R. Women’s experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 1997;90:1075-80.

8. Gin NE, Rucker L, Frayne S, et al. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.

9. Straus MA, Smith C. Family patterns and primary prevention of family violence. Trends in health care, law & ethics 1993;8:17-26.

10. Rodríguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282:468-74.

11. Bauer HM, Rodríguez MA, Pérez-Stable EJ. Prevalence and determinants of intimate partner abuse among public hospital primary care patients JGIM In press.

12. Brislin RW. Back-translation for cross-cultural research. J Cross-Cultural Psych 1970;1:185-216.

13. Soeken K, Parker B, McFarlane J, et al. The abuse assessment screen: a clinical instrument to measure frequency, severity, and perpetrator of abuse against women. In: Campbell JC, ed. Empowering survivors of abuse: health care for battered women and their children. Thousand Oaks, Calif: Sage Publications; 1998.

14. SPSS. Version 8.0 for Windows. Chicago, Ill: SPSS, Inc; 1998.

15. West CM, Kantor GK, Jasinski JL. Sociodemographic predictors and cultural barriers to help-seeking behavior by Latina and Anglo American battered women. Violence Victims 1998;13:361-75.

16. Bauer HM, Rodríguez MA, Quiroga SS, Flores-Ortiz YG. Barriers to health care for abused Latina and Asian immigrant women. J Health Care Poor Underserved 1999;11:33-44.

17. Morales LS, Cunningham WE, Brown JA, et al. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med 1999;14:409-17.

18. Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA 1996;275:783-88.

19. Rodríguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-58.

20. Sugg NK, Inui T. Primary care physicians’ response to domestic violence: opening Pandora’s box. JAMA 1992;267:3157-60.

21. Rodríguez MA, McLoughlin E, Bauer HM, et al. Mandatory reporting of intimate partner violence to police: views of physicians in California. Am J Public Health 1999;89:575-78.

22. Gerbert B, Caspers N, Bronstone A, et al. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131:578-84.

23. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995;173:381-87.

24. Tilden VP, Schmidt TA, Limandri BJ, et al. Factors that influence clinicians’ assessment and management of family violence. Am J Public Health 1994;84:628-33.

25. Harwell TS, Casten RJ, Armstrong KA, et al. Results of a domestic violence training program offered to the staff of urban community health centers. Am J Prev Med 1998;15:235-41.

Prevalence of Clinician-Patient Communication About Abuse

Summary prevalence data relating to clinician-patient communication are provided in Table 2. Among the 375 abused participants, 42% (159) reported communicating with a clinician about IPA. Among the 347 participants with a history of physical or sexual abuse, 45% (155) reported communicating with a clinician about IPA. Communication rates were significantly lower, however, among the 7% (28) of the participants who reported threats or fear of IPA in the absence of physical or sexual abuse (P <.05). Only 14% of the participants in this group reported having ever communicated with a clinician about abuse.

Overall, 28% of the participants reported direct questioning by a medical clinician about abuse; however, 85% of those who were questioned reported that they had disclosed the abuse when directly asked by their physicians. In the absence of direct questioning, only 25% of participants reported disclosing abuse to a physician. Rates of clinician inquiry about IPA did not vary significantly across ethnic groups.

There were no significant differences in frequency of communication between women reporting abuse in the past 12 months and women reporting abuse in the more distant past. Other variables not significantly associated with communication included employment, language, medical insurance status, primary care clinic, and clinician’s sex or ethnicity. In addition, having been asked directly about abuse by a clinician was not associated with age, ethnicity, birthplace, education, insurance status, or primary clinic site. However, on bivariate analysis, having been asked was significantly associated with having a regular physician (33% vs 21%, P=.02) and having been married (36% vs 23%, P=.01).

Barriers to Communication

Barriers that hindered patients’ desire to communicate included beliefs that clinicians do not ask directly about IPA and that clinicians lack time for and interest in discussing abuse. Participants were also asked whether their communication with clinicians was hindered by any of the following factors: concerns about confidentiality, fear of involving the police and courts, embarrassment, fear of shaming family, and fear that their partners would hurt or kill them.

Table 3 lists each of the perceived barriers by frequency of agreement according to participants’ abuse communication status (never communicated vs ever communicated). All of the factors (with the exception of one) were reported with greater frequency among women who had never disclosed abuse to a medical clinician than among those who had.

To determine if there were significant differences in the frequency of reported barriers according to communication status, we conducted cross-tabulations and determined statistical significance using the Pearson chi-square test. Statistical significance was defined as P less than .05. We obtained significant differences for each of the following barriers: beliefs that clinicians do not ask directly (P <.001), concerns about confidentiality (P <.001), beliefs that clinicians lack time for (P=.002) and interest in (P=.001) discussing abuse, and fear of involving the police and courts (P=.042).

Among the 108 abused Latina patients, 34% identified language barriers, and 21% reported concerns about the immigration authorities.

Predictors of Communication

To better understand the variables associated with clinician-patient communication about abuse, we used multivariate logistic regression Table 4. We found that the most significant predictor of communication was the presence of direct clinician questioning about abuse. Women who had been directly asked about abuse were much more likely to discuss it than were those who were not asked directly (OR=4.53; 95% CI, 3.20-6.40). Ethnicity also had an important effect on communication, with African American women more likely to communicate about abuse than white women (OR=1.77; 95% CI, 1.08-2.92). Immigrant status was also an important predictor. Patients born outside the United States were less likely than US-born women to have communicated about abuse (OR=0.57; 95% CI, 0.33-0.99). Also, women with concerns about confidentiality were less likely to discuss abuse with medical clinicians (OR=0.68; 95% CI, 0.48-0.94). Although age, formal education, regular clinician status, and perceptions about clinicians’ time and interest in discussing abuse had some impact on communication outcomes, none of these variables reached statistical significance.

Although each of the attitudinal barriers had an influence on the likelihood of communicating about abuse, only concerns about confidentiality reached statistical significance in the multivariate model.

Discussion

Our study is one of the first to quantitatively examine the patterns of IPA communication between an ethnically diverse group of abused women and their medical clinicians. Overall, the prevalence of IPA communication in our study (42%) was substantially higher than we had anticipated. In spite of this, most of the women (58%) had never disclosed abuse to a medical clinician. This suggests that improved efforts to identify and reduce barriers to IPA communication in the medical setting are still needed.