The Factors Associated with Disclosure of Intimate Partner Abuse to Clinicians

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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.

We found important differences in communication patterns between participants who had experienced threats or fear of IPA only (in the absence of physical or sexual abuse) and participants who had experienced physical or sexual abuse (14% vs 45%, respectively). Given the significant effects on physical health associated with psychological abuse, these findings suggest a need for greater clinician inquiry about psychological forms of IPA in addition to physical and sexual IPA. Our findings also underscore the importance of direct clinician questioning about IPA.^6,7 In our study, less than one third (28%) of all participants reported having ever been directly questioned by a clinician about abuse. Among those who had been directly questioned, 85% had disclosed their abuse to a clinician, compared with only 25% of those who had never been directly questioned by a clinician. These findings support current recommendations for direct clinician inquiry about intimate partner abuse.⁵

We also found that birthplace is an important determinant of clinician-patient communication about abuse. In our study, women born outside the United States were much less likely to have disclosed abuse to a medical clinician than women born in the United States. Overall, 32% of immigrant participants reported previous communication with clinicians about abuse, compared with 46% of US-born participants. Low levels of communication among immigrant women (most of whom were Latina) may be found because foreign-born women and Latinas face numerous barriers to seeking medical help and communication with clinicians. These barriers include low levels of acculturation,¹⁵ discrimination, and language.¹⁶ It is clear that there is a need for special efforts to encourage communication about abuse among immigrant and Latina patients.¹⁷ Increased use of interpreters might be one means of addressing these barriers,¹⁸ in addition to greater sensitivity and attention to sociocultural and sociopolitical differences between patients and clinicians.¹⁹ These findings underscore the importance of cultural and linguistic competency when caring for the Latina population.

We identified a number of important barriers to clinician-patient communication. One is the belief that clinicians lack the time to discuss abuse. Fifty-three percent of the participants in our study felt that clinicians do not have time to discuss abuse (compared with 40% of women who had previously discussed abuse). This is consistent with previous research in which physicians noted time constraints as one of the deterrents to IPA communication with patients.²⁰ One means of eliminating this barrier might involve delegating responsibility for abuse screenings to other medical professionals, such as nurses and physician assistants. Another barrier identified was patients’ fear of involving the police and courts. This finding is also consistent with previous research¹⁹ and reiterates questions about the utility of mandatory IPA reporting requirements.^21,22

We also found that patients’ perceptions that clinicians lack interest in discussing abuse and concerns about confidentiality pose significant barriers to communication. Specifically among women who had never communicated with a medical clinician about abuse, 38% believed that clinicians lack interest in discussing it (compared with 25% of women who had previously communicated), and 37% had concerns about confidentiality (compared with 21% of women who had previously communicated with a clinician). This suggests the need for mechanisms to reduce these barriers during the abuse screening process. Even though clinician education about intimate partner abuse has been found to improve IPA screening practices,^10,23-25 the most effective training modalities and follow-up mechanisms have not been identified.

We note that our findings indicate a lack of clinician’s sex/ethnicity effect, suggesting that these demographic differences may be less important than other factors in facilitating abuse-related communication.

Limitations

Our findings are subject to limitations. The sample consisted primarily of low-income women in an urban setting, and therefore our results may not apply to all ethnically diverse abused women attending primary care clinics. Also, our study did not include any women from Asian ethnic groups. We relied on self-reporting of an extremely sensitive issue that may have led to underidentification of IPA and inaccurate reporting of communication patterns because of recall bias and desirability effects. We were also unable to compare the degree of communication or reported barriers with other measures, such as clinician report or documentation of the medical record. Although our study had a very good response rate, we were unable to sample patients who did not have telephones, and resultant unrecognized selection bias may have occurred.

One final limitation pertains to the high rates of clinician-patient communication obtained in this study. Our findings may be disproportionately high because of greater-than-average levels of awareness about IPA among clinicians at the 3 clinics involved in this study. Many of these clinicians received training related to the detection of IPA before the study began. As a result, our findings may not accurately reflect the frequency of communication among demographically similar populations of abused women patients in other medical settings.