What Influences Behavior of Physicians Toward Victims of Spouse Abuse?

1
What Influences Behavior of Physicians Toward
Victims of Spouse Abuse?

• Ramani Garimella, M.D., Ph.D. Stacey Plichta,
  Sc.D.Clare Houseman, Ph.D.
• Laurel Garzon, D. N.Sc.

2
Objective

• To explore the relationship between demographic
  characteristics, practice characteristics,
  training characteristics and behavior of
  physicians toward victims of spouse abuse.

3
Introduction

• Non-identification of victims of spouse abuse by
  physicians and other health care providers may be
  largely responsible for missing the opportunity
  to help women when they do come in contact with
  the health center.

4
Problem Statement

• Annually, more than 1.5 million women nation-wide
  seek medical treatment for injuries related to
  abuse.
• Health care professionals are frequently the
  first or only professionals from whom spouse
  abuse victims seek help.
• Health care system can be a crucial point for
  identification, treatment and secondary
  prevention of abuse.
• Failing to diagnose and appropriately treat abuse
  may further the victims sense of entrapment and
  contribute to ongoing victimization.

5
Epidemiology

• Each year an estimated 4 - 6 million women in the
  United States are physically abused by their
  current or former intimate partners.
• Women are by far the most frequent victims of
  spouse abuse.
• Spouse abuse follows no clear demographic pattern
  and is distributed across all countries and all
  religions.
• No race or ethnic group is at a significantly
  greater risk.
• Very few predisposing factors, other than age,
  socioeconomic class and a history of child sex
  abuse, have been identified.

6
Health Effects of Spouse Abuse

• Physical Health
• immediate effects
• bruises, lacerations, especially to the central
  areas such as breasts and abdomen, and broken
  bones
• long-term effects
• chronic medical problems, particularly functional
  bowel disorders, chronic pain, and headaches
• poorer gynecological health, higher rates of
  urinary tract infections and sexually transmitted
  diseases
• effects on pregnancy
• abuse is a significant factor in miscarriages and
  abortions

7
Health Effects of Spouse Abuse

• Mental Health
• immediate effects
• fear, anxiety and confusion
• shame, guilt and humiliation
• long-term effects
• sleep disturbances, mood disorders and
  personality disorders
• increased risk of low self-esteem and being
  depressed
• one of the most significant precipitants of
  female suicide

8
Utilization of Health Services

• about 22 - 33 of women seeking care for any
  reason in emergency departments
• up to 25 of women in ambulatory care internal
  medicine clinics
• more than 50 of mothers of abused children
• about 25 of women utilizing psychiatric
  emergency services
• about 60 of women hospitalized in psychiatric
  facilities

9
Current State of Identification

• despite the poorer health status and high
  utilization of health care services by victims of
  abuse, the vast majority of abused women are not
  detected by health care providers, even when the
  injury they presented with was directly due to
  abuse
• without active screening, fewer than 10 of
  victims of abuse are identified in emergency rooms

10
Possible Barriers to Physician Identification

• Lack of knowledge and training in identification
  and assisting victims of abuse may be responsible
  for non-identification of victims of abuse in the
  health settings
• Negative attitudes held by physicians may also be
  a barrier

11
Method

• Physicians from four different specialties in a
  local general hospital (n 76 RR 51) were
  surveyed to assess their knowledge and attitudes
  toward victims of spouse abuse.
• Knowledge and attitudes were measured by a mail
  survey, physician survey on spouse abuse. This
  was adapted from the Health Care Provider Survey
  on Domestic Violence by the Group Health
  Cooperative of Puget Sound and Harborview Injury
  Prevention and Research Center.

12
Method (contd.)

• A cross-sectional mail survey, using a modified
  Dillman technique was adopted for this survey.
• Initial mail survey was followed by telephone
  follow-up. New surveys were faxed to providers
  who expressed interest. The responses were
  received over a period of 12 weeks.

13
Method-Measurement of Behavior

• This survey had 55 closed-ended and one
  open-ended questions to measure attitude and
  knowledge and 14 items on background information.
• Attitude was measured a composite of beliefs,
  feelings and behaviors.
• Behavior was measured by three variables, verbal
  statements about behavior, frequency of
  suspecting abuse and number of victims identified
  in the past year (self-reported).

14
Sample Items of verbal statements of behavior

• I dont have the time to ask about spouse abuse
  in my practice.
• I am afraid of offending the patient if I ask
  about spouse abuse.
• If I find a patient who is a victim, I dont know
  what to do.
• I dont know how to ask about the possibility of
  spouse abuse.
• (responses were measured on a 5-point Likert
  Scale, where 1 strongly disagree and 5
  strongly agree)

15
Suspecting a possibility of abuse

• In the past three months, when seeing someone
  with the following condition how often have you
  asked the patient about the possibility of abuse
• Injuries
• Chronic pain
• Irritable bowel syndrome
• Headaches
• Depression/anxiety
• Hypertension/coronary heart disease
• (responses were measured on 5-point scale where 1
  never and 5 always)

16

• Number of victims identified in the past year was
  measured by a single question
• How many victims of spouse abuse have you
  identified in the past year?
• (responses 1 0 2 1-5 3 610 4 11-20 5
  gt20)

17
Description of the Sample

• Demographic Characteristics
• 72 male
• mean age 44 years (82 gt 35 years of age)
• 90 white
• 88 married

18
Description of the Sample (Contd.)

• Practice Characteristics
• specialty (30 ER 24 FP 33 Ob-gyn 13 PM)
• mean years in profession 15 (71 gt10 years in the
  profession)
• 63 in private practice
• Training Characteristics
• 80 had little or no course content on spouse
  abuse in medical school
• 81 had no CME training in spouse abuse

19
Results

• Overall, more than 80 of the physicians scored
  positively on verbal statements of behavior
• about 50 of the physicians identified five or
  less than five victims in the past year.
• but only 22 scored positively on frequency of
  suspecting abuse.
• Even when seeing a patient with injuries only 20
  always enquired about a possibility of abuse.

20
Results

• Verbal statements of behavior were not
  significantly different by demographic or
  training characteristics.
• Specialty was significantly related to verbal
  statements of behavior.
• Psychiatrists were significantly more likely than
  family practitioners to make positive verbal
  statements of behavior.

21
Results

• Younger physicians (lt35 years of age) were likely
  to identify greater number of victims of abuse
  than older physicians (3.20 vs. 2.59).
• Family practitioners were significantly less
  likely to identify victims of spouse abuse than
  either emergency room physicians,
  obstetrician-gynecologists or psychiatrist (Fp-
  1.94 obgyn- 2.40 psy - 2.70 er - 3.65) .
• Family practitioners also suspected abuse less
  frequently than other practitioners.
• Positive verbal statements of behavior were also
  significantly correlated to frequency of
  suspecting abuse and higher number of victims
  identified in the past year.

22
Results

• In the logistic regression model six independent
  variables (gender, age, graduate curriculum,
  training, and personally knowing a victim) were
  regressed on the dependent variable number of
  victims identified in the past year and specialty
  was the strongest predictor.
• Family practitioners were .05 times (CI .01
  -.59) less likely to identify fewer than five
  victims of abuse in the past year.

23
Conclusions

• Specialty seems to be the greatest predictor of
  behavior.
• Family practitioners were less likely to identify
  or suspect abuse compared to other specialists.

24
Recommendations

• More emphasis needs to be placed on training
  family practitioners in identifying victims of
  spouse abuse.
• This is especially important in the growing
  managed care environment as family practitioners
  are most likely gate-keepers to women accessing
  health care.
• It might be useful to teach spouse abuse using
  the public health three level intervention for
  chronic diseases.

25
Clearly violence against women is not merely a
health issue it is a social issue, a personal
issue, a legal issue, etc., and physicians are
solely not responsible for alleviating this
problem. However, the medical community, is an
important resource for women who are victims of
violence, and has the power to make an impact on
this problem. If efforts of medical, social
service, and legal agencies are coordinated to
recognize and support victims of violence, women
who are victimized will have more choices about
eliminating fear from their lives (Burge, 1989).