2. 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.

3. 2 Objective To explore the relationship between demographic characteristics, practice characteristics, training characteristics and behavior of physicians toward victims of spouse abuse.

4. 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.

5. 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 victim’s sense of entrapment and contribute to ongoing victimization.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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).

15. 14 Sample Items of verbal statements of behavior I don’t 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 don’t know what to do. I don’t 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)

16. 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)

17. 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 = 6–10; 4 = 11-20; 5 = >20)

18. 17 Description of the Sample Demographic Characteristics –72% male –mean age 44 years (82% > 35 years of age) –90% white –88% married

19. 18 Description of the Sample (Contd.) Practice Characteristics –specialty (30% ER; 24% FP; 33% Ob-gyn; 13% PM) –mean years in profession 15 (71% >10 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

20. 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.

21. 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.

22. 21 Results Younger physicians (<35 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.

23. 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.

24. 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.

25. 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.

26. 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).”