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SCREENING AND INTERVENTION FOR DOMESTIC VIOLENCE LAGS BEHIND NEED

Hundreds of women in California who experience domestic violence are not getting the attention they need from their primary care physicians, according to a study released by the University of California, San Francisco.

Although primary care physicians frequently ask about domestic violence when treating a patient with injuries, they miss many opportunities to screen for abuse in less obvious situations, the study found.  The study appears in a special August 4 issue of Journal of the American Medical Association (JAMA) that focuses on violence.

“Domestic abuse is a major social and health care problem,” said Michael Rodriguez, MD, MPH, UCSF assistant professor in the Department of Family and Community Medicine who treats patients at San Francisco General Hospital Medical Center.  “Interactions with primary care physicians are incredibly important opportunities in the identification and intervention of domestic partner abuse.”  Rodriguez is the principal author of the study.

According to the California Department of Justice, there were roughly 220,000 incidents of domestic violence in California reported in 1997.  The vast majority of these victims are women, although men also experience abuse, said Rodriguez.  Thirty-two percent of women murdered in California are killed by their husbands, ex-husbands, or boyfriends, said Rodriguez.  Due to the extent of the problem, the American Medical Association recommends that physicians routinely screen patients for domestic violence.

The researchers analyzed 400 questionnaires (69 percent response rate) that were received from California family practice, internal medicine, or obstetrics/gynecology physicians in 1995.  These specialties were chosen because they provide primary medical care for the majority of female patients.  The respondents assessed how frequently they asked patients about domestic violence in various clinical situations.  Respondents also assessed intervention strategies and barriers to identifying and becoming involved in domestic violence cases.

Although physician inquiries into abuse were common among patients who already had physical injuries, they were less common during routine medical examinations.  When there was evidence of physical injuries, nearly 80 percent of primary care physicians frequently asked questions about intimate partner abuse.  But that percentage dramatically fell during initial prenatal care visits (11 percent), new patient visits (10 percent), and periodic check-ups (9 percent).  Physicians working in public clinics were statistically more likely to screen new patients for domestic violence than were physicians in private offices and HMOs (37 percent, 9 percent, and one percent, respectively).  There were no significant differences between male and female physician responses.

When physicians did intervene, they most often expressed concern for their patient’s safety to their patient (91 percent).  Other methods of intervention included recording battery in the patient’s chart (89 percent), making counseling referrals (88 percent), and providing information about shelters and services (79 percent).  However, fewer than half (46 percent) of California primary care physicians routinely inquire about guns in the home.

“Primary care physicians are getting better at intervening in domestic violence situations when there are injuries,” said Rodriguez.  “Now we need to find ways to prevent domestic violence from happening in the first place.”

Advocacy programs, such as the Family Violence Prevention Fund have helped raise awareness of domestic violence, said Rodriguez. Approximately 25 percent of the respondents in the study had taken a class on intimate partner abuse in the past three years.

But low levels of screening and intervention in the absence of injuries persist.  According to the study, several things routinely prevent physicians from becoming involved in a domestic violence situation, including a patient’s fear of retaliation by their partner.  Other barriers included a patient’s unwillingness to disclose previous batterings, a patient’s fear of police involvement, lack of follow-up referrals, and cultural differences between patients and physicians.

“We need to create conditions that facilitate physician and patient communication about the problem of abuse,” said Rodriguez.  “Physicians need to be more comfortable talking about domestic violence and patients need to be able to access resources and to understand that domestic violence is a crime.”

In addition to Rodriguez, co-authors of the study include Heidi Bauer, MD, MPH, research assistant, Department of Family and Community Medicine; Elizabeth McLoughlin, ScD, assistant director of the Pacific Center for Violence; and Kevin Grumbach, MD, UCSF associate professor and chief of the Department of Family and Community Medicine at SFGHMC.