Domestic violence in an inner-city ED

Examining the Domestic Violence Crisis in Ventura County in the Wake of the COVID-19 Pandemic

BACKGROUND

Domestic violence (DV) worsened during COVID-19 and Family Justice Centers (FJCs) were, even more so than before, a critical part of providing services to DV victims. This study characterizes the clinical and sociodemographic features of the clients that come to the Ventura County FJC (VCFJC) and examines the effect of COVID-19, thus informing awareness of services available to victims of DV.

METHODS

This was a retrospective cohort study utilizing the VCFJC database from 2019 to 2021. All client data normally collected was studied. A comparison of pre-COVID and post-COVID data was also conducted.

RESULTS

There were 3488 client entries. Clients were mostly female (79% [2755]; n = 3488), aged 25-40 (31.73% [1106]; n = 3448), white/Caucasian (44.42% [1531]; n = 3448) or Hispanic/Latinx (42.41% [1462]; n = 3448). Clients most often requested restraining orders (72.41% [2496]; n = 3448), and most commonly reported DV [physical] (47.90% [1651]; n = 3448). Most health-insured clients were covered by MediCal (45.06% [1231]; n = 2732). Pre- and post-COVID analysis showed the highest increases in DV [physical] (odds ratio = 1.26, P < .0007) and stalking/harassment (odds ratio = 2.45, P < .0007), and decreases in all Initial Service Request categories except one.

DISCUSSION

In serving clients affected by DV, FJCs are an important service for health care providers to be aware of. Post-COVID, clients reported DV and stalking/harassment at much higher percentages, which is consistent with national studies on the pandemic. The most alarming finding was the steep decrease in Initial Service Requests.Conclusion: This study shows the importance of collaboration and awareness of services, especially in a world of COVID-19.

Comparison of Intimate Partner Violence and Correlates at Urgent Care Clinics and an Emergency Department in a Rural Population

This paper describes the prevalence of and factors associated with intimate partner violence (IPV) in the urgent care setting and an academic emergency department in Appalachia. A questionnaire assessing social support, mental and physical health status, substance use, and intimate partner violence was administered to 236 women seeking care in an academic emergency department or two affiliated urgent care clinics. Data collected were compared to IPV screening data from medical records. Separate logistic regression models were fit to estimate the association between sociodemographic and health-related factors and lifetime physical and sexual intimate partner violence, adjusted for the clinical setting. Of the 236 participating women, 63 were seen in the emergency department and 173 were seen in an urgent care clinic. Emergency department patients were significantly more likely to report lifetime threatened physical, physical, or sexual abuse. Based on medical records, over 20% of participants had not been screened for IPV by clinical staff during their healthcare visit. Of those that were screened, none disclosed IPV, despite a substantial proportion reporting IPV on the survey. Although survey reports of IPV were lower in the urgent care clinics, this remains an important location to introduce screenings and resources.

2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting. Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health. Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting? Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

Clinical Features of Heterosexual Intimate Partner Violence Victims With Escalating Injury Severity

Intimate partner violence (IPV) is largely recognized to have a cyclical pattern and violence escalation in terms of frequency and intensity over time. However, there is a lack of systematic investigation of the profiles of victims and quantification of the patterns of injury of the victims associated with the first time versus repeated violence episodes. This study aimed to fill this knowledge gap by medical chart review of 878 victims in a 5-year period from 2010 to 2014 in Accident and Emergency Department (AED) of two public general hospitals in Hong Kong. The differences in injury patterns between the first IPV episode (FE) and recurrent IPV episodes (REs) experienced by male and female victims in heterosexual relationship were evaluated. The results indicated the violence escalation occurred in recurrent IPV in both genders. In female victims, there was significant increase in the number of injury locations (mean [M] = 2.0 vs. 2.2, p < .05), number of causes of injury (M = 1.7 vs. 2.2, p < .001) and police escort (15.2% vs. 22.1%, p < .05) in RE compared to FE. In male victims, however, only the increase in the number of causes of injury was significant (M = 1.6 vs. 2.1, p < .05) in RE compared to FE. In summary, our results highlight the escalation in the severity of harm of IPV victims in heterosexual relationship, and the gender differences in severity aggression and injury and help-seeking behavior change in recurrent IPV. Preventive measures are indicated to intervene the IPV occurrence and recurrence with rising morbidity and a potential of mortality.

Changes in Incidents and Payment Methods for Intimate Partner Violence Related Injuries in Women Residing in the United States, 2002 to 2015

BACKGROUND

Violence in interpersonal relationships is a substantial health and social problem in the United States and is associated with a myriad of immediate and long-term physical, behavioral, and neurocognitive impairments. The present study sought to determine the incidence of U.S. emergency department (ED)-attended intimate partner violence (IPV) from 2002 to 2015 and examine the differences in payment sources before and after implementation of the Affordable Care Act.

METHODS

We analyzed ED visits among female patients aged 15 years or older between 2002 and 2015 from the National Hospital Ambulatory Medical Care Survey. Using International Classification of Disease, Ninth Revision, Clinical Modification, codes from patient visit records, we classified each ED visit to determine the frequency and estimate the relative proportion and national frequency of IPV visits. We explored bivariate and multivariate associations between IPV-related injuries with age, race, ethnicity, method of payment, and region, noting changes over time.

RESULTS

Between 2002 and 2015, female patients visited EDs an estimated 2,576,417 times for IPV-related events, and the proportion of ED visits for IPV increased during that time period. The percentage of ED visits for IPV-related events did not differ significantly by region, race, or ethnicity. Compared with women 25-44 years of age, women aged 65 to 74 (odds ratio, 0.15; 95% confidence interval, 0.05-0.43; p < .001) and 75 years and older (odds ratio, 0.20; 95% confidence interval, 0.08-0.53; p = .001) were less likely to visit an ED for IPV. Women were more likely to pay for IPV-related services out-of-pocket (i.e., self-pay) (odds ratio, 1.85; 95% confidence interval, 1.24-277; p = .003) before the enactment of the Affordable Care Act.

CONCLUSIONS

The increase in the percentage of IPV-related ED claims paid by private insurance suggests that the Affordable Care Act may have increased women's willingness and ability to seek medical attention for IPV-related injuries and disclose IPV as the source of injuries.

Assault by strangulation: sex differences in patient profile and subsequent readmissions

OBJECTIVES

Assault by strangulation has the potential for severe brain injury or death. The objectives of this study were to describe the profile of individuals who had strangulation-related emergency department (ED) or acute care visits, and to explore 1-year readmission outcomes among survivors.

METHODS

A population-based retrospective cohort study was conducted using health administrative data in Ontario, Canada. Adults aged 15 years and older who were seen in the ED or acute care with assault by strangulation between fiscal years 2002/2003 and 2016/2017 were included in the study. Bivariate analyses were conducted to compare the patient profile and subsequent readmissions within 1 year of discharge, stratified by sex.

RESULTS

A total of 586 patients were included in the study. The majority of these patients were seen in the ED (93%), predominantly female (70%), aged ≤ 39 years (68%), and of lower income quintiles of ≤ 3 (73%). Of the 579 patients who survived the initial admission, 52% had subsequent ED readmission and 21% had acute care readmission within 1 year. In sex-stratified analyses, a higher proportion of females were between 20 to 39 years (58.7% vs. 44.1%, p = 0.001), discharged home (88% vs. 81%, p < 0.001), and had ED readmission within 1 year of discharge (56% vs. 17%, p = 0.002). Males had comparatively higher 1-year acute care readmissions.

CONCLUSION

The study shows high readmissions with sex differences among individuals with an assault by strangulation, suggesting sex-specific approach to health care practices to support the needs of this vulnerable population, thus reducing health system inefficiencies.

Psychiatric disorders associated with intimate partner violence and sexual violence in Thai women: Aresult from the Thai National Mental Health Survey

Background

Intimate partner violence (IPV) and sexual violence (SV) occur commonly and are a violation of basic human rights. There are limited studies to date that examine the impact of IPV, SV and mental health outcomes in Thailand.

Aims

The objective of the present study was to estimate the prevalence of intimate partner physical violence and IPV in Thai women and the association between these forms of violence and psychiatric disorders.

Methods

The present study used data from a national cross-sectional, population-based, household design survey. This study analysed data from 3009 female respondents above the age of 18 who were interviewed in person using the World Mental Health-Composite International Diagnostic Interview V.3.0 (WMH-CIDI 3.0). We estimated the lifetime and the 12-month period prevalence of IPV and SV, the lifetime and the past 12- month period correlation of IPV/SV with psychiatric disorders and the OR for psychiatric disorders associated with these types of violence.

Results

There was only 5.2 % of the weighted sample that reported experiencing some form of violence, including reported rates of intimate partner physical violence of 3.5% and IPV of 2.0%. Women who had experienced IPV have a lifetime prevalence for common psychiatric disorders of 28.9%, for suicidal behaviours of 12.2% and for substance use disorders of 8.8%. Women who had experienced SV have a lifetime diagnoses for common psychiatric disorders of 21.4%, for suicidal behaviours of 16.5% and for substance use disorders of 19.4%. There was a statistically significant association between IPV/SV and being diagnosed with a psychiatric disorder during the past year and also during one's lifetime.

Conclusion

The association between IPV/SV and psychiatric disorders is significant; therefore, performing a formal assessment for a history of violence in psychiatric patients is often beneficial in refining the diagnosis and treatment.

Conditions and Patterns of Intimate Partner Violence among Taiwanese Women

PURPOSE

Intimate partner violence (IPV) is a serious public health issue among women. IPV victims usually seek help from hospitals, and emergency nurses are the frontline staff with whom the victims come into contact first. This study examined the conditions and patterns of IPV in southern Taiwan.

METHODS

From designated hospitals in Kaohsiung under the Department of Health Injury Assessment Clinic, data were collected on 497 women regarding their injury assessment for IPV reported to the Kaohsiung City Government.

RESULTS

Taiwanese survivors were older compared to immigrant survivors. Taiwanese survivors also had higher education levels compared to immigrant survivors. Taiwanese survivors had higher employment rate than immigrant survivors did. The time between IPV and medical help seeking was longer for divorced than married women.

CONCLUSIONS

These results can facilitate understanding of the conditions and patterns of IPV in Taiwan, increase the awareness of nurses, especially the emergency nurses for the prevention of IPV, and increase professional competency for the provision of appropriate healthcare services to survivors of IPV.

Attitudes Toward Computer Interventions for Partner Abuse and Drug Use Among Women in the Emergency Department

BACKGROUND

Drug use and partner abuse often coexist among women presenting to the emergency department (ED). Technology offers one solution to the limited time and expertise available to address these problems.

AIMS

The aims of this study were to explore womens' attitudes about use of computers for screening and intervening in drug use and partner abuse.

METHODS

Seventeen adult women with recent histories of partner abuse and drug use were recruited from an urban ED to participate in one-on-one semi-structured interviews. A coding classification scheme was developed and applied to the transcripts by two independent coders. The research team collaboratively decided upon a thematic framework and selected illustrative quotes.

RESULTS

Most participants used computers and/or mobile phones frequently and reported high self-efficacy with them. Women described emotional difficulty and shame around partner abuse experiences and drug use; however, they felt that reporting drug use and partner abuse was easier and safer through a computer than face-to-face with a person, and that advice from a computer about drug use or partner abuse was acceptable and accessible. Some had very positive experiences completing screening assessments. However, participants were skeptical of a computer's ability to give empathy, emotional support or meaningful feedback. The ED was felt to be an appropriate venue for such programs, as long as they were private and did not supersede clinical care.

CONCLUSIONS

Women with partner abuse and drug use histories were receptive to computerized screening and advice, while still expressing a need for the empathy and compassion of a human interaction within an intervention.

Intimate partner violence: prevalence, health consequences, and intervention

Intimate partner violence (IPV) can be defined in many ways and encompasses many different types of physical and emotional abuse. IPV affects the health, safety, and quality of life for women, men, and children worldwide, regardless of race, sexual orientation, or socioeconomic status. The health effects include acute trauma; a wide range of physical and mental sequelae; and, for some, death. Because of the serious consequences of IPV, both the Centers for Disease Control and the World Health Organization identify IPV as a significant public health issue.

Gender-specific research on mental illness in the emergency department: current knowledge and future directions

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.

Inpatient hospitalization and intimate partner violence: who are we treating?

BACKGROUND

The majority of research into health care use of intimate partner violence (IPV) has focused on female victims and primarily their emergency department use. There are limited data on injury-related hospitalization rates for female victims and even less for male victims and perpetrators. The goal of this study was to determine the annualized rates of inpatient injury-related hospitalization among individuals involved as either victims or defendants in IPV.

METHODS

This was an observational retrospective study linking data from two Level 1 trauma centers and the county prosecutor's office from 2000 to 2010 in Kalamazoo County, Michigan. (1) Hospital data included injury-related admissions (DRG International Classification of Diseases-9th Rev. codes 800-959.9 excluding 905-909.9). (2) Prosecutor data contained all charging requests for crimes between intimate partners. Annualized rates were calculated for the year before the IPV crime and for the year after, using the following algorithm: (number of hospitalizations) / (total population) × (per 10,000). Confidence intervals and two-sided statistical significance were calculated at the 95% confidence level.

RESULTS

During the study period, 21,179 IPV crimes were committed, involving 12,913 individual defendants and 14,797 victims. There were 30,301 injury-related hospitalizations by this group during this period. Compared with national hospitalization rates of 3.2 per 10,000 people for injury/poisoning (DRG International Classification of Diseases-9th Rev. 800-959.9 and 990-995), IPV victim annual admission rates were 31.9, defendants at 90.4, and bidirectional individuals at 339.1 per 10,000 people, in the 2 years surrounding the crime. Males, regardless of crime role, have higher injury-related hospitalization rates in this period compared with females (male, 115.6; female, 41.8). Males (victims or defendants) and bidirectional participants of either sex had rates that were significantly higher the year after than the year before the crime.

CONCLUSION

Individuals involved in IPV have a 10-fold higher injury-related hospitalization rate as compared with age-matched national rates. Admission rates vary by sex, crime role, and time frame, with males and bidirectional participants having the highest rates.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Prevalence of Intimate Partner Violence Across Medical and Surgical Health Care Settings

Intimate partner violence (IPV) is a serious health problem and a leading cause of nonfatal injury in North American females. Prevalence of IPV has ranged from less than 20% to more than 50% across primary care, emergency medicine, and family medicine. We conducted a systematic review and meta-analysis of the literature to examine best estimates of IPV prevalence as opportunities for targeted interventions in health care specialties. We included 37 articles in this study. Based on our pooled data, best estimates of the lifetime prevalence of any type of IPV were 38% in family medicine and 40% in emergency medicine.

10-year trends in physical dating violence victimization among U.S. adolescent males

This study provides 10-year trend data on the psychosocial correlates of physical dating violence victimization (PDV) among male participants (N = 7,949 in 2009) in the national Youth Risk Behavior Surveys from 1999-2009. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) were examined followed by multivariate logistic regression analyses, which included all significant independent variables from the univariate analyses. Adjusted OR and 95% CI assessed the significance of the relationships. PDV was significantly and consistently associated with feelings of sadness or hopelessness, repeated engagement in physical fighting, current and multiple sex partners, and lack of condom use. A less consistent but noteworthy pattern was found for PDV and gun carrying and cocaine use among adolescent males. PDV is an important public health issue for adolescent males, not just females. There appears to be a set of stable correlates of dating violence victimization among high school males in the United States.

Male Perpetrators of Intimate Partner Violence: Support for Health Care Interventions Targeted at Level of Risk

The mental health correlates of male aggression or violence against an intimate partner (IPV) are examined using exploratory cluster analysis for 81 men who self-reported risk factors for IPV perpetration on a computer-based health risk assessment. Men disclosing IPV perpetration could be meaningfully subdivided into two different clusters: a high pathology/high violence cluster, and lower pathology/low violence cluster. These groups appear to perpetrate intimate partner violence in differing psychoemotional contexts and could be robustly identified using multiple distinct analytic methods. If men who self-disclose IPV in a health care setting can be meaningfully subdivided based on mental health symptoms and level of violence, it lends support for potential new targeted approaches to preventing partner violence perpetration by both women and men.

Derivation and validation of a short emergency department screening tool for perpetrators of intimate partner violence: the PErpetrator RaPid Scale (PERPS)

BACKGROUND

There is no short screening tool for perpetrators of intimate partner violence (IPV), although one is needed.

OBJECTIVE

To retrospectively derive and prospectively validate a brief screening tool for perpetrators of IPV: the PErpetration RaPid Scale (PERPS).

METHODS

In the derivation phase of the study, we developed the PERPS based on historical data. The PERPS consists of three Yes/No questions about physical abuse of a partner. In the validation phase, we prospectively screened subjects during randomized 4-h shifts in a busy emergency department (ED). Subjects were asked to complete the newly derived three-question PERPS as well as the Physical Abuse of Partner Scale (PAPS), a 25-question Likert scale that is the gold standard for detection of physical abuse of a partner. The main outcome measures were sensitivity, specificity, predictive values, accuracy, and Cronbach alpha of the PERPS for internal consistency.

RESULTS

The PERP Scale derivation was based on a 207-subject historical database, and resulted in a three-question PERPS. Validation was completed on a new set of 214 patients presenting to the ED during 52 randomized 4-h shifts. The prevalence of IPV perpetration using the PERPS was 47/207 (22.7%; 95% confidence interval [CI] 16-27). For the PAPS, prevalence was 56/207 (27%; 95% CI 20-32). Compared with the PAPS, the sensitivity of the PERPS was 66%, specificity 93%, negative predictive value 87%, positive predictive value 78%, with an accuracy of 85%. Cronbach alpha of the PERPS was 0.68. Age, gender, and race were not predictive of positive results on either scale.

CONCLUSION

We successfully derived and validated a three-question perpetrator of IPV scale that can be used in a busy ED or office setting.

Optimal methods to screen men and women for intimate partner violence: results from an internal medicine residency continuity clinic

Contradictory data exist regarding optimal methods and instruments for intimate partner violence (IPV) screening in primary care settings. The purpose of this study was to determine the optimal method and screening instrument for IPV among men and women in a primary-care resident clinic. We conducted a cross-sectional study at an urban, academic, internal medicine residency continuity clinic in Connecticut among English or Spanish speaking adult patients. One group of patients ( n = 340) received a self-administered questionnaire (SAQ) containing the partner violence screen (PVS) and the Hurt, Insulted, Threatened or Screamed at Questionnaire (HITS). A second group (n = 126) was screened with PVS and HITS by their primary care providers during face-to-face (FTF) clinical encounters. Multivariable logistic regression models were used to determine the association between IPV prevalence and screening method (SAQ or FTF) after adjusting for socio-demographic effects. The overall IPV prevalence was 17.3% using the SAQ and 9.0% with FTF screening (p = .008). Patients receiving the SAQ were more likely to report IPV than those who were screened FTF (adjusted odds ratio [AOR]: 2.6, 95% confidence interval [CI]: 1.2-5.6). This effect persisted for women, who had a higher odds of IPV when screened through a SAQ than when screened FTF (AOR: 3.5, 95% CI: 1.4-8.6). Men did not differ in reporting IPV between methods: 11% with SAQ versus 9.4% FTF (p = .69). In internal medicine residency continuity clinics, a SAQ for IPV may result in higher disclosure and completion rates among female patients compared to FTF screening. Unique screening instruments and methods may be needed for men.

Does the health status of intimate partner violence victims warrant pharmacies as portals for public health promotion?

OBJECTIVES

To explore whether the health status of intimate partner violence (IPV) victims warrants pharmacies to be portals for public health promotion. Specific objectives included (1) identifying prevalence of IPV including domestic violence (DV) and sexual assault (SA) in a community sample, (2) describing characteristics and correlates of DV/SA between participants who reported and did not report DV/SA, and (3) exploring whether DV/SA status is related to mental health medication use.

DESIGN

Cross sectional.

SETTING

Upstate New York during 2006.

PARTICIPANTS

English- and Spanish-speaking respondents younger than 65 years of age answering four questions to assess DV/SA.

INTERVENTION

Secondary analysis of a countywide random telephone survey, the 2006 Monroe County Adult Health Survey, which collects prevalence data on health behaviors and health status indicators.

MAIN OUTCOME MEASURE

To determine whether those reporting DV/SA are at increased odds for mental health medication use, controlling for other sociodemographic- and health-related variables.

RESULTS

The survey response rate was 30.3%, with 1,881 respondents meeting inclusion criteria. Those reporting DV/SA were almost twice as likely to use mental health medications. However, when controlling for other variables, only poor mental and physical health were significant in increasing the odds of mental health medication use.

CONCLUSION

The analyses reported here suggest that DV/SA victims in a community sample use mental health medications. When controlling for other variables, survey respondents reported worse physical and mental health. If pharmacies are suitable portals for DV/SA outreach, curricula would need to provide the knowledge and skills needed to take an active role in this public health promotion.

Impact of emergency department intimate partner violence intervention

The objective of the study is to assess the impact of emergency department (ED) intimate partner violence (IPV) counseling and resource referrals on patient-perceived safety and safety planning. ED patients with risk factors were offered consultation with trained IPV advocacy counselors who completed safety assessments, provided resource referrals, and helped patients develop safety plans. Patients were contacted after ED intervention to assess progress and further assist in IPV counseling. Over 96% of patients perceived an increase in their safety after the intervention, and approximately 50% had completed a portion of their safety plan. Legal assistance and/or law enforcement were considered the most beneficial resource referrals. Although follow-up was limited, this study appears to demonstrate that an ED IPV intervention program may be useful in helping IPV victims achieve safer living environments and access local resources.

Intimate partner violence and comorbid mental health conditions among urban male patients

PURPOSE

We wanted to explore the associations between intimate partner violence (IPV) and comorbid health conditions, which have received little attention in male patients.

METHODS

Using a computer-based self-assessment health questionnaire, we screened sequential emergency department patients who were urban, male, and aged 18 to 55 years. We then examined associations between types of IPV disclosures, co-occurring mental health symptoms, and adverse health behaviors.

RESULTS

Of 1,669 men seeking nonurgent health care, 1,122 (67.2%) consented to be screened, and 1,026 (91%) completed the screening; 712 (63%) were in a relationship in the past year. Of these men, 261 (37%) disclosed IPV: 20% (n = 144) disclosed victimization only, 6% (n = 40) disclosed perpetration only, and 11% (n= 77) disclosed bidirectional IPV (defined as both victimization and perpetration in their relationships). Men disclosing both victimization and perpetration had the highest frequencies and levels of adverse mental health symptoms. Rates of smoking, alcohol abuse, and drug use were likewise higher in IPV-involved men.

CONCLUSIONS

A cumulative risk of poor mental health and adverse health behaviors was associated with IPV disclosures. Self-disclosure by men seeking acute health care provides the potential for developing tools to assess level of risk and to guide tailored interventions and referrals based on the sex of the patient.

Caring for victims of intimate partner violence: a survey of Canadian emergency departments

OBJECTIVE

We sought to determine the proportion of Canadian emergency departments (EDs) that have intimate partner violence (IPV) universal screening programs and intervention policies and procedures. Of the EDs with programs, we determined what proportion had made changes in their practices during the past 10 years and since the 2003 Canadian Task Force on Preventive Health Care recommendations.

METHODS

Using the same sampling methods as a 1994 study, we mailed questionnaires to nurse managers of a stratified, random sample of 250 out of 638 (39%) Canadian EDs and followed up with a series of telephone calls.

RESULTS

Of the 250 EDs initially contacted, 6 were excluded before the surveys were mailed. The response rate was 78.3% (191/244). Sixty-one (31.9%) of the studied EDs reported the existence of IPV policies and procedures. In this group, 26 (42.6%) applied universal screening and 13 (21.3%) implemented their screening policies after the 2003 national recommendations were published. When these results were compared with those of the 1994 study, there was no difference in the proportion of EDs with IPV policies and procedures or in the proportion of EDs that applied universal screening.

CONCLUSION

Despite increased research into IPV there was no significant change between 1994 and 2004 in the existence of IPV polices or universal screening in Canadian EDs. Policies and procedures that address appropriate responses to patients exposed to IPV should be a priority, with most emphasis directed toward developing effective interventions to which women can be referred.

Addressing intimate partner violence with male patients: a review and introduction of pilot guidelines

Intimate partner violence (IPV) is a common and devastating problem affecting the health of women, men, and children. Most health-care research focuses on the effects of IPV on women and children and addressing IPV with women in the health-care setting. Less is known about addressing IPV with men in the health-care setting. This article reviews the challenges in interpreting research on IPV in men, its prevalence and health effects in men, and the arguments for addressing IPV with men in the health-care setting. It introduces pilot guidelines that are based on the existing literature and expert opinion.

Angry wives, abusive husbands: relationship between domestic violence and psychosocial variables

BACKGROUND

A small number of studies conducted in Pakistan have shown high rates of domestic violence. None of the studies, however, discussed associated psychosocial factors. We interviewed a group of women to look at violence and associated psychosocial factors. We wanted to see if self-esteem, quality of relationships, social support, stressful life events, psychiatric symptoms, and different measures of anger were associated with domestic violence.

METHODOLOGY

In a cross-sectional survey of women presenting to primary care physicians, we used Women's Experience with Battering and Domestic Abuse Checklist to measure domestic violence. The Relationship Assessment Scale, Oslo Social Support Scale, State Trait Anger Inventory, and Evaluative Belief Scale were used to look at the correlates of violence. We used the information in a regression model to identify independent predictors of violence in this sample.

RESULTS

More than half of the women reported experiencing battering and/or violence. Women in abusive relationships reported unhappiness with their intimate relationships and had high scores on 1 subscale of anger. Living in extended families was protective against violence.

CONCLUSIONS

We were able to replicate findings that women in abusive relationships are not satisfied with the relationships with their partners. Living in extended families was protective against violence. Community studies may provide a better design to look at the association between abuse and poverty, literacy, self-esteem, and social support.

Childhood family violence and perpetration and victimization of intimate partner violence: findings from a national population-based study of couples

PURPOSE

We sought to examine the relation between childhood family violence and intimate partner violence (IPV).

METHODS

We surveyed 1615 couples from the U.S. household population by using multistage cluster sampling. Childhood family violence measures included moderate and severe child physical abuse and witnessing interparental threats or physical violence. IPV was categorized as nonreciprocal male-to-female partner violence (MFPV), nonreciprocal female-to-male partner violence (FMPV), reciprocal IPV (MFPV and FMPV), and no IPV. We used multinomial logistic regression to estimate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between childhood family violence and IPV.

RESULTS

Men who experienced moderate (adjusted OR [AOR] 3.9, 95% CI, 1.3-11.8) or severe (AOR 4.5, 95% CI: 1.1-19.3) child physical abuse were at increased risk of nonreciprocal MFPV; a male history of severe childhood physical abuse or witnessing interparental violence was associated with a twofold increased risk of reciprocal IPV. Women who witnessed interparental threats of violence (AOR 1.9, 95% CI, 0.8-4.6) or interparental physical violence (AOR 3.4, 95% CI, 1.5-7.9) in childhood were at increased risk of nonreciprocal FMPV. Women exposed to any type of childhood family violence were more than 1.5 times as likely to engage in reciprocal IPV. Many strong positive ORs had CIs compatible with no association.

CONCLUSION

We provide new evidence that childhood family violence is associated with an increased risk of nonreciprocal and reciprocal IPV. Treatment providers and policy makers should consider childhood family violence history in both men and women in the context of IPV.

Differences in female and male victims and perpetrators of partner violence with respect to WEB scores

Measurements of intimate partner violence (IPV) based on acts of violence have repeatedly found substantial bilateral violence between intimates. However, the context of this violence is not well defined by acts alone. The objective of this research was to compare differences in women and men within each IPV status category (victim, perpetrator, and both) with respect to levels of battering as defined by their scores on the Women's Experience With Battering Scale (WEB), which asks gender-neutral questions about the abuse of power and control and fear in an intimate relationship. In our study, women disclosed higher levels of battering on the WEB, despite IPV status (victimization or both victimization and perpetration). In addition, female IPV victims were 5 times more likely than their male counterparts to disclose high rates of battering on the WEB. Depressive symptoms, symptoms of posttraumatic stress disorder, African American race, and IPV victimization were independently associated with higher WEB scores.

Disclosing intimate partner violence to health care clinicians - what a difference the setting makes: a qualitative study

Background

Despite endorsement by national organizations, the impact of screening for intimate partner violence (IPV) is understudied, particularly as it occurs in different clinical settings. We analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to clinicians across specialties.

Methods

Participants were English-speaking female IPV survivors recruited through IPV programs in Massachusetts. In-depth interviews describing medical encounters related to abuse were analyzed for common themes using Grounded Theory qualitative research methods. Encounters with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure), attribute (beneficial, unhelpful, harmful), and specialty (emergency department (ED), primary care (PC), obstetrics/gynecology (OB/GYN)).

Results

Of 27 participants aged 18–56, 5 were white, 10 Latina, and 12 black. Of 59 relevant health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in emotional distress and alienation from health care. Regardless of whether disclosure occurred, beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the abuse, respect and relevant referrals.

Conclusion

While no harms resulted from IPV disclosure, survivor satisfaction with disclosure is shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.

Intimate partner violence: how does it impact major depressive disorder and post traumatic stress disorder among immigrant Latinas?

Intimate Partner Violence (IPV) is prevalent in the general US population, as well as the Latino community. In a cross-sectional study at an immigrant, primary care clinic, we assessed the correlation between IPV history and symptoms of MDD and PTSD in Latino women. We used a structured interview format. Among the 105 women recruited, the 4-week incidence of MDD was 45.7% and the prevalence of PTSD was 19%. Abused women had three times the odds of meeting PTSD criteria than non-abused women. Women meeting PTSD criteria were 10 times likelier to also report MDD. There was no difference in the incidence of MDD among women who reported IPV and those who did not. This study found a correlation of IPV with PTSD, and PTSD with MDD, but not IPV with MDD. Our results indicate a need for mental health interventions in primary care settings for Latina women regardless of IPV history.

The role of race/ethnicity in the relationship between emergency department use and intimate partner violence: findings from the 2002 National Survey on Drug Use and Health

OBJECTIVES

We examined the relationship between intimate partner violence victimization among women in the general population and emergency department use. We sought to discern whether race/ethnicity moderates this relationship and to explore these relationships in race/ethnic-specific models.

METHODS

We used data on non-Hispanic White, Non-Hispanic Black, and His-panic married or cohabiting women from the 2002 National Survey on Drug Use and Health. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using logistic regression.

RESULTS

Women who reported intimate partner violence victimization were 1.5 times more likely than were nonvictims to use the emergency department, after we accounted for race/ethnicity and substance use. In race/ethnic-specific analyses, only Hispanic victims were more likely than their nonvictim counterparts to use the emergency department (AOR = 3.68; 95% CI = 1.89, 7.18), whereas substance use factors varied among groups.

CONCLUSIONS

Our findings suggest that the emergency department is an opportune setting to screen for intimate partner violence victimization, especially among Hispanic women. Future research should focus on why Hispanic victims are more likely to use the emergency department compared with nonvictims, with regard to socioeconomic and cultural determinants of health care utilization.

Care for emergency department patients who have experienced domestic violence: a review of the evidence base

AIMS

A literature review was conducted to identify and evaluate the research base underpinning care for emergency department patients who have experienced domestic violence.

BACKGROUND

The extent of domestic violence in the general population has placed it high on health and social policy agendas. The Department of Health has recognized the role of health care professionals to identify and provide interventions for patients who have experienced domestic violence.

METHOD

Systematic review.

RESULTS

At least 6% of emergency department patients have experienced domestic violence in the previous 12 months although actual prevalence rates are probably higher. Simple direct questioning in a supportive environment is effective in facilitating disclosure and hence detecting cases of abuse. Although routine screening is most effective, index of suspicion screening is the current mode of practice in the UK. Index of suspicion screening is likely to contribute to under-detection and result in inequitable health care. Patients with supportive networks have reduced adverse mental health outcomes. Women will have negative perceptions of emergency care if their abuse is minimalized or not identified. Women want their needs and the needs of their children to be explored and addressed. Access to community resources is increased if patients receive education and information.

CONCLUSION

Domestic violence is an indisputable health issue for many emergency department patients. Practitioners face challenges from ambiguity in practice guidelines and the paucity of research to support interventions. Recommendations for practice based on the current evidence base are presented.

RELEVANCE TO CLINICAL PRACTICE

The nursing care for patients in emergency and acute health care settings who have experienced domestic violence should focus on three domains of: (1) Providing physical, psychological and emotional support; (2) Enhancing safety of the patient and their family; (3) Promoting self-efficacy.

History of domestic violence and health service use among mid-aged Australian women

OBJECTIVES

To examine associations between history of domestic violence and health service use among mid-aged Australian women, adjusting for physical and psychological health status and demographic factors.

METHODS

Population-based cross-sectional postal survey (1996) of the Australian Longitudinal Study on Women's Health. Of 28,000 women randomly selected, 14,100 (53.5%) aged 45-50 years participated. Logistic regressions were used to assess associations between domestic violence and health service use.

RESULTS

After adjusting for demographic variables, multivariate analysis revealed associations between ever having experienced domestic violence and three or more consultations in the previous 12 months with a family doctor (OR 2.07, 95% CI 1.68-2.55), hospital doctor (OR 1.77, 95% CI 1.44-2.I7), or specialist doctor (OR 1.54, 95% CI 1.35-1.75), or being hospitalised (OR 1.36, 95% CI 1.20-1.54). After adjusting for demographic variables and physical and psychological health status, these associations were attenuated: three or more consultations with family doctor (OR 1.36, 95% CI 1.09-1.70), hospital doctor (OR 1.16, 95% CI 0.92-1.45), or specialist doctor (OR 1.14, 95% CI 0.98-1.32), and being hospitalised (OR 1.10, 95% CI 0.96-1.26).

CONCLUSIONS

Physical and psychological status accounted for the associations between domestic violence and higher health service use, with the exception of GP consultations, which remained associated with domestic violence.

IMPLICATIONS

Physical health status only partially explains the increased health service use associated with domestic violence, while both physical and psychological health status explained higher usage of specialist and hospital services. It seems likely that women who have experienced domestic violence may be seeking consultations from GPs for reasons additional to health status.

Men's arrack drinking and domestic violence against women in a Bangladesh village

Arrack, indigenously made and known as tari, is a widely-used alcoholic beverage among poor drinkers in rural Bangladesh. This study examines the influences of men's arrack drinking habits on violence against women at the family level in Parbattipur, a typical village of northwest Bangladesh. Fifty purposively-selected married male arrack drinkers as well as their wives were interviewed singly by using a semi-structured questionnaire. Results show that arrack drinkers suffer from behavioral abnormalities. It creates family problems and women are often victimized by their husbands' drunken behaviors. Although violence against women is a common phenomenon in rural Bangladesh, it is argued that men's habitual arrack drinking behaviors, through the interplay of a patriarchal family structure, are directly linked with incidences of violence against women within marriage.

Abused women disclose partner interference with health care: an unrecognized form of battering

BACKGROUND

Some providers observe that partners interfere with health care visits or treatment. There are no systematic investigations of the prevalence of or circumstances surrounding partner interference with health care and intimate partner violence (IPV).

OBJECTIVE

To determine whether abused women report partner interference with their health care and to describe the co-occurring risk factors and health impact of such interference.

DESIGN

A written survey of women attending health care clinics across 5 different medical departments (e.g., emergency, primary care, obstetrics-gynecology, pediatrics, addiction recovery) housed in 8 hospital and clinic sites in Metropolitan Boston.

PARTICIPANTS

Women outpatients (N = 2,027) ranging in age, 59% White, 38% married, 22.6% born outside the U.S.

MEASUREMENT

Questions from the Severity of Violence and Abuse Assessment Scale, the SF-36, and questions about demographics.

RESULTS

One in 20 women outpatients (4.6%) reported that their partners prevented them from seeking or interfered with health care. Among women with past-year physical abuse (n = 276), 17% reported that a partner interfered with their health care in contrast to 2% of women without abuse (adjusted odds ratios [OR] = 7.5). Further adjusted risk markers for partner interference included having less than a high school education (OR = 3.2), being born outside the U.S. (OR = 2.0), and visiting the clinic with a man attending (OR = 1.9). Partner interference raised the odds of women having poor health (OR = 1.8).

CONCLUSIONS

Partner interference with health care is a significant problem for women who are in abusive relationships and poses an obstacle to health care. Health care providers should be alert to signs of patient noncompliance or missed appointments as stemming from abusive partner control tactics.

Are alcohol problems linked with an increase in depressive symptoms in abused, inner-city African American women?

OBJECTIVE

Little is known regarding the link between intimate partner violence (IPV), alcohol problems (AP), and depression in inner-city African American women. We sought to investigate whether abused inner-city African American women reporting AP endorsed more depressive symptoms compared to women reporting either AP or IPV or reporting neither.

METHOD

Participants for this cross-sectional study were 361 African American women seeking medical care at a large public hospital. Measurements included the Index of Spouse Abuse, Michigan Alcoholism Screening Test, and the Brief Symptom Index-Depression Subscale to assess IPV, AP, and depressive symptoms, respectively. Based on IPV and AP status, participants were assigned to one of four non-hierarchical risk groups: (i) low or no IPV, no AP; (ii) high IPV alone; (iii) AP alone; or (iv) both high IPV and AP. Additive effect of high levels of IPV and AP on outcome were assessed using logistic regression techniques.

RESULTS

Thirty percent reported high IPV levels, and 18% had AP. Compared with participants reporting both no AP and low or no IPV, those reporting either high IPV levels or AP reported moderate to severe depressive symptoms 4 times more often (p < .001). Women reporting high IPV and AP endorsed moderate to severe depressive symptoms 8 times more often than women reporting neither (p < .001).

CONCLUSIONS

Among inner-city, African American women, depressive symptoms are highest among those reporting both high IPV levels and AP. Health care systems serving similar communities should implement a systematic approach to identifying IPV, AP, and depression in patients.

Borderline personality symptomatology and history of domestic violence among women in an internal medicine setting

In this study of primary care patients, we examined the relationship between a history of domestic violence (measured with the Severity of Violence Against Women Scale [SVAWS]) and borderline personality (measured with the Self-Harm Inventory [SHI] and the Personality Diagnostic Questionnaire-4 [PDQ-4]). We elected borderline personality for examination because several diagnostic criteria sets describe relationship features suggestive of partner abuse. In this study, both measures of borderline personality were highly related to each other (r = .73, p < .001) as well as to the SVAWS (r = .70, p < .001, for the SHI; r = .73, p < .001, for the PDQ-4). Using diagnostic cutoff scores on the measures for borderline personality, 64.0% of those with histories of domestic violence scored in the positive range on either or both measures, while only 11.1% of nonabused women did. We discuss the clinical implications of these findings.

Missed opportunities: emergency department visits by police-identified victims of intimate partner violence

STUDY OBJECTIVE

We examine all emergency department (ED) utilization by police-identified women victims of intimate partner violence as part of an intimate partner violence ED surveillance study to determine the frequency and characteristics of visits and the extent of intimate partner violence screening and identification by ED staff.

METHODS

We conducted a retrospective observational case series reviewing countywide EDs visits, 1999 to 2001, for women victims in the 2000 prosecutor's intimate partner violence database. Stratifying visits by whether the woman presented with an injury, we assessed documentation of intimate partner violence screening and identification and mental health and substance abuse in the medical records.

RESULTS

Of 964 female intimate partner violence victims in the 2000 prosecutor's intimate partner violence database, 616 (63.9 %) received care in at least 1 ED in the year of the index assault. During the 3-year study period, 788 (81.7%) victims generated a total of 4,456 ED visits. Intimate partner violence screening was documented in 1,349 (30.3%) of the 4,456 visits but resulted in only 259 (5.8%) positive screens. However, because they use the ED so frequently, 23.0% of individual intimate partner violence victims were eventually identified. The median number of visits for victim ED users was 4 (range 1 to 71), and visits were just as likely to occur before the known intimate partner violence incident as after, although ED visits tended to peak in the month of the incident. Injury-related visits were 50% more likely to have documented IPV screening, however, most visits (71.2%) by IPV victims were for noninjury-related complaints.

CONCLUSION

Police-identified intimate partner violence victims utilize emergency care at extremely high rates, usually without identification or referral to intimate partner violence resources.

Psychosocial and substance-use risk factors for intimate partner violence

OBJECTIVE

Few emergency department (ED) studies have described the relationship between family violence and subsequent intimate partner violence (IPV) or accounted for partner alcohol use in IPV victimization. This study sought to identify family history and substance-use factors associated with IPV among women presenting to an urban emergency department.

METHODS

Case-control study in which cases (women identified as having IPV concerns and an IPV history) and controls (women without IPV) were frequency-matched by age group and race/ethnicity. Logistic regression was performed to calculate adjusted odds ratios (AOR) for any IPV, physical IPV, and sexual IPV.

RESULTS

The sample included 182 cases and 147 controls. Living with a partner (not married) and witnessing parental violence were independent risk factors for any IPV (AOR 2.55 and AOR 2.21, respectively). Partner's alcohol use (AOR 1.22 for every five drinks consumed per week) and heavier drinking (AOR 5.07) were also significant risk factors, but not subject's substance-use. The pattern of risk factors varied only slightly for physical IPV and sexual IPV.

CONCLUSION

This study suggests a substantial relationship between partner alcohol use and IPV among women beyond the woman's substance-use and confirms previous reports regarding the cycle of violence in women's lives.

Severe Intimate Partner Violence and Alcohol Use among Female Trauma Patients

BACKGROUND

The lifetime prevalence of intimate partner violence (IPV) among women in the United States is reported to be between 18 and 50%. One-third of female homicide victims are killed by an intimate partner and alcohol is often involved. Despite these figures, 77% of women have never been screened for IPV. Substance abuse in male partners is known to place women at risk. We examined the role of female alcohol use on rates of severe IPV. Our hypotheses were: (1) the prevalence of IPV among women seen in trauma centers is greater than that found in national surveys; (2) alcohol problems among abused women and their partners are greater than those among non-abused women; (3) females and their partners alcohol problems are each independently associated with IPV; and (4) female trauma center patients support domestic violence screening.

METHODS

An in-person survey was administered to 95 consecutive adult female trauma patients admitted to a Level I Trauma Center. The survey included questions about past-year and lifetime severe IPV, female and male partner alcohol use, and willingness to participate in IPV screening and referral. The multivariate associations of female and partner alcohol use with past-year severe IPV were assessed with logistic regression.

RESULTS

Nearly one-half (46.3%) of women reported a lifetime history of severe IPV, with 26% experiencing severe IPV in the past year. Past-year IPV was identified in 59.1% of women screening positive for drinking problems, but in only 12.7% of those screening negative for drinking problems (p = 0.001). Similarly, past-year IPV prevalence was 55.2% when the partner was a problem drinker versus 8.3% when he was not (p = 0.001). Multivariate analysis showed that female problem drinking (odds ratio [OR] = 5.8) and partner problem drinking (OR=8.9) were independent predictors of past-year severe IPV. The majority of women (90.5%) felt that it was appropriate for health care professionals to screen for IPV; 90% of women with a history of IPV thought screening was important and 71% wished a previous healthcare provider had asked them about it.

CONCLUSIONS

Female trauma patients demonstrate a higher prevalence of severe IPV than the general population. IPV rates appear to be related to both female and partner alcohol misuse. Female trauma patients endorsed IPV screening and thus should be screened for alcohol use and IPV in a way that minimizes future violence risk. Further research is needed to elucidate whether intervention for alcohol misuse has an impact on rates of IPV in this population.

Violence-related injury and intimate partner violence in an urban emergency department

BACKGROUND

To facilitate the identification of ED patients at risk for intimate partner violence (IPV), we assessed the relationship of acute violence-related injury and history of IPV victimization or perpetration.

METHODS

: This cross-sectional study systematically sampled patients presenting to an urban ED. Reason for visit, past year history of IPV victimization and perpetration, alcohol and drug use and abuse, and sociodemographic factors were assessed. We hypothesized that violence-related injury would be positively associated with a history of IPV victimization and with IPV perpetration.

RESULTS

The odds of violence-related injury was increased three-fold among persons with a history of IPV victimization and nearly two-fold (although not statistically significant) among those with IPV perpetration history. Male gender, younger age, and problem drinking were independent risk factors in both models.

CONCLUSION

Screening for IPV among individuals presenting with a violence-related injury may be helpful in identifying individuals at risk of partner violence.

A positive domestic violence screen predicts future domestic violence

The objective of this study was to determine if a brief screen for domestic violence (DV) predicts future violence. We conducted a cohort study of adult women who presented to an inner-city emergency department during an 8-week study period. Participants were screened for DV using the Partner Violence Screen (PVS). At 4 months, follow-up telephone interviews were conducted: rates of verbal and physical violence were measured using the modified Conflict Tactics Scale. Relative risks of violent events (physical and verbal) were calculated. Of the 215 women who enrolled, 36 (16%) had an initial screen positive for DV. Ninety-six women participated in the follow-up phase; of these women, 9% had screened positive for DV. At 4 months, women with DV were 11.3 times more likely to experience physical violence and 7.3 times more likely to experience verbal aggression. The study's screen identified women at high risk for subsequent physical violence and verbal aggression.