Screening for domestic violence: practice patterns, knowledge, and attitudes of physicians in Arizona.

Objectives: Victims of domestic violence presenting for health care are frequently referred to medical specialists, but little is known about domestic violence screening among specialists. The aim of this study was to evaluate attitudes and behaviors concerning domestic violence of all physicians in Arizona.

Methods: A cross-sectional survey of 2,244 physicians from 13 medical specialties describes domestic violence screening practices, attitudes, and behaviors of practicing physicians in Arizona.

Results: Among 976 respondents, 56% reported prior education on domestic violence screening; 50.5% rarely or never screen their female patients for domestic violence; and 52% reported their competence for providing treatment for victims as poor to fair. Physicians from emergency medicine, psychiatry, obstetrics/gynecology, and family practice reported higher rates of domestic violence education, screening, awareness of services, and competence at treating victims. Physical medicine/rehabilitation, anesthesiology/pain control, surgical subspecialty, medicine subspecialty, general surgery, and orthopedic physicians scored lowest on these characteristics.

Conclusions: Differences in attitudes and behaviors regarding domestic violence screening were noted among specialty groups. Customizing physician training based on these findings may be beneficial.

Key Words: abuse, domestic violence, screening

**********

Domestic violence (DV) is defined by the Family Violence Prevention Fund (1995) as a pattern of assaultive and coercive behaviors used in the context of dating or intimate relationships. (1) A survey by the National Institute of Justice suggests that women are victims in 85% of all abuse cases in the United States. (2) Although physical, sexual, and emotional abuse is underreported, as many as 55% of women have reported being raped and/or physically assaulted at some point in their lives, (2) and 2 to 4 million women are victims of DV each year in the United States. (3,4) The medical community, along with the criminal justice system, is most frequently positioned to identify and treat abuse victims.

Because of its wide variation in presenting symptoms, the diagnosis of DV is challenging to the medical practitioner. In addition to obvious physical injuries, victims may present with chronic pain, gastrointestinal disorders such as irritable bowel syndrome, neurologic complaints such as headaches, recurrent sexually transmitted diseases, or other genitourinary disorders. (5-7) Behavioral presentations include eating disorders, depression, and substance abuse. (7,8) These conditions are often referred to medical specialists for diagnosis and treatment.

Unfortunately, physicians identify only 5 to 15% of abuse cases when they present in a medical setting. (9-12) They infrequently screen patients for DV, and often deny that they suspect abuse in their patient population. (13,14) Some also report discomfort with asking patients about abuse, and feeling powerless to help victims. (15)

Previous research on DV screening practices has focused on primary care, emergency, or women's health physicians. (13,15-21) One objective of this study was to evaluate the DV screening practices of a wider spectrum of specialists. In addition, we assessed their motivating factors and barriers to DV screening. Finally, we wished to determine how DV education, attitudes, and preferences differ among areas of specialization and thereby to inform the design of educational interventions that would appeal to all groups.

Materials and Methods

After approval was given by our institutional review board, a cross-sectional, descriptive approach was used in this study. A stratified probability sample of 2,244 physicians was selected from the Arizona State Board of Medical Examiners database. Equal proportions were randomized from the following 13 categories: anesthesiology and pain control, emergency medicine, family practice, general practice, internal medicine, medicine subspecialty, obstetrics/gynecology, obstetrics/gynecology subspecialty, physical medicine/rehabilitation, psychiatry, general surgery, orthopedic surgery, and surgical subspecialty. Intern/resident physicians, radiologists, pathologists, clinical pharmacologists, and physicians who did not have a current Arizona medical license and those not actively providing patient care were excluded. In addition, pediatricians were not included in the survey because they had been recently surveyed regarding DV education by one of the coauthors (unpublished manuscript). During the course of the survey, 121 subjects who were determined to be ineligible (retired, not in clinical practice or interns/residents) were replaced with subjects from the same practice categories.

From the 14,999 active physicians in the Arizona Board of Medical Examiners data base, up to 205 subjects were randomly selected from each of the 13 listed specialties. Sample size calculations were based on a 90% confidence interval ([+ or -]10%). If the number of physicians in a specific category was insufficient, all subjects in that category were sampled.

The study was conducted during the first half of 2000. Subjects were sent a maximum of three surveys over a 6-month period.

Definitions

Practicing physicians were defined as those who actively treat any number of inpatients or outpatients. A list of specializations comprising the subspecialty groups and a breakdown of number of participants is available, on request, from the authors.

Instrument

The study authors developed a 2-page, 23-item questionnaire based on previous studies (16,17,22-24) and designed to be completed in 5 minutes or less. Most questions were multiple-choice, with response sets framed as five-item Likert scales. A few open-ended questions were also asked.

Demographic data, years in practice, numbers of patients seen weekly, and specific practice settings were obtained. Subjects were asked about their experience with DV screening, preferences for learning about screening, and personal barriers to screening. Finally, subjects were asked whether they would like additional education on screening and if they would be willing to participate in a DV task force.

Data analysis

Data were entered into an ACCESS database. They were then imported into SPSS version 10 (SPSS Inc., Chicago, IL), where they were checked and cleaned. All analyses were conducted with the use of SPSS. Multiple-range tests, based on the Tukey Honestly Significant Differences test, were used to identify homogeneous subsets of response means. A criterion level of P = 0.05, two-tailed, was adopted for significance.

Results

Of the 2,244 surveys sent, 976 (43.5%) were returned and deemed eligible. Demographic characteristics of this sample are provided in Table 1. Most respondents (75.6%) were male and white/non-Hispanic (78%). The number of years in practice ranged from 1 to 57 (mean = 16.38 years, SD = 11.18). Most physicians (63.4%) were office-based. Only one variable, age, was available to assess the representativeness of our respondents. Respondents (mean age = 48.2 years) were slightly younger than nonrespondents (mean age = 49.6 years). Response rate differed notably across specialties (see Table 2). Obstetricians/gynecologists were most likely to return their questionnaires (57.2%); anesthesiology/pain control physicians were least likely (23.5%).

Previous education and training

Fifty-six percent of respondents reported prior education on DV screening, noting that this training occurred primarily in medical school (33.7%), during residency (24.2%), or through self-directed reading (26.4%). Fifty-two percent rated their education on DV as "poor" or "fair," and 19.9% as "good" or "excellent." Emergency medicine physicians and obstetrician/gynecologists rated their level of education highest, whereas physical medicine/rehabilitation physicians and medicine subspecialists rated their education lowest (Table 3, column 2).

Screening practices

Among all respondents, 51% reported that they screened female patients for DV during a routine office visit either "rarely" or "never." Twenty-seven percent indicated that they "sometimes" screen, and 22% reported that they "frequently" or "always" screen for DV. Emergency medicine, psychiatric, and obstetric/gynecology subspecialty groups reported the highest rates of DV screening (Table 3, column 3). Anesthesiology/pain control, physical medicine/rehabilitation, general surgery, and surgical subspecialty groups reported the lowest screening rates.

Awareness of services

When asked to rate their level of awareness of the DV services in their clinic, hospital, or community, 47.7% noted that they were not aware of or knew only a little about such services. Nine percent were aware of services, but had never used them. Forty percent were aware of and had previously used victim services. Emergency medicine, family practice, psychiatry, and obstetrics/gynecology noted the highest awareness; physical medicine/rehabilitation, medicine and surgical subspecialists, and anesthesiology/pain control rated their awareness the lowest (Table 3, column 4).

Competence

Many respondents (52.2%) rated their competence in providing treatment for DV victims as "poor" or "fair." Emergency medicine and psychiatry perceived themselves as the most competent, whereas medical subspecialists and physical medicine/rehabilitation physicians rated themselves lowest (Table 3, column 5).

Physician attitudes, preferences

Physicians were asked to classify DV, broadly, as a "type of problem." The overwhelming majority of respondents (86.8%) indicated that DV is primarily a social problem as opposed to a medical problem (12.3%) or a legal problem (7.4%). When asked to list barriers to screening, physicians noted that they were too busy to screen (19.3%), reported a lack of community resources for victims (18.5%), believed that screening is not their responsibility (8.8%), felt uncomfortable with it (6.9%), or believed that they would not make a difference (3%). Interestingly, 459 respondents (49.9%) did not identify any barriers to screening.

When asked to list motivating factors for DV training, having patients who are victims (59%) and the possibility of increased personal/professional knowledge (56.4%) were the most popular responses. Continuing medical education credit was somewhat less popular (26.4%). Physicians were unified in their dislike of mandatory continuing medical education; only 13.5% indicated that this would be a motivator for training. When asked to list preferences for a training format, educational conferences were favored (58%). Written materials were the second most popular format (31.4%). Social workers were the most favored trainers (38.0%), followed by physicians (32.6%). Small-group facilitators (14%), nurses (11.9%), or DV survivors (9.1%) were less likely to be selected as trainers.

Regarding content of training, 67.7% indicated that they would prefer presentations by advocacy groups, and 41.9% wished to hear about laws regarding DV. Physicians were less interested in learning statistics on DV homicides/suicides (29.6%), the dynamics of power and control (29.5%), personal stories from victims (20.6%), or historic information (12.3%).

Finally, we examined willingness to receive training, use DV screening and resource materials, and to participate in a task force; 82.6% of the respondents reported that they were willing to use DV materials in their practice, 76.5% were comfortable with using a screening tool, 41.1% were interested in receiving training, and 10.3% were interested in participating on a DV task force.

Discussion

Our data suggest a range of differences in DV attitudes and behaviors among areas of medical specialization. Physicians from emergency medicine, psychiatry, obstetrics/gynecology, and family practice reported that they were most knowledgeable of DV and victim services, and more likely to screen and feel competent at treating victims. Physicians in the areas of physical medicine/rehabilitation, anesthesiology/pain control, surgical subspecialty, medicine subspecialty, and general and orthopedic subspecialty were least likely to know about DV and victims' services. These groups also were less likely to screen patients, and were less competent at treating victims.

Overall, 22% of respondents indicated that they screened female patients "frequently" or "always." A survey of obstetrician-gynecologists reported DV screening rates of 27% of nonpregnant and 39% of pregnant females. (13) Three studies have reported lower screening rates of 3%, (18) 9 to 11% (17) and 10%. (19) Interestingly, these studies concerned specialty groups who reported higher rates of screening in our study. Finally, a study of internists and family practitioners reported screening rates of 13% for repeat patients and 19% for new patients, (21) which are comparable to our study.

Fifty-six percent of respondents reported some DV training. Published reports on prior training in DV vary. A study of California primary care physicians reported that 22% had taken training on intimate partner abuse in the past 3 years. (17) This study surveyed physicians in 1995, so our study may represent improvement over time. A national study of obstetrics/gynecology, emergency, family, and internal medicine physicians published in 2002 reported that 80% of respondents had received training in DV, 39% within the previous 12 months. (19) A survey of obstetrician-gynecologists (1998) reported that 30% had DV training in medical school, 37% during residency, and 67% since residency. (13) A survey of obstetrics/gynecology, emergency, family, and psychiatric physicians (2002) revealed that 79% had DV training in medical school and 20% since graduation. (20) A recent study of pediatricians and family practitioners reported that 37% of their respondents had no

previous DV training. (25) In summary, most of these studies show higher rates of training than our report. This might be explained by our inclusion of specialties that have not been targeted for education.

Quality of DV education has received less attention. A Canadian survey, comparing recently trained with longer-practicing obstetrician-gynecologists, noted that 90% of those certified before 1990 and 74% certified after 1990 believed that their training was deficient. (18) In contrast, our study found a lower percentage, 52%, who believed that their DV education was fair to poor. Notably, the Canadian survey found lower rates of screening (3%), (18) potentially suggesting that quality of education is an important determinant of screening behavior.

In addition to a lack of training, a perception of incompetence at providing care for victims may contribute to low screening rates among physicians. Fifty-two percent of the respondents in our study rated their competence at providing care as poor to fair, and 48% were not aware of or knew little about services for victims. One study reported that 45% of respondents had inadequate resources for victims. (19) A survey of pediatricians and family practitioners reported that 54% of respondents were not trained to deal with DV, 40% did not have time for victims, and 24% "cannot do anything" for victims. (26) In this context, it is notable that the preferred content of training in our study was information from advocacy groups, and that the preferred teacher was a social worker. This suggests a desire to receive practical information as part of training.

There are several limitations to this study that should be noted. Because of the limited data available from the Arizona Board of Medical Examiners' database, we were not able to track the number of nonresponding subjects who were ineligible (those who were retired with active licensure) and inadvertently sent a survey. This probably resulted in the computation of response rates that are artificially low. We speculate that respondents were possibly more interested in the topic than nonrespondents, and therefore the data may not truly represent the population surveyed. Although previous studies of DV screening practices among obstetricians, psychiatrists, emergency room physicians, primary care physicians, and pediatricians reported higher response rates, (13,14,16-21,26) we found that research directed at multi-specialties reported response rates similar to ours. (27) A report of a survey on intimate partner abuse screening practices sent to pediatricians and family physicians reported an overall response rate of 36%. (25) A review of response rates to physician surveys found that the average rate for studies with a sample of 1,000 or more was 52%. (28) Nevertheless, due to the 43.5% response rate in this study, some caution should be used when making generalizations about the data.

This study was motivated by our concern that despite recommendations from groups such as the American Medical Association (3) and the American College of Obstetricians and Gynecologists (29) calling for routine DV screening of female patients, physician rates of screening continue to be suboptimal. (13,17,19,21) We acknowledge that a recent review (30) has questioned screening for DV based on a lack of demonstrated efficacy. However, since DV has been associated with a number of conditions such as chronic headaches, (8) irritable bowel syndrome, (6) and chronic pelvic pain, (8) which are frequently referred to specialists, asking about DV may be diagnostically significant. Also, given that it has been well documented that those experiencing DV are not likely to disclose unless asked, (10,31) we believe that screening is an important skill for physicians. Our study suggests a need to provide quality DV education and practical information to both primary and specialty physicians and points to some methods of customizing this training.

Conclusion

This study details obvious variations in DV screening attitudes and practices among physician groups in Arizona. We are encouraged by the reported interest in training and the willingness to use screening tools. The high percentage of respondents who expressed a desire to gain information from advocacy groups implies that physicians are willing to collaborate with others to best serve the needs of DV victims.

The optimist proclaims that we live in the best of all possible worlds,
and the pessimist fears this is true.
--James Branch Cabell

Table 1. Characteristics of respondents (n = 976)

Characteristic                   n (%)

Sex
  Femaie                         233 (23.9)
  Male                           738 (75.6)
  Missing                          5 (0.5)
Race
  African-American                13 (1.3)
  American Indian                 10 (1.0)
  Asian/Pacific Islander          91 (9.3)
  Hispanic                        49 (5.0)
  White/Non-Hispanic             762 (78.1)
  Other                           51 (5.3)
Age, mean (SD)                    48.2 (11.03)
Practice setting
  Government                      72 (7.4)
  Hospital-based patient care    260 (26.6)
  Office-based private practice  619 (63.4)
  Salaried employee of HMO        60 (6.1)
Number of patients seen weekly
  <20                            101 (10.3)
  20-39                          155 (15.9)
  40-59                          222 (22.7)
  [greater than or equal to]60   480 (49.2)
  Unknown                         18 (1.8)
Years in practice, mean (SD)      16.4 (11.18)

Table 2. Response rates by specialty

Field of Practice                   n (%)

Anesthesiology/pain control          47 (23.5)
Emergency Medicine                   86 (47.0)
Family Practice                     110 (53.1)
General Practice                     56 (35.4)
Internal Medicine                    84 (40.0)
Medicine subspecialty                94 (45.0)
Obstetrics/Gynecology               103 (57.2)
Obstetrics/Gynecology subspecialty   46 (50.0)
Physical Medicine/rehabilitation     34 (51.5)
Psychiatry                           96 (52.5)
Surgery, general                     70 (40.0)
Surgery, orthopedic                  61 (34.5)
Surgical subspecialty                88 (43.3)
Total                               976 (43.5)

Table 3. Mean responses to items measuring previous education, screening
frequency, awareness of services, and perceived competence by
specialty (a)

                       Previous              Screening
                       Education             Frequency
Field of Practice      Mean (SD)             Mean (SD)

Anesthesiology/Pain    2.05                  1.73
  Control              (1.07)[.sup.1,2]      (1.18)[.sup.1]
Emergency Medicine     2.90                  3.24
                       (1.13)[.sup.5]        (0.98)[.sup.5,6]
Family Practice        2.72                  2.86
                       (1.08)[.sup.3,4,5]    (0.80)[.sup.3,4,5]
General Practice       2.66                  2.64
                       (1.14)[.sup.2,3,4,5]  (1.05)[.sup.3,4]
Internal Medicine      2.23                  2.57
                       (1.18)[.sup.1,2,3,4]  (0.95)[.sup.2,3]
Medicine subspecialty  2.00                  2.06
                       (1.02)[.sup.1]        (0.89)[.sup.1,2]
Obstetrics/Gynecology  2.87                  3.17
                       (1.17)[.sup.4,5]      (1.08)[.sup.4,5]
Obstetrics/Gynecology  2.49                  3.29
  subspecialty         (1.18)[.sup.1,2,3,4]  (1.12)[.sup.5,6]
Physical Medicine/     1.83                  1.82
  rehabilitation       (0.91)[.sup.1]        (0.72)[.sup.1]
Psychiatry             2.80                  3.74
                       (1.19)[.sup.3,4,5]    (0.96)[.sup.6]
Surgery, general       2.18                  1.72
                       (1.03)[.sup.1,2,3]    (0.84)[.sup.1]
Surgery, orthopedic    2.17                  2.05
                       (1.13)[.sup.1,2,3]    (1.09)[.sup.1,2]
Surgical subspecialty  2.01                  1.76
                       (0.97)[.sup.1,2]      (0.73)[.sup.1]
Total                  2.44                  2.60
                       (1.15)                (1.16)

                       Awareness             Perceived
                       of Services           Competence
Field of Practice      Mean (SD)             Mean (SD)

Anesthesiology/Pain    2.20                  1.88
  Control              (1.24)[.sup.1,2]      (1.22)[.sup.1,2]
Emergency Medicine     4.07                  3.23
                       (1.30)[.sup.5]        (1.18)[.sup.5]
Family Practice        3.52                  2.85
                       (1.32)[.sup.4,5]      (0.98)[.sup.4,5]
General Practice       3.24                  2.72
                       (1.45)[.sup.3,4]      (1.20)[.sup.3,4,5]
Internal Medicine      2.83                  2.39
                       (1.28)[.sup.2,3,4]    (1.02)[.sup.2,3,4]
Medicine subspecialty  2.29                  1.76
                       (1.10)[.sup.1,2]      (0.92)[.sup.1]
Obstetrics/Gynecology  3.48                  2.70
                       (1.34)[.sup.4,5]      (1.08)[.sup.3,4,5]
Obstetrics/Gynecology  3.32                  2.44
  subspecialty         (1.31)[.sup.3,4]      (0.96)[.sup.2,3,4]
Physical Medicine/     2.06                  1.70
  rehabilitation       (1.13)[.sup.1]        (0.92)[.sup.1]
Psychiatry             3.50                  3.28
                       (1.47)[.sup.4,5]      (1.00)[.sup.5]
Surgery, general       2.63                  1.89
                       (1.17)[.sup.1,2,3]    (0.95)[.sup.1,2]
Surgery, orthopedic    2.45                  2.19
                       (1.06)[.sup.1,2]      (1.11)[.sup.1,2,3]
Surgical subspecialty  2.15                  1.94
                       (1.07)[.sup.1,2]      (0.99)[.sup.1,2]
Total                  2.99                  2.47
                       (1.41)                (1.16)

"Superscripts indicate subset membership based on Tukey HSD multiple
range tests. Groups that appear in the same homogeneous subset (ie, have
the same superscript) are not significantly different from each other.
Groups that do not have common superscripts are significantly different
from one another (P < 0.05).

Acknowledgments

The authors thank Donna Irwin and the staff from the Arizona Governor's Office for Domestic Violence Prevention, sponsor of this project. The grant was administered by Maricopa Medical Foundation, and overseen by Maricopa Medical Center, Phoenix, AZ. Dr. Betty Gale provided assistance on behalf of Arizona State University and the Mel and Enid Zuckerman Arizona College of Public Health.

Accepted April 6, 2004.

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RELATED ARTICLE: Key Points

* Fifty-six percent of respondents reported prior education on domestic violence screening; however, 50.5% rarely or never screen their female patients for domestic violence, and 52% reported their competence in providing treatment for victims as poor to fair.

* Significant differences were noted among areas of medical specialization.

Kelli J. Williamson, RN, MPH, Dean V. Coonrod, MD, MPH, R. Curtis Bay, PHD, M. Jane Brady, RN, MS, Anu Partap, MD, MPH, and Wauneta Lone Wolf, BA

From the Departments of Obstetrics, Gynecology and Women's Health, Academic Affairs, and Pediatrics, Maricopa Integrated Health System and MedPro, Phoenix, AZ.

This research was funded by the Arizona Governor's Office for Domestic Violence Prevention. The authors have no commercial or proprietary interests in the article's subject matter. This research received approval from Maricopa Integrated Health System Institutional Review Board for Human Research.

Correspondence to Kelli J. Williamson, RN, MPH, Department of Obstetrics, Gynecology and Women's Health, Maricopa Integrated Health System, 2601 E Roosevelt, Phoenix, AZ 85008. Email: [e-mail]