Screening for abuse: barriers and opportunities

Screening for partner violence in the early postpartum period: are we missing families most at risk of experiencing violence?

OBJECTIVES

In Manitoba, government policy is for public health nurses to screen families with newborns within 1-week post-discharge for risk factors associated with poor child developmental health. The purpose of this study was to compare the characteristics of families who are screened for intimate partner violence (IPV) with families without a documented response to an IPV screen item. This information can be used to help identify and target families in need of support whose needs are not being met within the current system.

METHODS

Manitoban women giving birth to a live singleton in the province from January 1, 2003 to December 31, 2006 were included in the analyses (N = 52,710). Data were part of a larger research study following these families for several years to examine longer-term developmental outcomes. Administrative databases from the Manitoba Centre for Health Policy provided data for the study. Descriptive statistics and logistic regression were used to examine relationships between IPV screen status and socio-demographic covariates and birth outcomes.

RESULTS

In the study population, 66.7% of the sample were screened for IPV. Women less than 20 years of age, not in married or common-law unions, and living in lower income areas were less likely to have a documented response to the IPV screen item. A low number of prenatal care visits, prenatal mental health problems, and prenatal substance use, as well as premature and low birthweight delivery, were associated with a decreased likelihood of having a documented response to the IPV screen item.

CONCLUSION

Incorporating violence screening into routine prenatal and postnatal care, rather than only screening women after birth, may help to better identify families with unmet needs and ensure more timely referrals to positive strengths-based supports and services.

Sexual abuse history in GI illness, how do gastroenterologists deal with it?

INTRODUCTION

Data support an increased prevalence of sexual abuse (SA) among patients with gastrointestinal (GI) complaints. Sexual abuse causes multiple symptoms related to pelvic floor and stress mediated brain-gut dysfunctions. Treating these patients asks for a holistic approach, using centrally targeted interventions. However, gastroenterologists have never been surveyed regarding their practice patterns and constraints about inquiring into SA.

AIM

To evaluate whether gastroenterologists address SA in their daily practice and to evaluate their knowledge regarding the implications of SA in GI illness.

METHODS

A 42-item anonymous questionnaire was mailed to all 402 members of the Dutch Society of Gastroenterology (gastroenterologists and fellows in training). The questionnaire addressed SA and pelvic-floor-related complaints.

MAIN OUTCOME MEASURES

The results of this survey.

RESULTS

One hundred eighty-three of the 402 (45.2%) questionnaires were returned. Overall, 4.7% of the respondents asked their female patients regularly about SA; in males, this percentage was 0.6%. Before performing a colonoscopy, these percentages were even smaller (2.4% and 0.6%, respectively). When patients presented with specific complaints, such as chronic abdominal pain or fecal incontinence, 68% of the gastroenterologists asked females about SA and 29% of the males (P < 0.01). The majority of respondents stated it as rather important to receive more training on how to inquire about SA and its implications for treatment.

CONCLUSION

Gastroenterologists do not routinely inquire about a history of SA and they rarely ask about it before performing colonoscopy. There is a need for training to acquire the skills and knowledge to deal with SA.

Violence among female users of healthcare units: prevalence, perspective and conduct of managers and professionals

OBJECTIVE

To estimate the prevalence of violence in women who are primary healthcare users and to verify if these situations were detected and how they were tackled by these services' professionals.

METHODS

Descriptive, cross-sectional study carried out with 14 municipal women's health coordinators, 2,379 women who are users of primary healthcare units, 75 managers and 375 professionals, in 15 municipalities of the State of São Paulo (Southeastern Brazil), between August 2008 and May 2009. Data were collected through structured questionnaires and a descriptive analysis was conducted.

RESULTS

A specific protocol for assisting women in situations of violence was mentioned in five municipalities. The majority (83%) of the coordinators reported that situations of violence among female users were detected, although 74% said this was not routinely investigated, which was confirmed by 72.3% of the professionals. Among the women, 76.5% reported having experienced some type of violence throughout their lives, and 56.4% said that an intimate partner was the perpetrator of that violence; almost 30% reported at least one episode in the 12 months prior to the interview; 6.5% reported looking for help at a Primary Healthcare Unit.

CONCLUSIONS

A relevant proportion of users experienced violence in their daily routine, mainly perpetrated by an intimate partner. Most of the women were neither identified nor approached in these services and did not receive help. Although health managers and professionals realized the magnitude of the problem, they did not consider that primary care was prepared to assist these women. The study showed that there is no intersectoral care network to assist women in situation of violence.

Postpartum nurses' perceptions of barriers to screening for intimate partner violence: a cross-sectional survey

Background

Intimate partner violence (IPV) is a human rights violation that is pervasive worldwide, and is particularly critical for women during the reproductive period. IPV includes physical, sexual and emotional abuse. Nurses on in-patient postpartum units are well-positioned to screen women for IPV, yet low screening rates suggest that barriers to screening exist. The purpose of this study was to (a) identify the frequency of screening for IPV, (b) the most important barriers to screening, (c) the relationship between the barriers to screening and the frequency of screening for types of abuse, and (d) to identify other factors that contribute to the frequency of screening for IPV.

Methods

In 2008, we conducted a cross-sectional survey of 96 nurses from postpartum inpatient units in three Canadian urban hospitals. The survey included the Barriers to Abuse Assessment Tool (BAAT), adapted for postpartum nurses (PPN). Ordinary least squares (OLS) regression models were used to predict barriers to screening for each type of IPV.

Results

The frequency of screening varied by the type of abuse with highest screening rates found for physical and emotional abuse. According to the BAAT-PPN, lack of knowledge was the most important barrier to screening. The BAAT-PPN total score was negatively correlated with screening for physical, sexual, and emotional abuse. Using OLS regression models and after controlling for demographic characteristics, the BAAT-PPN explained 14%, 12%, and 11% of the variance in screening for physical, sexual and emotional abuse, respectively. Fluency in the language of the patient was negatively correlated with screening for each type of abuse. When added as Step 3 to OLS regression models, language fluency was associated with an additional decrease in the likelihood of screening for physical (beta coefficient = -.38, P < .001), sexual (beta coefficient = -.24, P = .05), and emotional abuse (beta coefficient = -.48, P < .001) and increased the variance explained by the model to 25%, 17%, and 31%, respectively.

Conclusions

Our findings support an inverse relationship between rates of screening for IPV and nurses' perceptions of barriers. Barriers to screening for IPV, particularly related to knowledge and language fluency, need to be addressed to increase rates of screening on postpartum units.

Strong discomfort during vaginal examination: why consider a history of abuse?

OBJECTIVE

To study factors associated with strong discomfort during vaginal examinations (SD/VE) by means of four hypotheses.

STUDY DESIGN

A cross sectional postal questionnaire study, conducted at three Swedish departments of obstetrics and gynaecology and with a random population sample (n=4453).

MAIN OUTCOME MEASURES

The associations between a self-reported history of emotional, physical and sexual abuse and abuse in health care, flashbacks during the previous year, emotional contact with the examiner, and SD/VE during the index visit (discomfort estimated on a ten-point scale; six-ten=SD). Statistical analyses used were Chi-square, Binary logistic regression, and Pearson Correlation.

RESULTS

Eighteen percent of the women reported SD/VE. There was an association between SD/VE and a lifetime history of abuse. Having experienced combinations of abuse, especially combinations including emotional abuse and abuse in health care, was strongly associated with SD/VE. SD/VE was furthermore associated with flashbacks during the previous year, and negative emotional contact with the examiner during the index visit.

CONCLUSIONS

We conclude that women who unexpectedly react with SD/VE are more likely to have a background of abuse, and may even run a risk of feeling re-traumatised during the VE. A clinical implication is to consider a history of abuse in patients who react with SD/VE or experience negative emotional contact during the consultation.

Partner violence during pregnancy: prevalence, effects, screening, and management

The purpose of this review is to provide an overview of the current state of knowledge regarding the experience of intimate partner violence (IPV) during pregnancy. Pregnancy IPV is a significant problem worldwide, with rates varying significantly by country and maternal risk factors. Pregnancy IPV is associated with adverse newborn outcomes, including low birth weight and preterm birth. Many mechanisms for how IPV may impact birth outcomes have been proposed and include direct health, mental health, and behavioral effects, which all may interact. Screening for IPV during pregnancy is essential, yet due to time constraints and few clear recommendations for assessment, many prenatal providers do not routinely inquire about IPV, or even believe they should. More training is needed to assist health care providers in identifying and managing pregnancy IPV, with additional research needed to inform effective interventions to reduce the rates of pregnancy IPV and resultant outcomes.

"I'm a mother first": The influence of mothering in the decision-making processes of battered immigrant Latino women

Healthcare providers (HCPs) may be perplexed by the decision-making processes of battered Latino women in situations involving intimate partner violence (IPV). In particular, decisions may appear contradictory and hazardous to the women's children. The findings of this interpretive descriptive study reveal that the mothering role was central to battered Latina mothers' decisions. The mothers strove to prioritize, protect, and provide for their children in every way, including managing the abuse and avoiding IPV disclosure to HCPs. Disparate understandings of the women's decisions and mothering create a Catch-22 between battered Latina mothers and their HCPs. A trusting mother-HCP relationship is necessary for effective screening and intervention for IPV. This requires HCPs' understanding of these mothers' decisions and changes in clinical practice.

Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population

OBJECTIVES

The goal of this investigation was to examine the prevalence of different types of intimate partner violence (IPV) during pregnancy, as well as the association between both physical and psychological IPV and negative health behaviors, including smoking, other substance use, inadequate prenatal care utilization, and nutrition, in a rural sample.

METHODS

104 southern Appalachian women, primarily Caucasian and lower SES, completed a pregnancy interview focused on IPV (CTS2) and health behaviors. Medical records were also reviewed.

RESULTS

81% of participants reported some type of IPV during the current pregnancy, with 28% reporting physical IPV, and 20% reporting sexual violence. More than half were current smokers. Physical IPV during pregnancy was associated with significantly increased rates of pregnancy smoking (including decreased rates of quitting and reducing), increased rates of alcohol, marijuana, and harder illicit drug use around the time of conception, and later entry into prenatal care. The experience of psychological IPV during pregnancy was associated with a significantly decreased likelihood of quitting or reducing smoking during pregnancy, an increased rate of alcohol use around the time of conception, and an increased rate of pre-pregnancy obesity.

CONCLUSIONS

In this sample, pregnancy IPV and smoking occurred at rates well above national averages. Additionally, while physical IPV during pregnancy was associated with several negative pregnancy health behaviors, the experience of psychological IPV, even in the absence of physical IPV, also placed women at increased risk for negative health behaviors, all of which have been linked to poor pregnancy and newborn outcomes.

Intimate Partner Violence: Continuing Education for Registered Nurses

Intimate partner violence, also known as domestic violence, is a leading health problem affecting approximately 50% of women during the course of their lifetime. A large percentage of the abusers also abuse their children and older adults. Nurses are in a key position to identify and intervene with victims of abuse. However, a major barrier to screening and referral is lack of education. Nurses indicate a lack of education in their formal undergraduate and graduate programs. Therefore, nurses should be introduced to this topic through a 2-hour continuing education program.

Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature

For more than a decade, professional medical and nursing associations have recommended universal screening for intimate partner abuse (IPA). This review of 44 studies examines IPA screening during this period. The purposes of the review are to (a) identify mutable influences on IPA screening, (b) summarize what is known about altering these influences, and (c) outline an agenda for improving IPA screening. Evidence to date indicates that screening is not universal. Promising approaches to improvement start with provider training and relatively simple environmental adjustments. Unanswered empirical questions include "What are the essential components of effective training? Which health care providers are best positioned to screen under which circumstances? Which of the untested mutable influences will further improve IPA screening practice?" The review leads to the following practice recommendations: (a) Interventions should focus on clinicians in training (e.g., medical residents), and (b) screening approaches must be tailored to various practice settings.

Survival of intimate partner violence as experienced by women

AIMS AND OBJECTIVES

The study set out to describe women's experiences of intimate partner violence, the consequences of such violence, the help they received and women's experiences of their survival.

BACKGROUND

Social and health professionals do not have sufficient ability to identify and help families who suffer from intimate partner violence. Methods for identifying and treating partner violence not have been developed adequately.

METHOD

The study was conducted in Finland by loosely formulated open-ended interviews with seven battered women. The data were analysed by inductive qualitative content analysis.

FINDINGS

Women had past experience of maltreatment and a distressing climate at their parental home. Women experienced both themselves and their spouse as having weak identities; their ideals, patterns of marriage and sexuality were different. Violence occurred in situations of disagreement. Women tried to strike a balance between independence and dependence in the relationship. The different forms of couple violence were interlinked. The women sought help when their health and social relationships got worse. An awareness of the problem, taking action, counselling and social relationships helped them survive. Religiousness was a factor that involved commitment to the couple relationship, made religious demands on women and promoted the recovery of integrity.

CONCLUSIONS

Intimate partner violence was associated with the family model, childhood experience of maltreatment, the partners' weak identity and conflicts between individualism and familism. Social and healthcare professionals need competence in early intervention and skills to discuss moral principles, sexuality, and violence in a way that is free of prejudice and condemning attitudes. Spiritual approaches in the context of interventions should be taken into consideration.

RELEVANCE TO CLINICAL PRACTICE

In a clinical context, nurses should be aware of the symptoms of violence, and they should have skills in dealing with intimate moral and spiritual issues.

Emotional, physical, and sexual abuse in patients visiting gynaecology clinics: a Nordic cross-sectional study

BACKGROUND

Abuse against women causes much suffering for individuals and is a major concern for society. We aimed to estimate the prevalence of three types of abuse in patients visiting gynaecology clinics in five Nordic countries, and to assess the frequency with which gynaecologists identify abuse victims.

METHODS

We did a cross-sectional, multicentre study of women attending five departments of gynaecology in Denmark, Finland, Iceland, Norway, and Sweden. We recruited 4729 patients; 3641 (77%) responded and were included in the study. Participants completed a postal questionnaire (norvold abuse questionnaire) confidentially. Primary outcome measures were prevalences of emotional, physical, and sexual abuse, and whether abused patients had told their gynaecologist about these experiences. We assessed differences between countries with Pearson's chi(2) test.

FINDINGS

The ranges across the five countries of lifetime prevalence were 38-66% for physical abuse, 19-37% for emotional abuse, and 17-33% for sexual abuse. Not all abused women reported current ill-effects from the abusive experience. Most women (92-98%) had not talked to their gynaecologist about their experiences of abuse at their latest clinic visit.

INTERPRETATION

Despite prevalences of emotional, physical, and sexual abuse being high in patients visiting gynaecology clinics in the Nordic countries, most victims of abuse are not identified by their gynaecologists. This lack of discussion might increase the risk of abused patients not being treated according to their needs. Gynaecologists should always consider asking their patients about abuse.