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A Statewide Survey of Domestic Violence Screening Behaviors Among Pediatricians and Family Physicians
Garry Lapidus, PA-C, MPH;
Michelle Beaulieu Cooke, MPH;
Erica Gelven, MA;
Keith Sherman, PhD;
Mary Duncan, PhD;
Leonard Banco, MD
Arch Pediatr Adolesc Med. 2002;156:332-336.
ABSTRACT
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Objective To assess rates of previous domestic violence (DV) training, current
screening practices, and barriers to screening among Connecticut pediatric
primary care physicians.
Design Self-administered mail survey.
Setting State of Connecticut.
Participants Pediatricians and pediatric care–providing family practice physicians
(N = 903).
Results The response rate was 49% (n = 438). The demographic characteristics
of the response sample were as follows: 70% male, 76% older than 40 years,
84% white, 87% in private practice, and 64% in suburban practice. Only 12%
of the physicians reported routinely screening for DV at all well-child care
visits, 61% reported screening only selective patients, and 30% said they
did not screen for DV at all. Sixteen percent of the physicians reported having
an office protocol for dealing with victims of DV. Respondents practicing
in an urban setting were significantly more likely to screen routinely for
DV than those practicing in a suburban setting (odds ratio, 1.77; 95% confidence
interval, 1.12-2.79). Prior DV training was the strongest predictor of routine
screening (odds ratio, 5.17; 95% confidence interval, 3.13-8.56). In fact,
respondents with previous training made up 64% of those who routinely screened
for DV.
Conclusions Only a minority of Connecticut pediatric care physicians routinely screen
mothers for DV. Primary care physicians with education and training about
DV are screening at higher rates than physicians with no education and training.
Pediatric physicians need training, protocols, and best-practice models on
how to identify and intervene with families experiencing DV.
INTRODUCTION
APPROXIMATELY 4 million women are victims of physical domestic violence
(DV) each year in the United States, and many more are subject to emotional
abuse.1 In many of these homes, children are
also victims of DV, either as witnesses or as victims of abuse themselves.2-6
Researchers estimate that 40% to 60% of child victims of physical abuse have
also witnessed the abuse of their mother by her male partner on one or more
occasions.7-8 Children from violent
homes are often overly aggressive, noncompliant, and disruptive. Some also
display clinically significant internalizing problems, including frequent
crying, sadness, social withdrawal, and somatic complaints.2
Even among children who are not directly abused, serious emotional damage
and physical health consequences may result from witnessing DV directed against
their mothers.9
The pediatric primary care setting offers a unique opportunity to screen
mothers for DV. Female victims of DV are often isolated from their own health
care providers, reducing the likelihood of screening in this setting.10 However, battered women often cite their children's
welfare as their greatest concern, suggesting that they may be more likely
to obtain medical care for their children than for themselves and can be screened
more often in this setting.11 In addition,
several studies indicate a high rate of DV among mothers seen in the pediatric
setting, particularly during the postpartum period.12-14
Health care providers outside the pediatric setting are increasingly
recognizing the importance of DV as a health issue, and several national organizations
actively encourage providers to identify and refer victims of DV through routine
screening.10, 15-18
Pediatricians are only beginning to appreciate their unique opportunity to
play a role in DV screening, and few guidelines exist to support this role.2-4,18-20
Despite this fact, the American Academy of Pediatrics strongly encourages
pediatricians to learn to recognize the signs of DV in the pediatric setting
and to include questions about DV as part of routine anticipatory guidance.19
In light of these factors, we sought to assess DV education and training,
DV screening, and barriers to DV screening among a representative statewide
sample of pediatricians and family physicians. To our knowledge, this is the
first published statewide survey of DV screening by pediatric primary care
physicians. The results have implications for developing guidelines and policies
to improve and support DV screening in this setting.
PARTICIPANTS AND METHODS
The study protocol was reviewed and approved by the institutional review
board of the Connecticut Children's Medical Center, Hartford. We used an instrument
developed by Parsons et al21 to measure DV
screening of patients by obstetrician-gynecologists and adapted it to measure
DV screening of patients' mothers by pediatric primary care physicians (ie,
pediatricians and family physicians). Domestic violence was defined for physicians
as "past or current physical, sexual, emotional or verbal harm to a woman
caused by a spouse, partner or family member." Domestic violence screening
was defined as "assessing an individual to determine if she has been a victim
of domestic violence."
In the first section of the survey, we requested demographic information,
including sex, age, ethnicity, year of residency or medical training completion,
location of practice (urban, suburban, or rural), type of practice (private,
public, hospital-based, university-based, or health maintenance organization),
participation in teaching residents, and participation in practicing general
pediatrics. In section 2 of the survey, we questioned respondents on issues
associated with DV screening, including past training, availability of public
educational materials, screening activities, actions taken for victims of
DV, respondents' personal histories of DV, and barriers to screening. The
survey is described in more detail in Parsons et al.21
Address lists for active members of the Connecticut chapters of the
American Academy of Pediatrics and the American Academy of Family Physicians
were obtained from the Connecticut Children's Medical Center Foundation. Self-administered
surveys were mailed to all pediatricians (n = 525) and family practice physicians
(n = 378) engaged in the practice of general ambulatory pediatrics. Coded
identification numbers accessible only to the principal investigator (G.L.)
and research coordinator (E.G.) were used to maintain participant confidentiality.
The surveys were mailed with a return addressed, postage-paid envelope and
a cover letter explaining the purpose of the study, assuring confidentiality,
and indicating that the survey would take less than 5 minutes to complete.
Of 903 surveys mailed in the first wave, 220 physicians (24%) responded. Two
additional mailings yielded an additional 169 and 49 responses, respectively,
for a total of 438 respondents and an overall response rate of 49%.
Data from the survey were entered into Microsoft Access (Microsoft Corp,
Seattle, Wash) and then imported into SPSS Version 9.0 (SPSS, Chicago, Ill)
for analysis. Characteristics of the health care providers that may affect
DV screening behaviors (sex, age, and past training) were treated as categorical
variables and were analyzed using  2 contingency tables. Multivariate
analyses and interaction effects were investigated using logistic regression.
For these analyses, sex, age, previous DV training, and practice location
were dichotomous variables: male/female, age 40 years or younger/age older
than 40 years, any training/no training, and urban/suburban (rural was eliminated
because there were too few respondents in this category).
RESULTS
Demographic and practice characteristics and responses to potential
DV screening barriers were compared among respondents in mailing waves 1,
2, and 3 to assess the possibility of response bias owing to repeated exposure
to the study measures. Since there were no significant differences (P>.05) between the mailing waves, we pooled all respondents
for subsequent analysis.
Table 1 lists the demographic
and practice characteristics of the respondent sample. Most were men (70.3%),
aged older than 40 years (76.0%), and white (84.3%). Most respondents were
practicing medicine in either a suburban practice (63.6%) or a private practice
(89.0%). Almost half of the respondents (47.0%) said they taught residents.
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Table 1. Demographic and Practice Characteristics of 438 Responding
Pediatric Primary Care Physicians*
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Sixteen percent of the physicians indicated that they had an office
protocol for dealing with victims of DV. Thirty percent of all respondents
reported they do not screen for DV, 61% said they screen only selected patients,
and 12% reported routine screening for DV during well-child or all visits.
Multiple responses to this series of questions were permitted, so screening
behaviors reported by health care providers were not mutually exclusive. Table 2 summarizes the relationship between
health care provider characteristics and DV screening behavior. Respondents
practicing in an urban setting were less likely to report no screening than
those in a suburban or rural setting (P<.05).
Those in a health maintenance organization, hospital-based, university-based,
or public practice were more likely to screen routinely than those in private
practice (P<.05). Respondents with prior DV training
were more likely to report both routine screening (P<.05)
and selective screening (P<.001) than respondents
with no prior DV training. Furthermore, respondents with previous training
made up two thirds of those who reported routine screening for DV. Most respondents
(64%) said that physicians ask women about DV in their practices. However,
12% said that nurses assume this responsibility, 7% designated this responsibility
to nurse practitioners, and 5% said physician assistants ask women about DV
in their practices.
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Table 2. Physician Screening Prevalence by Demographic, Practice, and
Domestic Violence (DV) Training Characteristics for 438 Respondents*
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Logistic regression analyses using training, age, sex, and practice
location as the predictor variables and screening behavior as the dependent
variable confirmed significant relationships among DV training level and practice
location and screening behavior (Table 3). Respondents with previous DV training were 5 times (odds ratio,
[OR] 5.17; 95% confidence interval [CI], 3.13-8.56) more likely to screen
for DV than those without training. Respondents practicing in an urban setting
were almost 2 times (OR, 1.77; 95% CI, 1.12-2.79) more likely to screen than
those practicing in a suburban setting. There were no statistically significant
relationships between age or sex and screening behavior.
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Table 3. Statistical Analysis of Predictive Factors in Physicians'
Domestic Violence (DV) Screening Behavior
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When asked what actions they or their staff take when a mother screens
positive for DV, physicians most frequently cited the following actions: record
DV in the patient's medical record (85%), inquire about abuse of the child
(82%), obtain a more detailed history (78%), advise counseling (74%), provide
emergency numbers (73%), and perform a homicide danger assessment (48%). Many
respondents did not report providing educational materials or referral information,
or scheduling another visit to discuss the issue of DV.
The most common barrier to screening cited by physicians was a lack
of training on how to deal with DV (53.8%; OR, 1.93). Other significant barriers
(Table 4) included a lack of time
for fully evaluating mothers who screen positive for DV (39.6%; OR, 1.29),
frustration with an inability to help DV victims (24.4%; OR, 1.32), lack of
time for DV screening (22.8%; OR, 1.65), fear of offending their patients'
mothers (17.4%; OR, 1.30), and belief that DV is not a problem in this population
(13.8%; OR, 1.54; P<.05 for all). Additional significant
barriers were cited as barriers by fewer than 10% of all physicians surveyed.
Of the 51 physicians (12%) who reported a personal or family history of DV,
most (67%) felt their experiences led them to attempt to identify victims
of DV, rather than deterring them from screening for DV.
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Table 4. Significant Barriers to Domestic Violence (DV) Screening by
438 Physicians
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COMMENT
To our knowledge, ours is the first published report of DV screening
behavior among a statewide sample of pediatric primary care providers that
includes pediatricians and family physicians. Our study has 3 major findings.
First, only a small proportion of Connecticut pediatric primary care physicians
are routinely screening mothers for DV at well-child care visits. Second,
the major barrier to screening cited by our sample is a lack of sufficient
training about DV. Third, pediatric primary care physicians who receive training
about DV are more than 5 times more likely than untrained physicians to screen
mothers for DV during well-child care visits.
In our study, only 12% of the physicians reported routinely screening
mothers for DV at pediatric well-child care visits, 61% reported screening
selected women, and almost 33% said they did not screen for DV at all. Our
findings are consistent with the findings of a 2001 study by Erickson et al,22 who reported that only 8.5% of the physicians with
admitting privileges at their children's medical center routinely screened
their patients' mothers for DV, while 51% selectively screened. In the study
by Parsons et al21 of obstetrician-gynecologists,
20.5% reported routinely screening patients for DV and 65.4% said they screened
their patients' mothers selectively.
Similar to physicians in other settings, pediatric primary care physicians
cited a lack of training as the greatest barrier to screening mothers for
DV.9, 21-22 Only 42%
of the physicians in our sample reported receiving any type of prior DV training.
While this finding is somewhat encouraging compared with other studies of
pediatric health care providers, which report DV training rates of only 26%
to 30%,22-23 the DV training rate
in our sample is substantially lower than that reported by Parsons et al in
their survey of obstetrician-gynecologists (66%).21
This difference is not surprising, however, given the active role the American
College of Obstetricians and Gynecologists takes in promoting DV awareness
and training among its members and all health care providers.
Other major barriers to DV screening in our study included a lack of
time for screening and for evaluating and counseling mothers who screen positive,
frustration that the physician cannot help victims of DV, fear of offending
their patients' mothers, and a belief that DV is not a problem in this population.
Many of these barriers have been observed in other health care settings as
well.5, 9-10,24-26
In other studies, barriers to effective screening by physicians included lack
of training, a routine protocol, and experience, and insufficient time for
screening.5-6,9-10,23-28
While it has been suggested that personal experience with DV could inhibit
health care providers from identifying and intervening with other victims
of DV,29 our results show otherwise. Physicians
in our study who had been victims of or witnessed DV reported being more likely
to identify and intervene with other victims of DV, not less likely.
The central finding of this study is the strong, significant association
between DV training and reported physician screening behaviors. Forty-two
percent of the physicians in our sample reported receiving some form of DV
training prior to our study. These physicians accounted for 64% of all physicians
who reported routine screening during well-child care visits and 52% of those
who reported screening on a selective basis. Parsons et al21
also reported a significant association between DV training and screening,
and Erickson et al22 reported a more than 10-fold
increase in screening rates in pediatric physicians who had received training
about DV. While our finding may not represent a cause-and-effect relationship,
the strength and consistency of the association between DV training and screening
in this and other studies is indicative of causality. However, when Waalen
et al30 reviewed the evaluations of 12 interventions
designed to increase DV screening by health care providers, they found that
health care provider education alone was not successful in improving screening
rates, but that education must be combined with other interventions, such
as providing physicians with specific screening questions. Since we did not
ask physicians about the type of training they received, we cannot determine
if those who received more hands-on training or specific screening tools were
more likely to screen than physicians who received only education about DV.
This study has a few important limitations. First, because we had no
information on the demographic or practice characteristics of nonresponders
or the survey sample as a whole, we were unable to control for response bias
in our analysis. Second, our response rate was only 49% after 3 waves of mailing.
While this rate compares favorably with that in the study by Parsons et al21 of obstetrician-gynecologists (15%), it is somewhat
lower than the average response rate for mail surveys of physicians of a similar
sample size (n<1000), which was 61% in a recent review.31
However, given the sensitive nature of the topic of our survey, it is reasonable
to expect a lower than average response rate, as has been encountered in other
studies.21, 32 A third limitation
of our study is self-selection. It is reasonable to hypothesize that those
health care providers who took the time and effort to complete the survey
did so because they had an interest in issues of DV.31
Such bias among respondents could have resulted in an overrepresentation of
physicians with DV training, personal DV experience, or current DV screening
experience in our sample. In addition, physicians who have an interest in
DV or who have received DV training may be more likely than others to offer
what they believe to be socially acceptable responses to our questions about
DV screening, thereby inflating the strength of the association between DV
training and DV screening in this study. However, the consistency of this
association with prior reports suggests that the association is real, and
perhaps even underestimated in our sample.21-22
An important strength of our study is the size of our sample. Our response
sample included 438 physicians compared with only 310 physicians included
in the study of DV screening practices at a single children's medical center
by Erickson et al.22
Our findings have several important implications. Few pediatric primary
care physicians are routinely screening their patients' mothers for DV, despite
recommendations by the American Academy of Pediatrics to the contrary. One
reason for this inconsistency could be the lack of training about DV available
to pediatricians. Only 42% of the pediatricians and family practice physicians
in our sample reported obtaining some form of previous DV training. Moreover,
a lack of training was cited by physicians as the greatest barrier to screening
in their practices, supporting current recommendations by the American Academy
of Pediatrics to include DV training in residency training programs and continuing
medical education.19 Education and training
interventions designed to improve screening rates in this setting will need
to address the many barriers to DV screening identified in this and other
studies, including the development of standard protocols for DV screening
in pediatric primary care, training physicians and other health care providers
to better address the psychological issues associated with DV, and finding
creative ways to reduce the time commitment for physicians to screen all of
their patients' mothers for DV. Recently, other investigators have examined
the ability of computer-based screening to address many of these issues, with
some early success.33-34 In our
busy, urban, primary care center, women who screen positive for DV are referred
to a social worker who then facilitates a referral to a battered women's shelter.
For our practice this helps take the burden off the medical provider, as well
as address the time constraints associated with screening during well-child
care visits.
| What This Study Adds
Maternal DV is common in the pediatric primary care setting and has
important negative consequences for the long-term health and development of
children. Since pediatric physicians have repeated exposure to their patients'
mothers, they are in a unique position to screen for maternal DV. However,
little is known about how often pediatricians actually screen for maternal
DV in this setting and what health care provider characteristics enhance screening
rates. The findings from our study show that few pediatricians and family
physicians actually screen mothers routinely for DV and that prior training
about DV significantly improves screening rates. The findings suggest that
health care provider training may be an effective intervention for improving
DV screening rates among pediatric primary care physicians.
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AUTHOR INFORMATION
Accepted for publication December 31, 2001.
Corresponding author and reprints: Garry Lapidus PA-C, MPH, Injury
Prevention Center, Connecticut Children's Medical Center, 282 Washington St,
Hartford, CT 06106 (e-mail: glapidu{at}ccmckids.org).
From the Injury Prevention Center, Connecticut Children's Medical Center
(Mr Lapidus, Mss Beaulieu Cooke and Gelven, and Drs Sherman and Banco), Hartford;
Departments of Pediatrics (Mr Lapidus and Ms Beaulieu Cooke) and Community
Medicine (Mr Lapidus and Dr Duncan), University of Connecticut School of Medicine,
Hartford.
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