Rural Health-Care Providers' Attitudes, Practices, and Training Experience Regarding Intimate Partner Violence -- West Virginia, March 1997

Primary health-care providers are an important resource to women who have experienced intimate partner violence (IPV) (1). IPV patients in rural areas often face obstacles to preventive services such as physical isolation from health care and a lack of adequate community services. In March 1997, a pilot project was conducted to survey the attitudes and practices of rural health-care providers (RHCPs) toward women at risk for IPV * in primary-care clinics in West Virginia and to determine the training experience of RHCPs in IPV intervention and prevention during the preceding 2 years. This report summarizes the results of the survey, which indicate that most RHCPs recognized barriers to identification and referral of abused women in their practices but few screened female patients for IPV or have had recent continuing education on IPV.

The survey was conducted by the West Virginia Coalition Against Domestic Violence Health Partnership in collaboration with the West Virginia University Center for Rural Emergency Medicine and the Rural Health Education Partnership, which coordinates rural health educational experiences for health sciences undergraduates at West Virginia University. The survey instrument was adapted from surveys designed by the Family Violence Prevention Fund, American College of Emergency Physicians, and the Emergency Nurses Association (2).

Of 15 primary-care clinics recommended by the Rural Health Education Partnership's site coordinators, 13 agreed to participate, representing 12 counties in West Virginia. All RHCPs at each participating clinic were asked to complete a survey. For this survey, domestic violence was defined as physical abuse by a current or former partner (e.g., throwing an object at a person, hitting with a fist, or sexual abuse) and/or verbal abuse (e.g., threatening physical harm). A partner could be of the opposite or same sex. For this survey, respondents were asked to limit their responses to female patients. All health-care providers did not respond to each question.

Of 127 health-care providers at primary-care clinics, 97 (76%) responded; most (64 {70%}) were female. The average age of respondents was 40 years (n=87; range: 21-66 years) (for five respondents, sex and professional status were not reported). Respondents included physicians (37 {40%}), nurses (31 {34%}), physician assistants/family nurse practitioners (PAs/FNPs) (13 {14%}), and persons with other occupations (11 {12%}). Only respondents responsible for obtaining medical histories (physicians, PAs/FNPs, and nurses) were included in the analysis.

To assess perceptions of barriers to identification and referral to community or on-site services for persons who experience IPV, all RHCPs were asked whether they agreed or disagreed with items on a list of potential hindrances. The five barriers to identification most often agreed with were "patient denies battering as a cause of injury" (84% {76 of 91}), "patient fears repercussions of being identified as abused" (82% {75 of 91}), "patient does not mention abuse during history-taking" (79% {74 of 94}), "patient lacks privacy within the clinic" (77% {72 of 93}), and "what I view as abuse, my patient accepts as normal" (72% {67 of 93}). The two barriers to referral to community services most often agreed with were "fear of partner's reaction to referral" (78% {69 0f 88}) and "battered patients do not want a referral" (72% {63 of 88}).

Forty-six percent (13 of 28) of physicians, 42% (five of 12) of PAs/FNPs, and 46% (13 of 28) of nurses reported that their facility adequately identified victims of abuse, and 73% (22 of 30) of physicians, 58% (seven of 12) PAs/FNPs, and 68% (19 of 28) of nurses reported that their facility adequately counseled, informed, and referred victims of IPV. Half (18 of 36) of physicians, 54% (seven of 13) PAs/FNPs, and 37% (11 of 30) of nurses reported attending a continuing education or in-service program on domestic violence during the preceding 2 years. However, 16% (six of 37) of physicians, 31% (four of 13) of PAs/FNPs, and 21% (six of 29) of nurses indicated that they "routinely ask female patients if they have been physically hurt or threatened during the past twelve months." Forty-three percent (16 of 37) of physicians, 46% (six of 13) of PAs/FNPs, and 17% (five of 29) of nurses reported they "routinely ask female patients if their headaches, insomnia, or other stress-related disorders are related to domestic violence," and 29% (10 of 35) of physicians, 8% (one of 13) of PAs/FNPs, and 57% (16 of 28) of nurses reported that they were "not sure how to screen for abuse."

Reported by: S Derk, MA, West Virginia Univ Center for Rural Emergency Medicine, Morgantown; D Reese, MA, West Virginia Coalition Against Domestic Violence, Charleston, West Virginia. Family and Intimate Violence Prevention Team, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: RHCPs care for many victims of abuse and treat injuries and illnesses that are directly related to IPV (3-5). In rural areas, health-care providers may be the only persons with whom victims have contact who can assist with developing a safety plan, make a referral to a shelter, or provide reassurance that a partner's violence is not the woman's fault. However, the findings in this report suggest that, in West Virginia, few rural physicians routinely screen for physical abuse or stress-related disorders related to domestic violence; this finding is consistent with previous studies of the health-care experiences of IPV patients (5).

Barriers to health care for many residents of rural communities may include poverty; underinsurance or lack of health insurance; shortages of health-care providers; lack of public transportation systems; physical obstacles for women with disabilities; and communication difficulties for those who cannot speak, read, or write English. In addition, women residing in rural areas may have less access to resources (e.g., advanced education, job opportunities, and adequate child care) that would make leaving an abusive relationship easier (6). RHCPs may be acquainted with or related to their patients and their families, creating a barrier to disclosing abuse confidentially and further isolating these women (4).

Although many physicians in this study reported barriers to identifying and referring victims of IPV, some reported that their facility was adequately identifying, counseling, informing, and referring victims of IPV. Health services research can address discrepancies between clinical preventive services guidelines and practices (7). Systems approaches, such as continuous quality improvement, should be considered for improving IPV screening practices.

The findings in this report are subject to at least three limitations. First, because a convenience sample was used, these findings cannot be generalized to all rural health-care providers in West Virginia. Second, the small sample size reduces the reliability of these findings. Finally, because respondents tend to provide socially desirable responses, self-reported data may overestimate screening practices of health-care providers.

American Medical Association guidelines recommend that health-care providers screen all women for evidence of IPV (8). RHCPs who adhere to practice guidelines can play a critical role in a woman's decision to obtain preventive services (9). Barriers to ascertainment of IPV by physicians include the perception of low prevalence of family and intimate violence in clinical populations (1,4). This perception may be accentuated among RHCPs; however, rural or suburban residence does not decrease a woman's risk for IPV (10). The special needs of rural patients must be included in curricula and protocols developed for practicing RHCPs on IPV prevention and intervention, including attention to isolation, lack of programs, cultural attitudes, issues of confidentiality, and use of community resources (4).

References

1. Reid SA, Glasser M. Primary care physicians' recognition of and attitudes toward domestic violence. Acad Med 1997;72:51-3.

2. CDC. Emergency departments response to domestic violence -- California, 1992. MMWR 1992;42:617-20.

3. Johnson MM, Elliott BA. Domestic violence among family practice patients in midsized and rural communities. J Fam Pract 1997;44: 391-400.

4. Goeckermann C, Hamberger K, Barber K. Issues of domestic violence unique to rural areas. Wis Med J 1994;93:473-9.

5. Hamberger KL, Saunders D, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24: 283-7.

6. Bushy A. Health issues of women in rural environments: an overview. JAMWA 1998;53:53-6.

7. Solberg L, Kottke TE, Brekke ML, et al. Using continuous quality improvement to increase preventive services in clinical practice -- going beyond guidelines. Prev Med 1996;25:259-67.

8. American Medical Association. Diagnostic and treatment guidelines on domestic violence. Chicago, Illinois: American Medical Association, March, 1992.

9. Lantz P, Weigers M, House J. Education and income differentials in breast and cervical cancer screening: policy implications for rural women. Med Care 1997;35:219-36.

10. Bachman R, Saltzman LE, eds. Violence against women: estimates from the redesigned survey. Washington, DC: US Department of Justice, August 1995.

In this report, IPV is used interchangeably with "domestic violence" (DV), which was the term used in the questionnaire.

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