AbstractThe Health Care Professional (HCP) has an ideal opportunity to assess for and intervene in domestic violence, the largest cause of injury to women in the United States. This article reviews key information the HCP must know to proactively address this health care dilemma. The prevalence, health risks to families, indicators, and resources are reviewed. Primary, secondary, and tertiary interventions to facilitate action are presented. Show Key Words: health care professional, domestic violence, intervention.
Domestic violence, a public health menace, is the largest cause of injury to women in the United States. Between two and four million women in this country are battered annually by their partners (Strauss & Gelles, 1990). Domestic violence often begins or escalates during pregnancy (Bohn, 1990). Domestic violence is the result of power, control, and coercive behavior of one individual over another in a relationship. This relationship may include marital, non-marital, dating, and gay/lesbian partnerships. The abuse often involves repetitive battering and injuries, psychological abuse, sexual assault, progressive social isolation, and intimidation (Flitcraft, Hadley, Hendricks-Matthews, McLeer, & Warshaw, 1992). Approximately 90% of the victims of domestic violence are females (Buel, 1995) from all socio-economic, educational, and ethnic backgrounds. Routine screening of women for domestic violence at initial office visits and annual exams has been encouraged (ACOG, 1989). For some health care professionals (HCPs), asking about domestic violence is synonymous with "opening Pandora's Box" or "opening a can of worms" (Sugg & Inui, 1992), considering this problem "too complicated" to address. The American Medical Association (1992) reported that many professionals are falsely influenced by societal misconceptions including: (a) Domestic violence is a rare occurrence; (b) Domestic violence is a private matter; (c) Domestic violence does not occur in normal relationships; and (d) The woman is somehow responsible for her abuse. Lack of knowledge and training in domestic violence may contribute to the inability of providers to recognize and correctly interpret behaviors associated with domestic violence (AMA, 1992). Deficiencies in the education of HCPs listed by Holtz and Safran (1989) included the inability to identify, assess, document, and manage the care of clients experiencing domestic violence. Chambliss, Curtis-Bay, and Jones (1995) found limitations in the education of obstetric/gynecology residents related to domestic violence including: (a) lack of faculty interest; (b) underestimated prevalence; and (c) failure to recognize common presentations. Two unpublished studies confirm that the lack of professional education in both basic and continuing education among nurses and physicians in the state of Michigan continues to exist. In one study of physicians and nurses (n = 109) working with prenatal patients, 72% had not attended a program on domestic violence during the last year (McClure, 1993). In another study of 155 physicians working in ob/gyn, family practice, and internal medicine, 90% (n = 140) had received no education in their basic medical programs and 76% (n = 117) had not attended a program on domestic violence within the last year (McClure & Meierhenry, 1995). The complexity of domestic violence and its impact on the family presents a major challenge for HCPs. Domestic violence is a multidisciplinary problem requiring coordination with the legal system (e.g., police, prosecutors, and court system), the social system (e.g., legal aid, social services, and shelters), the community at large (e.g., neighbors, families, friends, schools, and churches), and the health profession (e.g., physicians, nurses, counselors, and social workers). This article reviews the role of the HCP as an integral part of a coordinated community approach to domestic violence. Information presented includes: (a) prevalence; (b) health risks to families living with domestic violence; (c) indicators of abuse; (d) referral resources for women experiencing abuse; and finally (e) the primary, secondary, and tertiary interventions that HCPs may use to facilitate a proactive role toward ending the cycle of violence. PREVALENCE OF ABUSEIn 1985, the National Family Violence Survey (Straus & Gelles, 1990) estimated that approximately two million women were battered annually by their male partners in the United States—although other experts project the number to be closer to four million (AMA, 1992). In a community family practice, the prevalence of domestic violence and the rate of physician inquiry was demonstrated in a study by Hamberger, Saunders, and Hovey (1992). Of 394 women, approximately 28% had been physically assaulted by their partner within the last year; 39% had been physically assaulted at some point in their lifetime. Only six of the women in this study had ever been asked about domestic violence by their physician. Smikle, Satin, Dellinger, and Hankins (1995) found the prevalence of physical and sexual abuse in a middle-class population (n = 531) to be 21% and 14%, respectively. The prevalence of domestic violence during pregnancy has been documented as ranging from 8.3% to 14.2% in adults (Campbell, Poland, Waller, & Ayer, 1992) and 20.6% in teens (Parker, McFarlane, & Soenken, 1994). HEALTH RISKS TO FAMILIESThe woman—in a relationship where domestic violence exists—is at risk for numerous health problems. Approximately 1/4 to 1/2 are sexually as well as physically abused (Campbell, 1986). In this country, it is estimated that approximately 4,000 deaths occur annually among women who are murdered by their former or current partner (American Academy of Family Physicians, 1994). Amaro, Fried, Cobral, and Auckerman (1990) have shown that female victims of violence are at risk for depression, suicide, and are more likely to be users of alcohol and drugs. Abused women may also experience somatic complaints such as insomnia, headaches, gastrointestinal symptoms, and pelvic, chest, and back pain (ACOG, 1989). Campbell et al. (1992) found that the correlates of battering in pregnancy included anxiety, depression, drug and alcohol use, and decreased prenatal care. McFarlane, Parker, Soenken, and Bullock (1992) found that abused women were two times more likely to begin prenatal care in the third trimester. The fetus is at risk because adverse pregnancy outcomes such as miscarriage, stillbirths, and premature delivery have been reported following battering episodes (Bullock, McFarlane, Bateman, & Miller, 1989). Pregnant women are more likely to have multiple sites of injury than non-pregnant women (Helton, 1987) and are more likely to be struck in the abdomen (Bohn, 1990). Two of the most common causes of blunt abdominal trauma to the pregnant woman are falls and assaults (Pearlman, Tintinalli, & Lorenz, 1990). Placental or direct fetal injury can occur with minor maternal injuries resulting in death of the fetus. Ribe, Teggatz, and Harvey (1993) cited three cases where pregnant women were hit or kicked in the abdomen—causing fetal demise. For Jackie, the risk of an abdominal assault during pregnancy was great. Bullock and McFarlane (1989) explored the issue of physical abuse and the incidence of low birth weight infants. They found that approximately 18% of infants born to battered women were below 2,500 grams compared to 4.2% of the control infants (born to women not experiencing violence in their relationships). Other researchers have confirmed a positive correlation between low birth weight and domestic violence (Parker, McFarlane, & Soenken, 1994) Children of battered women may experience newborn feeding problems, failure to thrive (Helton, 1987), and over 1/3 will experience sexual abuse at the hands of the perpetrator. Older children witnessing violence—such as battering—may experience emotional trauma, difficulties in school, domestic complaints, and may become active participants in violence as well (Flitcraft, Hadley, Hendricks-Matthews, McLeer, & Warshaw, 1992). Teens living in homes where abuse is present are more likely to be homeless, delinquent, substance abusers, have sexually transmitted diseases, and have early pregnancies (Kaplan, 1994). Additionally, these teens are more likely to manifest higher suicide rates and may demonstrate self-mutilating behavior. Perpetrators of violence often have low self-esteem, have been victims of violence in the past, or have witnessed violence in their childhood (Bohn, 1990; Chez, 1994). They are at risk for increased substance abuse and for injury related to their violent behavior outside of the home (ACOG, 1989; Chez, 1994). Cindy's alcoholic husband grew up in a home where his father beat his mother. INDICATORS OF VIOLENCEThe indicators of domestic violence often go unrecognized by the HCP if bruises are not evident. Furniss (1993) and Buel (1995) discuss several indicators that may be clues to identifying a domestic violence victim. These include:
RESOURCESResources available for families experiencing abuse include family and friends, the criminal justice system, clergy, health care professionals, and battered women's shelters (Bohn, 1990). Women located in rural settings are often more isolated from resources than women located in an urban setting and may be required to travel several miles for safety or to call long distance for information (Bohn, 1990). Knowing the local community resources that exist for victims of violence will provide access for the HCP and may facilitate referral, provide crisis intervention for the victim, and support that may empower the affected families. PRIMARY INTERVENTIONThe goal of primary intervention is to prevent a detrimental health event from occurring. HCPs may become involved in primary intervention through political action, through the promotion of linkages with referral resources, and through the education of communities and professional colleagues. Political action involves awareness of current legislation within the state regarding (a) personal protection orders that are available for individuals experiencing violence at the hands of their partner—whether in marital, dating, or gay/lesbian relationships; and (b) mandatory arrest by police if there is evidence that an assault has occurred. Political action may also be utilized with the insurance industry where women with a history of experiencing domestic violence may be denied health and life insurance policies (Buel, 1995). The promotion of linkages with health care facilities, health care providers, local shelters, and other resources for families experiencing violence allows contacts with "the system" before a need arises. These contacts will help the HCP to know what can be done and to enhance confidence of the HCP to empower the family if domestic violence is identified. Education of communities and professionals about domestic violence is a primary intervention. Health professionals may become involved in community forums, in their offices, in schools, or in the education of other health professionals. Community forums increase awareness in the general public of the problem of domestic violence and offer a mechanism for various resource persons to present a "panel" discussion, thereby providing a coordinated community approach. In schools, HCPs can become involved and/or support efforts toward conflict resolution, anger control, and peer review programs. Speaking at middle and high school seminars provides an opportunity for the HCP (a) to emphasize warning signs in dating relationships that may lead to later violence and (b) to encourage young adults to build relationships on trust; to avoid relationships that confuse "love" with power, control, and jealousy; and to emphasize that sincere love does not interfere with success, other friendships, and growth as an individual. In offices, the HCP can increase awareness with posters and by providing resource cards (see Figure 1) that list services available in the community and a "plan for quick escape." Having a small card—the size of a business card—allows individuals in violent relationships to take the card and keep it safely. Posters and resource cards communicate to patients in the office that you are aware of the problem and may open the door to communication. SIDE 1 IF YOU ARE BEING ABUSED, HELP IS AVAILABLE
SIDE 2 PLAN AHEAD FOR A QUICK ESCAPE
Figure 1. Information on domestic violence should be included in the educational programs of all HCPs. Continuing education programs should be offered every one to two years with updates on interventions, resources, and current legislation. Panel discussions are very valuable for HCPs, allow association of "a face with a name," and may provide a forum for building linkages within the community. A panel with "victims of abuse" may make the problem of violence "real" to HCPs who are influenced by societal myths. Another mechanism of education is "role play" on how to assess for domestic violence. When asking personal questions, professionals are often very uncomfortable. Having the knowledge of "how" to ask questions about domestic violence may make the subject more approachable. SECONDARY INTERVENTIONSecondary intervention is aimed at early identification and intervention of the health problem. Assessment for violence should be routine in annual and new client visits for prenatal or other health-related care. Asking specific questions about violence implies knowledge of the problem and a willingness to help. McFarlane, Christoffel, Bateman, Miller, and Bullock (1991) demonstrated the value of direct questioning in pregnant women (n = 477). Only eight percent reported abuse on a standard self-completed history form, but when asked the same questions by a HCP, 29% reported abuse. Questions assessing abuse need to be very specific and presented in a "matter of fact" way. A close-ended question such as, "Are you being abused?" leaves too much room for interpretation by the client. A more direct method for obtaining sound information is asking, "Are you in a relationship where you are being hit, slapped, kicked, or punched?" or "Are you being forced to have sex against your will?" These questions leave no room for discrepancy with interpretation. Another statement that may be used if injuries are present and abuse is suspected is, "Sometimes when I see injuries like yours, the person has been hurt by someone close. Is that happening to you?" In our ob/gyn practice, we have begun asking the above questions at initial prenatal, initial office, and at annual visits. Domestic violence is affecting clients in our practice, and the majority were not identified until they were asked specifically. We are also discovering that these questions are "opening the door" for clients to verbalize past experiences with rape and incest. When a client verbalizes that she is in a violent relationship, Furniss (1993) has recommended the HCP follow these suggestions: (a) Reassure the woman that she is not alone; (b) Believe that violence is unacceptable; (c) Assure confidentiality though the information must be documented; (d) Document (discussed in the following paragraph); (e) Educate the client on her options, such as a personal protection order, the resources available, and the likelihood that the violence will be repetitive; and (f) Develop a safety plan that may be utilized by the client for a "quick escape." Women in violent relationships also should be assessed for the risk of homicide. Some indicators of potential homicide exist if there are guns in the home, and if the perpetrator has threatened to kill the woman, is violent outside of the home, or is violently jealous (Campbell, 1986). Documentation for acute battering, according to Flitcraft, Hadley, Hendricks-Matthews, McLeer, and Warshaw (1992) should include: (a) description of the chief complaint, using the client's own words; (b) relationship of the client to the abuser; (c) significant medical and social history; (d) explicit description of injuries, using a body map; (e) results of pertinent diagnostic tests; and (f) plans including resource options given and disposition of the client when leaving the health care setting. In addition, taking color photographs may be very helpful—especially if the client decides to prosecute. Photos should be taken immediately and 1 to 2 days after an incident to document bruises which may become evident days after the injury. Permission to take photos is required and each photo must be labeled with name, date, and location of injury. TERTIARY INTERVENTIONTertiary intervention involves long-term planning related to a health problem that exists. For a woman in a violent relationship, the choice of leaving is hers. Leaving often places the woman at greater risk for homicide as in Mindy's situation. Often the woman will remain because of financial, educational, family, or religious constraints. Tertiary intervention by the HCP involves accepting the women's decision for action or for lack of action, remaining supportive to the family, and continuing to listen and to pursue alternative problem-solving methods. SummaryHealth care professionals need to become involved in the prevention and treatment of domestic violence—a public health dilemma. Having a sound knowledge base of the prevalence (family health risks related to domestic violence), indicators, and referral resources is crucial. To intervene in domestic violence requires planned interventions. By asking routinely, the HCP may begin to proactively address domestic violence. An instant "cure" may not be achieved with the woman in a violent relationship; however, success may be defined as small steps toward empowerment. Resources for the Health Care Provider
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A home health nurse is speaking to a group of acute care nurses about domestic violence
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