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Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and Intervention for Intimate Partner AbusePractices and Attitudes of Primary Care Physicians. JAMA. 1999;282(5):468–474. doi:10.1001/jama.282.5.468
Context Although practice guidelines encouraging the screening of patients for
intimate partner abuse have been available for several years, it is unclear
how well and in which circumstances physicians adhere to them.
Objective To describe the practices and perceptions of primary care physicians
regarding intimate partner abuse screening and interventions.
Design, Setting, and Participants Cross-sectional survey of a stratified probability sample of 900 physicians
practicing family medicine, general internal medicine, and obstetrics/gynecology
in California. After meeting exclusion criteria, 582 were eligible for participation
in the study.
Main Outcome Measure Reported abuse screening practices in a variety of clinic settings,
based on a 24-item questionnaire, with responses compared by physician sex,
practice setting, and intimate partner abuse training.
Results Surveys were completed by 400 (69%) of the 582 eligible physicians,
including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists.
Data were weighted to estimate the practices of primary care physicians in
California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%)
of these primary care physicians routinely screen injured patients for intimate
partner abuse. However, estimated routine screening was less common for new
patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%),
and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent
intimate partner abuse training had significant effects on reported new patient
screening practices. Obstetrician/gynecologists (17%) and physicians practicing
in public clinic settings (37%) were more likely to screen new patients. Internists
(6%) and physicians practicing in health maintenance organizations (1%) were
least likely to screen new patients. Commonly reported routine interventions
included relaying concern for safety (91%), referral to shelters (79%) and
counseling (88%), and documentation in the medical chart (89%). Commonly cited
barriers to identification and referral included the patients' fear of retaliation
(82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up
(52%), and cultural differences (56%).
Conclusions These findings suggest that primary care physicians are missing opportunities
to screen patients for intimate partner abuse in a variety of clinical situations.
Further studies are needed to identify effective intervention strategies and
improve adherence to intimate partner abuse practice guidelines.
Physical violence is estimated to occur in 4 to 6 million intimate relationships
each year in the United States.1,2
The term intimate partner abuse refers to the physical,
sexual, and/or psychological abuse to an individual perpetrated by a current
or former intimate partner. While this term is gender-neutral, women are more
likely to experience physical injuries and incur psychological consequences
of intimate partner abuse.3
In addition to injuries, abused women often experience somatic and stress-related
illnesses, chronic pain syndromes, depression, posttraumatic stress disorder,
and substance abuse disorders.4,5
Furthermore, compared with women with no history of abuse, abused women have
higher levels of health care use.6 In fact,
31% to 54% of female patients seeking emergency services,7,8
21% to 66% of those seeking general medical care,5,9-11
and up to 20% of those seeking prenatal care report experiencing intimate
Despite the high prevalence of intimate partner abuse, less than 15%
of female patients report being asked about abuse by health care professionals
or disclosing abuse to them.9,14-16
Yet, in 2 studies, the majority of female patients favored physician inquiry
and reported that they would reveal abuse histories if asked directly.14,16 Prior studies examining physician
practices suggest that only a small fraction of physicians and other health
care professionals commonly inquire about intimate partner abuse.14,17,18 Unfortunately, these
findings are limited by small sample sizes, low response rates, and/or the
use of convenience samples. Patient attitudes, lack of institutional support,
and other environmental factors may hinder efforts to address intimate partner
abuse in clinical settings.19,20
In addition, physicians' feelings of discomfort and powerlessness may also
contribute to this low level of inquiry.21-23
Early identification of abuse has been a priority in efforts to improve
the health care response to intimate partner abuse.24
Because of the prevalence and associated health care costs of intimate partner
abuse, national public health organizations have endorsed the use of interventions
such as protocols in clinical settings for the identification of patients
Several national medical organizations have developed practice guidelines
for intimate partner abuse that encourage routine screening and interventions.28-30 Although many of
these guidelines have been available for several years, it is unclear how
often and in which clinical circumstances health care professionals actually
adhere to them.
Lawmakers have attempted to respond to intimate partner abuse by passing
legislation, such as mandatory reporting laws, to help improve the health
care response. Our previous work addressed physicians' perspectives on mandatory
reporting of intimate partner violence to police in California.31
We previously reported on conflicting attitudes among California primary care
and emergency physicians toward mandatory reporting. An estimated 64% of primary
care physicians and 25% of emergency medicine physicians might not report
abuse if patients object. While almost all states have laws that require reporting
certain injuries, 5 states have reporting laws that specifically address reporting
intimate partner violence. California's law, which passed in 1994, requires
that health care professionals report cases in which they provide medical
care for female or male patients whom they suspect are suffering from an intimate
partner violence-related injury to the police with or without the patient's
The objectives of the current study included (1) estimating intimate
partner abuse screening and intervention practices of primary care physicians
in California, (2) exploring how physician specialty, sex, and training might
influence screening and intervention practices, and (3) examining primary
care physicians' perceived barriers to identification and intervention.
We selected a stratified probability sample of 900 physicians from the
California Medical Association database, which includes licensed California
physicians (members and nonmembers) and incorporates information from the
Medical Board of California and the American Medical Association. Equal proportions
were drawn from each of 3 specialties: family practice, internal medicine,
and obstetrics/gynecology. In this report, these specialties are collectively
referred to as primary care physicians because they provide primary medical
care for the majority of female patients. To increase our ability to assess
the influence of physician sex, female physicians were oversampled. Because
women represent nearly one quarter of physicians in these 3 specialties, they
were sampled at 1.5 times their proportion in each specialty. Physicians were
excluded if they were retired, in training, practicing outside the state,
or working primarily in nonclinical areas. Physicians without a valid California
telephone number or address, as verified by local telephone companies and
the Medical Board of California, were also excluded.
Recruitment involved 3 mailings of the questionnaire starting in July
1995. Physicians who had not responded after 3 mailings were contacted by
telephone and sent an additional survey if requested. A letter that accompanied
the questionnaire provided information about the study purpose, procedure,
confidentiality, and contact data for further information. Informed consent
was implied when a respondent returned the completed questionnaire. This study
was approved by the University of California, San Francisco, Committee on
A 24-item questionnaire was developed based on published research21,23,32 and discussions with
domestic violence advocates. Pilot testing was performed with 30 physicians,
both male and female, from all 3 primary care specialties. Based on the feedback
from the pilot study, all references to intimate partner abuse were made gender-neutral
to enhance acceptability to respondents. Screening practices were assessed
in 4 different clinical situations: evidence of injury, new patient visit,
periodic checkup, and first prenatal visit. The frequency of screening was
assessed by asking, "How frequently do you ask direct, specific questions
about domestic violence to patients?" For each clinical situation, respondents
were given choices on a 4-point Likert scale of never, sometimes, often, or
always. Respondents' use of 7 selected intervention practices was assessed
using the same 4-point scale. Perceived barriers to identification and intervention
were assessed by providing a list of potential barriers and asking respondents
to identify each as a major barrier, minor barrier, or not a barrier.
The survey also included questions about demographics (age, sex, ethnicity),
US vs non-US medical training, practice setting, knowledge of relevant legislation,
and personal experience with intimate partner abuse. In addition, respondents
were asked whether they had "taken a class or continuing medical education
course on domestic violence in the last 3 years." To assess childhood exposure
to intimate partner abuse, respondents were asked, "When you were growing
up, did one of your parents ever threaten, hit, slap, kick or otherwise physically
hurt the other?" To assess personal experience with intimate partner abuse,
respondents were asked, "Have you ever feared for your safety or been hit,
slapped, kicked, or otherwise physically hurt by an intimate or previously
Routine screening and intervention practice was defined as a response
of "often" or "always" to the different clinical situations and interventions.
These variables were dichotomized (never/sometimes vs often/always) for statistical
comparison. Similarly, responses to barriers were dichotomized (not/minor
vs major) for statistical comparison. The data were analyzed using SPSS statistical
software.33 Analysis of variance was used for
statistical comparison of means. For cross-tabulations of proportions with
greater than 2 rows or columns, statistical significance was determined using
Pearson χ2. For 2×2 cross-tabulations, Yates corrected χ2 was used. Statistical significance was defined as P<.05.
To generate population estimates, weighted overall proportions were
calculated using the inverse of the sampling fraction for each of the 6 sex/specialty
strata. Based on data from the 1995 California Medical Association database,
practicing California physicians included 5968 family physicians, 9020 internal
medicine physicians, and 3831 obstetrician/gynecologists. With the exception
of the sample descriptions, all proportions and bivariate statistical analyses
make use of weighted estimates. The 95% confidence intervals (CIs) for weighted
proportions were calculated by multiplying the SE of proportion by 1.96.
We used logistic regression analysis to estimate adjusted odds ratios
(ORs) and 95% CIs for the factors associated with reported screening practices.
Four variables were included as predictors in the multivariate models. Three
of these variables (specialty, practice setting, and intimate partner abuse
training) were included because each was significantly associated with screening
practices in at least 1 of the 4 clinical settings using univariate logistic
regression models. Although sex was not predictive of screening practices
in any clinical setting, it was retained in the models because it was of particular
interest. Other potential predictors were not significant in the bivariate
analyses. The final models were reviewed for goodness-of-fit and validated
using the Hosmer-Lemeshow statistic. Because multivariate models included
both specialty and sex, data were not weighted.
Of the 900 physicians sampled, 582 were ultimately determined to be
eligible for the study and 400 (69%) completed the survey. Of the 400 respondents,
149 (37%) practiced family medicine, 115 (29%) practiced internal medicine,
and 136 (34%) practiced obstetrics/gynecology. Response rates for the different
specialties did not vary significantly; however, female physicians had a higher
response rate compared with male physicians (78% vs 63%; P=.001).
The characteristics of the study group are presented in Table 1. The mean age was 46 years. Compared with male, female physicians
were younger (mean age, 42.0 vs 48.9 years; P<.001).
The sample was predominantly white and the majority of physicians practiced
in private clinic settings.
An estimated 22% (95% CI, 18%-26%) of California primary care physicians
had taken a class or continuing medical education course on intimate partner
abuse in the past 3 years. This proportion did not differ significantly by
physician specialty, sex, age, or practice setting. Overall, the majority
of physicians (80%; 95% CI, 76%-84%) had identified intimate partner abuse
at some time in their career. However, reported identification varied significantly
by specialty: 90% of family physicians, 80% of obstetrician/gynecologists,
and 74% of internal medicine physicians (P=.001).
Identification of a patient who had experienced intimate partner abuse did
not differ significantly by physician sex or having taken recent training
course on intimate partner abuse.
An estimated 15% (95% CI, 12%-19%) of California primary care physicians
had witnessed intimate partner abuse between their parents at some time during
their childhood. This exposure did not significantly differ by physician specialty
or sex. Overall, 12% (95% CI, 9%-15%) of physicians reported experiencing
physical abuse from an intimate partner or feared for their safety as an adult.
This experience did not differ by physician specialty. However, compared with
male physicians, twice as many female physicians reported having experienced
intimate partner abuse (20% vs 10%, P=.01).
Although screening for intimate partner abuse was common among injured
patients, screening was less common for routine medical encounters (Table 2). In circumstances that involved
physical injuries, an estimated 79% of California primary care physicians
often or always ask patients direct questions about intimate partner abuse.
An estimated 10% of physicians routinely screen for intimate partner abuse
during new patient visits and 9% screen during periodic checkups. Of physicians
who provide prenatal care, an estimated 11% routinely screen for intimate
partner abuse during the first prenatal visit. Obstetrician/gynecologists
reported the highest level of new patient screening (17%), followed by family
physicians (10%), and internal medicine physicians (6%). Routine screening
in the different clinical situations was not significantly associated with
physician age, ethnicity, international medical training, personal experience
with intimate partner abuse, or knowledge of the California domestic violence
injury mandatory reporting legislation.
We used logistic regression to further clarify the relationship between
physician characteristics and reported screening practices in new patient
encounters (Table 3). After controlling
for the effects of physician sex, practice setting, and training, the higher
level of screening among obstetrician/gynecologists remained significant compared
with internal medicine physicians. Although more female physicians reported
routinely screening new patients, these sex differences were not statistically
significant. Physicians working in public clinics reported the highest level
of new patient screening (37%); routine screening was less frequent for physicians
in private offices (9%), health maintenance organizations (1%), and other
practice settings (12%) (P<.001). These differences
remained significant after controlling for physician specialty, sex, and training.
More physicians with recent intimate partner abuse training reported routine
screening, but the effect was not statistically significant.
Similar analytic approaches were used to determine the associations
between physician characteristics and reported screening practices in the
other clinical situations. In contrast to new patient screening, routine screening
during the first prenatal visit did not differ significantly by specialty
or practice setting. However, compared with physicians without recent training
in intimate partner abuse, a greater proportion of those with training reported
routine screening of prenatal patients (24% vs 8%; P=.007).
Although reported screening during periodic checkups was not significantly
associated with physician specialty, sex, or training, physicians working
in public clinics reported the highest level of screening (26%) compared with
physicians in health maintenance organizations (5%), private clinics (9%),
and other practice settings (10%) (P=.02). This difference
remained significant after controlling for the effects of physician specialty,
sex, and training. Screening practices for injuries did not differ significantly
by specialty, sex, practice setting, or recent training in intimate partner
The most commonly reported interventions included discussing physician's
concern for safety with the patient (91%; 95% CI, 88%-94%), recording battering
in the patient's chart (89%; 95% CI, 86%-93%), making referrals to counseling
(88%; 95% CI, 85%-92%), and giving information about shelters and services
(79%; 95% CI, 74%-83%). Asking about guns in the home (46%; 95% CI, 40%-51%)
and reporting to police (44%; 95% CI 38%-49%) were less common. Reported interventions
were not consistently associated with physician specialty or sex.
Compared with physicians with no recent training in intimate partner
abuse, physicians who had received training in the last 3 years were more
likely to report routinely using information about shelters (89% vs 76%; P=.02), reporting to police (65% vs 37%; P<.001), and asking about guns in the home (58% vs 42%; P=.02).
Patient-related factors were most frequently identified as major barriers
to identifying and referring patients experiencing intimate partner abuse
(Table 4). The most commonly cited
major barriers included the patient's fear of retaliation by the partner (82%)
and the lack of disclosure of battering during history taking (78%). In addition,
a majority of physicians agreed that the patient's fear of police involvement,
lack of follow-up on referrals, and cultural differences between patients
and physicians are major barriers. Less than half of physicians identified
lack of training, lack of time, lack of information about local community
agencies, or the belief that physicians cannot make a difference in intimate
partner abuse as major barriers.
Compared with physicians without recent training in intimate partner
abuse, physicians who had received training in the last 3 years were less
likely to report the lack of information about local community agencies as
a major barrier (17% vs 33%; P=.005). Perceived barriers
were not consistently associated with physician specialty, sex, or reported
screening practices in the different clinical situations.
This study documents significant differences for routine screening for
intimate partner abuse, depending on the clinical situation. An estimated
majority of primary care physicians (79%) routinely screen patients with injuries.
However, for patients seeking care in other clinical situations, screening
for intimate partner abuse was less common (9%-11%). The higher level of reported
screening of patients with injuries is likely to reflect physician's awareness
that intimate partner abuse is an important cause of injury in women. In contrast,
the lower level of routine screening of patients in other clinical situations
suggests that primary care physicians are missing important opportunities
to detect intimate partner abuse and intervene on behalf of those experiencing
Our findings, which are consistent with previous physician
surveys,14,17 suggest that most
physicians do not adhere to current practice guidelines for intimate partner
abuse screening. Interventions that focus on administrative changes, such
as protocols, may improve adherence. Recently, researchers have begun to examine
the sensitivity and specificity of a variety of screening protocols34-36 and the effect of
incorporating screening questions into self-administered history forms.37 Preliminary results are encouraging. Most of these
protocols are concise, easy to use, and effective at identifying intimate
partner abuse. However, there are unanswered questions regarding the efficacy
of universal screening. While identification of the problem is essential,
the utility of screening ultimately depends on the yet unproven benefits of
In our study, recent education in intimate partner
abuse was associated with higher levels of screening of prenatal patients,
the routine use of information about shelters and protective services, reporting
to police, and inquiring about guns in the home. In contrast, recent training
had little effect on reported screening practices in other clinical situations.
Previous cross-sectional surveys have found that professional training positively
influenced reported intimate partner abuse screening practices17,32;
however, studies that directly examined the effects of training have produced
conflicting results depending on the type of training and length of follow-up.38-40 Professional training
has the potential to increase knowledge, comfort, and skills for effective
inquiry and intervention. However, without structural changes, regular in-service
education, and institutional policies, physician training is unlikely to be
sufficient to change clinical practice.38,40-42
Controlled studies are needed to determine the effectiveness of interventions
for improving physician behavior regarding intimate partner abuse. In light
of the evidence that US medical schools require an average of only 2 hours
of training in adult domestic violence43 and
less than half of family practice residencies have required education about
intimate partner abuse,44 effective training
programs should be identified and expanded. In addition, information about
local shelters and community resources should be widely disseminated to health
Obstetrician/gynecologists reported the highest
level of new patient screening, followed by family physicians and internal
medicine physicians. These differences should be viewed with caution given
our finding that specialty had only a modest effect on reported screening
practices in other clinical situations, including prenatal visits. These variations
may be related to differences in patient demographics, types of medical problems
encountered, clinical procedures, or advocacy and awareness within the field.
In particular, obstetrician/gynecologists are more likely to provide care
for young female patients, who are at the highest risk for intimate partner
abuse. A better understanding of these differences will require further investigation.
Physicians working in public clinics reported the highest level
of screening in clinic situations involving new patients and routine checkups.
Routine screening was markedly less frequent for physicians practicing in
health maintenance organizations. These differences may be related to differences
in the patient population, clinic procedures, or institutional policies and
support. Different clinic settings may also have other health care professionals
or staff who provide routine screening procedures. Further research is necessary
to explain these compelling results.
Contrary to our expectations,
we found no significant associations between physician sex and reported screening
practices. Prior research that examined the effects of physician sex on screening
for intimate partner abuse has produced conflicting results. Some studies
have found that a significantly higher proportion of female physicians reported
such screening17 or had better skills in detecting
intimate partner abuse.39 However, other related
research found no effect of physician sex.40
Although physician sex has been found to significantly affect both patient-physician
communication45 and the delivery of women's
preventive care,46 further work is needed to
determine the effects of physician sex on the delivery of care for intimate
Routine interventions reported by a majority of
physicians in each specialty included relaying concern for safety to the patient,
referral to shelters and counseling, and documentation in the medical chart.
These interventions are among the most accepted and recommended.28-30
Reporting to the police without patient consent is more controversial because
of potential risks to patient safety and violations of medical ethics.47,48 The California law contains recommendations
for physicians to refer patients to local intimate partner abuse services
and provides protection for these persons from civil or criminal liability.
We estimated that less than half (46%) of California primary
care physicians routinely inquire about guns in the home. Given the increased
risk of injury and death with firearms, determining the accessibility of guns
is an essential part of a safety assessment. Research has demonstrated that
the presence of a firearm in the home is a key contributor to the escalation
of intimate partner abuse to homicide.49,50
In 1 study, firearm-associated intimate assaults were 12 times more likely
to result in death compared with assaults not involving firearms.51 Knowledge of the availability of a firearm determines
the type and urgency of interventions when physicians discuss gun safety issues.
A greater proportion of respondents identified patient-related
barriers to identification and intervention (fear of retaliation, fear of
police involvement, lack of disclosure, and lack of follow-up) compared with
physician-related barriers (lack of time, lack of training, lack or resources
and referrals, and sense of inefficacy). Similar barriers have been identified
in previous studies of physicians21-23
and abused patients.15,52,53
Knowledge of the specific barriers encountered by different types of physicians
helps to shape future training and tools for identification and intervention.
Based on the results of our study, future training should provide strategies
to deal with patients' fears and reluctance to disclose abuse and address
cultural differences. Furthermore, training should be customized to address
the unique barriers faced within the different specialties or practice settings.
This study had several limitations. California's mandatory reporting
law (adopted January 1994) may have prompted specific policy development within
medical organizations that increased awareness of intimate partner abuse among
physicians. As a result, physician inquiry in California, particularly in
cases of injury, may be more frequent than in states with different reporting
requirements.31 In addition, the potential
bias of overreporting socially desirable behavior may have overestimated actual
screening practices. Because the definition of intimate partner abuse and
other survey language were gender-neutral, we are unable to determine how
patient sex affects reported screening practices. Finally, this study did
not survey other health care professionals (eg, nurses, physician assistants,
social workers, and psychologists) who often play key roles in patient assessment
and management, particularly in relation to psychosocial issues.
This study provided insight into the practices and attitudes of a representative
sample of California primary care physicians regarding intimate partner abuse.
As the discussion regarding the appropriate role of health care professionals
in addressing intimate partner abuse evolves, these data will inform our understanding
of the patterns, justifications, and barriers to physician inquiry. The rationale
for universal screening is based on the high prevalence, the high association
with an array of health problems, the low level of suspicion and inquiry on
the part of physicians, abused women's general unwillingness to volunteer
information, and the high level of patient acceptance of direct physician
inquiry. Furthermore, screening incurs minimal costs and risks to patients,
while offering significant potential benefits.54
Because of the newness of intimate partner abuse as a health issue, studies
examining the impact of routine health care screening and interventions on
health or the prevention of future abuse is unknown. Although recommendations
for screening cannot yet be based on evidence of proven efficacy, the magnitude
and severity of the problem, coupled with the feasibility of screening and
the potential for meaningful intervention, make intimate partner abuse an
important issue in primary care practice.