The Factors Associated with Disclosure of Intimate Partner Abuse to Clinicians

It is estimated that intimate partner abuse (IPA) occurs in 4 to 6 million relationships each year in the United States^1,2 and that many health care interactions involve abused patients in primary care settings.^3,4 Clinicians are therefore well placed to identify IPA and to provide appropriate care and referrals. However, in spite of its high prevalence and the existence of published guidelines and recommendations for routine clinician screening,⁵ the majority of abused women patients are not identified in the medical system and do not receive needed assistance.^6,7 Estimates of the prevalence of clinician-patient communication about IPA range from 10% to slightly less than one third of all abused women.^2,8

Previous studies have shown that the low rates of clinician-patient communication about IPA result in part from a lack of direct questioning by many clinicians and because women rarely volunteer information about abuse without being asked. Less than 15% of women patients in primary care settings report being asked about abuse by health care professionals.^2,4,6,7,9 A recent statewide study of primary care clinicians in California found that only 10% reported routine screening for abuse among new patients, and 9% reported such screening at periodic checkups.¹⁰ Yet the majority of women patients report that they favor direct questioning by clinicians about IPA and would reveal abuse histories if asked directly.^6,7

Despite these studies there is much that remains unknown about abuse-related communication patterns and patient attitudes about communication in the medical setting. We examined the prevalence and determinants of clinician-patient communication about intimate partner abuse by interviewing an ethnically diverse group of abused women primary care patients to determine whether differences in disclosure of abuse were related to any of the following: age, ethnicity, education, language, and immigrant status of the patient, as well as clinician sex and ethnicity and the presence of an established clinician-patient relationship. We also looked into patients’ perceived barriers to communication about IPA, including lack of direct clinician questioning about abuse, perceptions about clinicians’ lack of time or interest in discussing abuse, fears about involving the police and courts, embarrassment, concerns about confidentiality, fear of shaming the family, and fear that the patient’s partner might hurt or kill her.

Methods

Study Population

Our sample consisted of women seen at 3 primary care outpatient clinics at San Francisco General Hospital in California.¹¹ Each year these family medicine, general internal medicine, and obstetrics/gynecology clinics serve nearly 100,000 ethnically and socioeconomically diverse women aged 18 to 45 years. During the 3-year period preceding our study, many staff members at the 3 clinics received training to encourage identification and management of IPA in the medical setting. The training incorporated lectures and continuing medical education.

We selected the sample from a computerized patient utilization database for the 3 clinics during 1997. Selection criteria included: (1) female sex; (2) race/ethnicity African American, non-Latina white, or Latina; (3) age 18 to 45 years; and (4) receipt of care in 1 of the 3 primary care clinics in the previous 6 months. Women were selected for participation in this study because they are much more likely to have been abused by an intimate partner than are men. Only women who reported histories of abuse were included in this analysis.

Patients were considered eligible if they met all the selection criteria, spoke English or Spanish, had verifiable phone numbers, and were mentally and physically capable of completing the survey.

Survey Instrument

We developed the survey instrument through a review of the literature, including the results from some of the authors’ previous qualitative research, consultation with domestic violence researchers and advocates, and discussions with a focus group of 6 abused women. Final survey modifications were made following expert review and pilot testing with 75 women, 25 from each target ethnic group. The instrument included questions about patients’ social, health, and demographic characteristics; clinic and medical clinician utilization; and IPA experiences. Women who indicated histories of IPA were questioned about their experiences in obtaining abuse-related help in the medical system, the barriers to IPA communication with medical clinicians, and clinician demographics. The questionnaire was prepared in English and translated to Spanish using standard translation methods.¹²

Questions about abuse were adapted from the 4-question Abuse Assessment Screen, which has been validated in multiethnic populations.¹³ These questions asked whether the participants had ever experienced physical, sexual, or psychological abuse. For each positive response, women indicated whether the abuse had occurred in the past 12 months (recent abuse) or in the more distant past.

Prevalence of communication with clinicians about abuse was assessed by asking participants if they had ever mentioned or discussed abuse with a physician: (1) in response to direct clinician questioning or (2) in the absence of direct clinician questioning.

Data Collection

The survey was administered to the sample by computer-assisted telephone interview between October 1997 and March 1998. An introductory letter was mailed to the homes of all potential participants (to ensure safety the topic of abuse was not mentioned in this letter). Following this, trained women interviewers contacted potential participants by telephone. After confirming eligibility, privacy, and safety and obtaining verbal consent, interviews lasting approximately 25 minutes were conducted in English or Spanish. The study protocol was approved by the Committee for Human Research at the University of California, San Francisco.

Data Analyses

We analyzed the data using SPSS statistical software.14 IPA was defined as having ever been exposed as an adult to physical abuse, sexual abuse, or threats/fear of abuse. The principal outcome variable was previous communication with a medical clinician about IPA experiences. Predictor variables included age, ethnicity, birthplace, language, employment and medical insurance status, and education, as well as clinician sex and ethnicity, direct clinician questioning about abuse, and presence of an established relationship with a clinician (regular clinician). Additional predictor variables included patients’ perceived barriers to communication.

We used multiple logistic regression analysis to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the factors associated with clinician-patient communication about abuse. Our final model includes variables of primary interest to our study (patient age, ethnicity, education, and presence of a regular clinician), as well as those variables that significantly influenced abuse-related communication (birthplace, direct questioning by a clinician, perceptions that clinicians lack time and interest in discussing abuse, and concerns about confidentiality). For cross tabulations, statistical significance was determined using the Pearson chi-square test. Statistical significance was defined as P less than .05.

Results

Sample Description

Of the 1390 patients selected from the database, 992 (71%) met the eligibility criteria. Of the 398 ineligible women, 315 (23%) did not have verifiable phone numbers, and 83 (6%) either did not speak English or Spanish, were incapable of completing the survey, or did not meet the original selection criteria. The overall collaboration rate was 74% (734/992) of the available eligible participants. Of the women interviewed, 51% (375) reported having ever been abused by an intimate partner as an adult. Further descriptive analyses are reported elsewhere.¹¹ Among the 375 participants who reported a history of abuse: 88% (328) reported having experienced physical abuse; 33% (122) reported having experienced sexual abuse; and 66% (246) reported having experienced threats or fear of IPA. There was substantial overlap between abuse categories for most participants, and almost all women reporting a history of sexual abuse also reported a history of physical abuse. However, 7% (28) of the participants reported previous threats or fear of IPA in the absence of physical or sexual abuse.

Sample characteristics of all study participants with histories of abuse are summarized in Table 1. The mean age was 34.3 years (standard deviation [SD]=7.3 years). The study participants were primarily of lower socioeconomic status. Years of education ranged from none to postgraduate, with a mean of 11.9 years (SD=3.5 years).

Prevalence of Clinician-Patient Communication About Abuse

Summary prevalence data relating to clinician-patient communication are provided in Table 2. Among the 375 abused participants, 42% (159) reported communicating with a clinician about IPA. Among the 347 participants with a history of physical or sexual abuse, 45% (155) reported communicating with a clinician about IPA. Communication rates were significantly lower, however, among the 7% (28) of the participants who reported threats or fear of IPA in the absence of physical or sexual abuse (P <.05). Only 14% of the participants in this group reported having ever communicated with a clinician about abuse.

Overall, 28% of the participants reported direct questioning by a medical clinician about abuse; however, 85% of those who were questioned reported that they had disclosed the abuse when directly asked by their physicians. In the absence of direct questioning, only 25% of participants reported disclosing abuse to a physician. Rates of clinician inquiry about IPA did not vary significantly across ethnic groups.

There were no significant differences in frequency of communication between women reporting abuse in the past 12 months and women reporting abuse in the more distant past. Other variables not significantly associated with communication included employment, language, medical insurance status, primary care clinic, and clinician’s sex or ethnicity. In addition, having been asked directly about abuse by a clinician was not associated with age, ethnicity, birthplace, education, insurance status, or primary clinic site. However, on bivariate analysis, having been asked was significantly associated with having a regular physician (33% vs 21%, P=.02) and having been married (36% vs 23%, P=.01).

Barriers to Communication

Barriers that hindered patients’ desire to communicate included beliefs that clinicians do not ask directly about IPA and that clinicians lack time for and interest in discussing abuse. Participants were also asked whether their communication with clinicians was hindered by any of the following factors: concerns about confidentiality, fear of involving the police and courts, embarrassment, fear of shaming family, and fear that their partners would hurt or kill them.

Table 3 lists each of the perceived barriers by frequency of agreement according to participants’ abuse communication status (never communicated vs ever communicated). All of the factors (with the exception of one) were reported with greater frequency among women who had never disclosed abuse to a medical clinician than among those who had.

To determine if there were significant differences in the frequency of reported barriers according to communication status, we conducted cross-tabulations and determined statistical significance using the Pearson chi-square test. Statistical significance was defined as P less than .05. We obtained significant differences for each of the following barriers: beliefs that clinicians do not ask directly (P <.001), concerns about confidentiality (P <.001), beliefs that clinicians lack time for (P=.002) and interest in (P=.001) discussing abuse, and fear of involving the police and courts (P=.042).

Among the 108 abused Latina patients, 34% identified language barriers, and 21% reported concerns about the immigration authorities.

Predictors of Communication

To better understand the variables associated with clinician-patient communication about abuse, we used multivariate logistic regression Table 4. We found that the most significant predictor of communication was the presence of direct clinician questioning about abuse. Women who had been directly asked about abuse were much more likely to discuss it than were those who were not asked directly (OR=4.53; 95% CI, 3.20-6.40). Ethnicity also had an important effect on communication, with African American women more likely to communicate about abuse than white women (OR=1.77; 95% CI, 1.08-2.92). Immigrant status was also an important predictor. Patients born outside the United States were less likely than US-born women to have communicated about abuse (OR=0.57; 95% CI, 0.33-0.99). Also, women with concerns about confidentiality were less likely to discuss abuse with medical clinicians (OR=0.68; 95% CI, 0.48-0.94). Although age, formal education, regular clinician status, and perceptions about clinicians’ time and interest in discussing abuse had some impact on communication outcomes, none of these variables reached statistical significance.

Although each of the attitudinal barriers had an influence on the likelihood of communicating about abuse, only concerns about confidentiality reached statistical significance in the multivariate model.

Discussion

Our study is one of the first to quantitatively examine the patterns of IPA communication between an ethnically diverse group of abused women and their medical clinicians. Overall, the prevalence of IPA communication in our study (42%) was substantially higher than we had anticipated. In spite of this, most of the women (58%) had never disclosed abuse to a medical clinician. This suggests that improved efforts to identify and reduce barriers to IPA communication in the medical setting are still needed.

We found important differences in communication patterns between participants who had experienced threats or fear of IPA only (in the absence of physical or sexual abuse) and participants who had experienced physical or sexual abuse (14% vs 45%, respectively). Given the significant effects on physical health associated with psychological abuse, these findings suggest a need for greater clinician inquiry about psychological forms of IPA in addition to physical and sexual IPA. Our findings also underscore the importance of direct clinician questioning about IPA.^6,7 In our study, less than one third (28%) of all participants reported having ever been directly questioned by a clinician about abuse. Among those who had been directly questioned, 85% had disclosed their abuse to a clinician, compared with only 25% of those who had never been directly questioned by a clinician. These findings support current recommendations for direct clinician inquiry about intimate partner abuse.⁵

We also found that birthplace is an important determinant of clinician-patient communication about abuse. In our study, women born outside the United States were much less likely to have disclosed abuse to a medical clinician than women born in the United States. Overall, 32% of immigrant participants reported previous communication with clinicians about abuse, compared with 46% of US-born participants. Low levels of communication among immigrant women (most of whom were Latina) may be found because foreign-born women and Latinas face numerous barriers to seeking medical help and communication with clinicians. These barriers include low levels of acculturation,¹⁵ discrimination, and language.¹⁶ It is clear that there is a need for special efforts to encourage communication about abuse among immigrant and Latina patients.¹⁷ Increased use of interpreters might be one means of addressing these barriers,¹⁸ in addition to greater sensitivity and attention to sociocultural and sociopolitical differences between patients and clinicians.¹⁹ These findings underscore the importance of cultural and linguistic competency when caring for the Latina population.

We identified a number of important barriers to clinician-patient communication. One is the belief that clinicians lack the time to discuss abuse. Fifty-three percent of the participants in our study felt that clinicians do not have time to discuss abuse (compared with 40% of women who had previously discussed abuse). This is consistent with previous research in which physicians noted time constraints as one of the deterrents to IPA communication with patients.²⁰ One means of eliminating this barrier might involve delegating responsibility for abuse screenings to other medical professionals, such as nurses and physician assistants. Another barrier identified was patients’ fear of involving the police and courts. This finding is also consistent with previous research¹⁹ and reiterates questions about the utility of mandatory IPA reporting requirements.^21,22

We also found that patients’ perceptions that clinicians lack interest in discussing abuse and concerns about confidentiality pose significant barriers to communication. Specifically among women who had never communicated with a medical clinician about abuse, 38% believed that clinicians lack interest in discussing it (compared with 25% of women who had previously communicated), and 37% had concerns about confidentiality (compared with 21% of women who had previously communicated with a clinician). This suggests the need for mechanisms to reduce these barriers during the abuse screening process. Even though clinician education about intimate partner abuse has been found to improve IPA screening practices,^10,23-25 the most effective training modalities and follow-up mechanisms have not been identified.

We note that our findings indicate a lack of clinician’s sex/ethnicity effect, suggesting that these demographic differences may be less important than other factors in facilitating abuse-related communication.

Limitations

Our findings are subject to limitations. The sample consisted primarily of low-income women in an urban setting, and therefore our results may not apply to all ethnically diverse abused women attending primary care clinics. Also, our study did not include any women from Asian ethnic groups. We relied on self-reporting of an extremely sensitive issue that may have led to underidentification of IPA and inaccurate reporting of communication patterns because of recall bias and desirability effects. We were also unable to compare the degree of communication or reported barriers with other measures, such as clinician report or documentation of the medical record. Although our study had a very good response rate, we were unable to sample patients who did not have telephones, and resultant unrecognized selection bias may have occurred.

One final limitation pertains to the high rates of clinician-patient communication obtained in this study. Our findings may be disproportionately high because of greater-than-average levels of awareness about IPA among clinicians at the 3 clinics involved in this study. Many of these clinicians received training related to the detection of IPA before the study began. As a result, our findings may not accurately reflect the frequency of communication among demographically similar populations of abused women patients in other medical settings.

Suggestions for future research

Although our findings support the need for direct clinician inquiry about IPA among all women patients in the medical setting, there is a need for more information about how to most effectively screen patients, particularly among demographically diverse populations. There is also a need for clarification around the meaning of “routine screening” and for information about the extent to which differences in screening practices might affect communication outcomes. These differences include factors such as the type of clinician doing the screening and the frequency of screenings (ie, screenings at every visit vs annually vs only if the patient is in a new relationship).

Relatively little is known about clinician-patient communication patterns among different immigrant groups in the United States. Although our study examined the general influence of birthplace on communication outcomes, most of the immigrant women in our study were from Spanish-speaking countries, and immigration was not a focus of our study. Future research might look specifically at determinants of communication among various immigrant groups in the United States, in particular, Asian women, about whom relatively little is known regarding abuse-related communication.

Finally, we were unable to specifically examine the determinants of decreased IPA communication among immigrant women. It is possible that decreased communication within this population may have resulted from less contact with the medical system or from differential treatment by medical clinicians. Future research might look more closely at this issue.

Acknowledgements

Our research was supported by the Commonwealth Foundation and by a grant under the Resource Centers for Minority Aging Research Program by the National Institute on Aging, the National Institute of Nursing, and the Office of Research on Minority Health, National Institute of Health, grant # 1 P30 AG15272. Dr Rodriguez was a Picker/Commonwealth Scholar when this work was completed. We wish to thank Drs Kevin Grumbach and Elizabeth McLoughlin for assistance with study design, Dr Liza Pressor for data collection, and Gregory Nah for data management. In addition, we thank the many San Francisco advocates against domestic violence for their input into the survey content and design, and we thank the women who participated in our study.

Related resources

• National Domestic Violence Hotline http://www.ndvh.org, 1-800-799-SAFE (7233), 1-800-787-3224 (TDD)
• The Family Violence Prevention Fund http://www.fvpf.org/
• Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Healthcare Providers http://www.cdc.gov/ncipc/pub-res/pdf/newguide.pdf
• American Medical Association Violence Prevention Website http://www.ama-assn.org/ama/pub/category/3242.html

It is estimated that intimate partner abuse (IPA) occurs in 4 to 6 million relationships each year in the United States^1,2 and that many health care interactions involve abused patients in primary care settings.^3,4 Clinicians are therefore well placed to identify IPA and to provide appropriate care and referrals. However, in spite of its high prevalence and the existence of published guidelines and recommendations for routine clinician screening,⁵ the majority of abused women patients are not identified in the medical system and do not receive needed assistance.^6,7 Estimates of the prevalence of clinician-patient communication about IPA range from 10% to slightly less than one third of all abused women.^2,8

Previous studies have shown that the low rates of clinician-patient communication about IPA result in part from a lack of direct questioning by many clinicians and because women rarely volunteer information about abuse without being asked. Less than 15% of women patients in primary care settings report being asked about abuse by health care professionals.^2,4,6,7,9 A recent statewide study of primary care clinicians in California found that only 10% reported routine screening for abuse among new patients, and 9% reported such screening at periodic checkups.¹⁰ Yet the majority of women patients report that they favor direct questioning by clinicians about IPA and would reveal abuse histories if asked directly.^6,7

Despite these studies there is much that remains unknown about abuse-related communication patterns and patient attitudes about communication in the medical setting. We examined the prevalence and determinants of clinician-patient communication about intimate partner abuse by interviewing an ethnically diverse group of abused women primary care patients to determine whether differences in disclosure of abuse were related to any of the following: age, ethnicity, education, language, and immigrant status of the patient, as well as clinician sex and ethnicity and the presence of an established clinician-patient relationship. We also looked into patients’ perceived barriers to communication about IPA, including lack of direct clinician questioning about abuse, perceptions about clinicians’ lack of time or interest in discussing abuse, fears about involving the police and courts, embarrassment, concerns about confidentiality, fear of shaming the family, and fear that the patient’s partner might hurt or kill her.

Methods

Study Population

Our sample consisted of women seen at 3 primary care outpatient clinics at San Francisco General Hospital in California.¹¹ Each year these family medicine, general internal medicine, and obstetrics/gynecology clinics serve nearly 100,000 ethnically and socioeconomically diverse women aged 18 to 45 years. During the 3-year period preceding our study, many staff members at the 3 clinics received training to encourage identification and management of IPA in the medical setting. The training incorporated lectures and continuing medical education.

We selected the sample from a computerized patient utilization database for the 3 clinics during 1997. Selection criteria included: (1) female sex; (2) race/ethnicity African American, non-Latina white, or Latina; (3) age 18 to 45 years; and (4) receipt of care in 1 of the 3 primary care clinics in the previous 6 months. Women were selected for participation in this study because they are much more likely to have been abused by an intimate partner than are men. Only women who reported histories of abuse were included in this analysis.

Patients were considered eligible if they met all the selection criteria, spoke English or Spanish, had verifiable phone numbers, and were mentally and physically capable of completing the survey.

Survey Instrument

We developed the survey instrument through a review of the literature, including the results from some of the authors’ previous qualitative research, consultation with domestic violence researchers and advocates, and discussions with a focus group of 6 abused women. Final survey modifications were made following expert review and pilot testing with 75 women, 25 from each target ethnic group. The instrument included questions about patients’ social, health, and demographic characteristics; clinic and medical clinician utilization; and IPA experiences. Women who indicated histories of IPA were questioned about their experiences in obtaining abuse-related help in the medical system, the barriers to IPA communication with medical clinicians, and clinician demographics. The questionnaire was prepared in English and translated to Spanish using standard translation methods.¹²

Questions about abuse were adapted from the 4-question Abuse Assessment Screen, which has been validated in multiethnic populations.¹³ These questions asked whether the participants had ever experienced physical, sexual, or psychological abuse. For each positive response, women indicated whether the abuse had occurred in the past 12 months (recent abuse) or in the more distant past.

Prevalence of communication with clinicians about abuse was assessed by asking participants if they had ever mentioned or discussed abuse with a physician: (1) in response to direct clinician questioning or (2) in the absence of direct clinician questioning.

Data Collection

The survey was administered to the sample by computer-assisted telephone interview between October 1997 and March 1998. An introductory letter was mailed to the homes of all potential participants (to ensure safety the topic of abuse was not mentioned in this letter). Following this, trained women interviewers contacted potential participants by telephone. After confirming eligibility, privacy, and safety and obtaining verbal consent, interviews lasting approximately 25 minutes were conducted in English or Spanish. The study protocol was approved by the Committee for Human Research at the University of California, San Francisco.

Data Analyses

We analyzed the data using SPSS statistical software.14 IPA was defined as having ever been exposed as an adult to physical abuse, sexual abuse, or threats/fear of abuse. The principal outcome variable was previous communication with a medical clinician about IPA experiences. Predictor variables included age, ethnicity, birthplace, language, employment and medical insurance status, and education, as well as clinician sex and ethnicity, direct clinician questioning about abuse, and presence of an established relationship with a clinician (regular clinician). Additional predictor variables included patients’ perceived barriers to communication.

We used multiple logistic regression analysis to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the factors associated with clinician-patient communication about abuse. Our final model includes variables of primary interest to our study (patient age, ethnicity, education, and presence of a regular clinician), as well as those variables that significantly influenced abuse-related communication (birthplace, direct questioning by a clinician, perceptions that clinicians lack time and interest in discussing abuse, and concerns about confidentiality). For cross tabulations, statistical significance was determined using the Pearson chi-square test. Statistical significance was defined as P less than .05.

Results

Sample Description

Of the 1390 patients selected from the database, 992 (71%) met the eligibility criteria. Of the 398 ineligible women, 315 (23%) did not have verifiable phone numbers, and 83 (6%) either did not speak English or Spanish, were incapable of completing the survey, or did not meet the original selection criteria. The overall collaboration rate was 74% (734/992) of the available eligible participants. Of the women interviewed, 51% (375) reported having ever been abused by an intimate partner as an adult. Further descriptive analyses are reported elsewhere.¹¹ Among the 375 participants who reported a history of abuse: 88% (328) reported having experienced physical abuse; 33% (122) reported having experienced sexual abuse; and 66% (246) reported having experienced threats or fear of IPA. There was substantial overlap between abuse categories for most participants, and almost all women reporting a history of sexual abuse also reported a history of physical abuse. However, 7% (28) of the participants reported previous threats or fear of IPA in the absence of physical or sexual abuse.

Sample characteristics of all study participants with histories of abuse are summarized in Table 1. The mean age was 34.3 years (standard deviation [SD]=7.3 years). The study participants were primarily of lower socioeconomic status. Years of education ranged from none to postgraduate, with a mean of 11.9 years (SD=3.5 years).

Prevalence of Clinician-Patient Communication About Abuse

Summary prevalence data relating to clinician-patient communication are provided in Table 2. Among the 375 abused participants, 42% (159) reported communicating with a clinician about IPA. Among the 347 participants with a history of physical or sexual abuse, 45% (155) reported communicating with a clinician about IPA. Communication rates were significantly lower, however, among the 7% (28) of the participants who reported threats or fear of IPA in the absence of physical or sexual abuse (P <.05). Only 14% of the participants in this group reported having ever communicated with a clinician about abuse.

Overall, 28% of the participants reported direct questioning by a medical clinician about abuse; however, 85% of those who were questioned reported that they had disclosed the abuse when directly asked by their physicians. In the absence of direct questioning, only 25% of participants reported disclosing abuse to a physician. Rates of clinician inquiry about IPA did not vary significantly across ethnic groups.

There were no significant differences in frequency of communication between women reporting abuse in the past 12 months and women reporting abuse in the more distant past. Other variables not significantly associated with communication included employment, language, medical insurance status, primary care clinic, and clinician’s sex or ethnicity. In addition, having been asked directly about abuse by a clinician was not associated with age, ethnicity, birthplace, education, insurance status, or primary clinic site. However, on bivariate analysis, having been asked was significantly associated with having a regular physician (33% vs 21%, P=.02) and having been married (36% vs 23%, P=.01).

Barriers to Communication

Barriers that hindered patients’ desire to communicate included beliefs that clinicians do not ask directly about IPA and that clinicians lack time for and interest in discussing abuse. Participants were also asked whether their communication with clinicians was hindered by any of the following factors: concerns about confidentiality, fear of involving the police and courts, embarrassment, fear of shaming family, and fear that their partners would hurt or kill them.

Table 3 lists each of the perceived barriers by frequency of agreement according to participants’ abuse communication status (never communicated vs ever communicated). All of the factors (with the exception of one) were reported with greater frequency among women who had never disclosed abuse to a medical clinician than among those who had.

To determine if there were significant differences in the frequency of reported barriers according to communication status, we conducted cross-tabulations and determined statistical significance using the Pearson chi-square test. Statistical significance was defined as P less than .05. We obtained significant differences for each of the following barriers: beliefs that clinicians do not ask directly (P <.001), concerns about confidentiality (P <.001), beliefs that clinicians lack time for (P=.002) and interest in (P=.001) discussing abuse, and fear of involving the police and courts (P=.042).

Among the 108 abused Latina patients, 34% identified language barriers, and 21% reported concerns about the immigration authorities.

Predictors of Communication

To better understand the variables associated with clinician-patient communication about abuse, we used multivariate logistic regression Table 4. We found that the most significant predictor of communication was the presence of direct clinician questioning about abuse. Women who had been directly asked about abuse were much more likely to discuss it than were those who were not asked directly (OR=4.53; 95% CI, 3.20-6.40). Ethnicity also had an important effect on communication, with African American women more likely to communicate about abuse than white women (OR=1.77; 95% CI, 1.08-2.92). Immigrant status was also an important predictor. Patients born outside the United States were less likely than US-born women to have communicated about abuse (OR=0.57; 95% CI, 0.33-0.99). Also, women with concerns about confidentiality were less likely to discuss abuse with medical clinicians (OR=0.68; 95% CI, 0.48-0.94). Although age, formal education, regular clinician status, and perceptions about clinicians’ time and interest in discussing abuse had some impact on communication outcomes, none of these variables reached statistical significance.

Although each of the attitudinal barriers had an influence on the likelihood of communicating about abuse, only concerns about confidentiality reached statistical significance in the multivariate model.

Discussion

Our study is one of the first to quantitatively examine the patterns of IPA communication between an ethnically diverse group of abused women and their medical clinicians. Overall, the prevalence of IPA communication in our study (42%) was substantially higher than we had anticipated. In spite of this, most of the women (58%) had never disclosed abuse to a medical clinician. This suggests that improved efforts to identify and reduce barriers to IPA communication in the medical setting are still needed.

We found important differences in communication patterns between participants who had experienced threats or fear of IPA only (in the absence of physical or sexual abuse) and participants who had experienced physical or sexual abuse (14% vs 45%, respectively). Given the significant effects on physical health associated with psychological abuse, these findings suggest a need for greater clinician inquiry about psychological forms of IPA in addition to physical and sexual IPA. Our findings also underscore the importance of direct clinician questioning about IPA.^6,7 In our study, less than one third (28%) of all participants reported having ever been directly questioned by a clinician about abuse. Among those who had been directly questioned, 85% had disclosed their abuse to a clinician, compared with only 25% of those who had never been directly questioned by a clinician. These findings support current recommendations for direct clinician inquiry about intimate partner abuse.⁵

We also found that birthplace is an important determinant of clinician-patient communication about abuse. In our study, women born outside the United States were much less likely to have disclosed abuse to a medical clinician than women born in the United States. Overall, 32% of immigrant participants reported previous communication with clinicians about abuse, compared with 46% of US-born participants. Low levels of communication among immigrant women (most of whom were Latina) may be found because foreign-born women and Latinas face numerous barriers to seeking medical help and communication with clinicians. These barriers include low levels of acculturation,¹⁵ discrimination, and language.¹⁶ It is clear that there is a need for special efforts to encourage communication about abuse among immigrant and Latina patients.¹⁷ Increased use of interpreters might be one means of addressing these barriers,¹⁸ in addition to greater sensitivity and attention to sociocultural and sociopolitical differences between patients and clinicians.¹⁹ These findings underscore the importance of cultural and linguistic competency when caring for the Latina population.

We identified a number of important barriers to clinician-patient communication. One is the belief that clinicians lack the time to discuss abuse. Fifty-three percent of the participants in our study felt that clinicians do not have time to discuss abuse (compared with 40% of women who had previously discussed abuse). This is consistent with previous research in which physicians noted time constraints as one of the deterrents to IPA communication with patients.²⁰ One means of eliminating this barrier might involve delegating responsibility for abuse screenings to other medical professionals, such as nurses and physician assistants. Another barrier identified was patients’ fear of involving the police and courts. This finding is also consistent with previous research¹⁹ and reiterates questions about the utility of mandatory IPA reporting requirements.^21,22

We also found that patients’ perceptions that clinicians lack interest in discussing abuse and concerns about confidentiality pose significant barriers to communication. Specifically among women who had never communicated with a medical clinician about abuse, 38% believed that clinicians lack interest in discussing it (compared with 25% of women who had previously communicated), and 37% had concerns about confidentiality (compared with 21% of women who had previously communicated with a clinician). This suggests the need for mechanisms to reduce these barriers during the abuse screening process. Even though clinician education about intimate partner abuse has been found to improve IPA screening practices,^10,23-25 the most effective training modalities and follow-up mechanisms have not been identified.

We note that our findings indicate a lack of clinician’s sex/ethnicity effect, suggesting that these demographic differences may be less important than other factors in facilitating abuse-related communication.

Limitations

Our findings are subject to limitations. The sample consisted primarily of low-income women in an urban setting, and therefore our results may not apply to all ethnically diverse abused women attending primary care clinics. Also, our study did not include any women from Asian ethnic groups. We relied on self-reporting of an extremely sensitive issue that may have led to underidentification of IPA and inaccurate reporting of communication patterns because of recall bias and desirability effects. We were also unable to compare the degree of communication or reported barriers with other measures, such as clinician report or documentation of the medical record. Although our study had a very good response rate, we were unable to sample patients who did not have telephones, and resultant unrecognized selection bias may have occurred.

One final limitation pertains to the high rates of clinician-patient communication obtained in this study. Our findings may be disproportionately high because of greater-than-average levels of awareness about IPA among clinicians at the 3 clinics involved in this study. Many of these clinicians received training related to the detection of IPA before the study began. As a result, our findings may not accurately reflect the frequency of communication among demographically similar populations of abused women patients in other medical settings.

Suggestions for future research

Although our findings support the need for direct clinician inquiry about IPA among all women patients in the medical setting, there is a need for more information about how to most effectively screen patients, particularly among demographically diverse populations. There is also a need for clarification around the meaning of “routine screening” and for information about the extent to which differences in screening practices might affect communication outcomes. These differences include factors such as the type of clinician doing the screening and the frequency of screenings (ie, screenings at every visit vs annually vs only if the patient is in a new relationship).

Relatively little is known about clinician-patient communication patterns among different immigrant groups in the United States. Although our study examined the general influence of birthplace on communication outcomes, most of the immigrant women in our study were from Spanish-speaking countries, and immigration was not a focus of our study. Future research might look specifically at determinants of communication among various immigrant groups in the United States, in particular, Asian women, about whom relatively little is known regarding abuse-related communication.

Finally, we were unable to specifically examine the determinants of decreased IPA communication among immigrant women. It is possible that decreased communication within this population may have resulted from less contact with the medical system or from differential treatment by medical clinicians. Future research might look more closely at this issue.

Acknowledgements

Our research was supported by the Commonwealth Foundation and by a grant under the Resource Centers for Minority Aging Research Program by the National Institute on Aging, the National Institute of Nursing, and the Office of Research on Minority Health, National Institute of Health, grant # 1 P30 AG15272. Dr Rodriguez was a Picker/Commonwealth Scholar when this work was completed. We wish to thank Drs Kevin Grumbach and Elizabeth McLoughlin for assistance with study design, Dr Liza Pressor for data collection, and Gregory Nah for data management. In addition, we thank the many San Francisco advocates against domestic violence for their input into the survey content and design, and we thank the women who participated in our study.

Related resources

• National Domestic Violence Hotline http://www.ndvh.org, 1-800-799-SAFE (7233), 1-800-787-3224 (TDD)
• The Family Violence Prevention Fund http://www.fvpf.org/
• Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Healthcare Providers http://www.cdc.gov/ncipc/pub-res/pdf/newguide.pdf
• American Medical Association Violence Prevention Website http://www.ama-assn.org/ama/pub/category/3242.html

It is estimated that intimate partner abuse (IPA) occurs in 4 to 6 million relationships each year in the United States^1,2 and that many health care interactions involve abused patients in primary care settings.^3,4 Clinicians are therefore well placed to identify IPA and to provide appropriate care and referrals. However, in spite of its high prevalence and the existence of published guidelines and recommendations for routine clinician screening,⁵ the majority of abused women patients are not identified in the medical system and do not receive needed assistance.^6,7 Estimates of the prevalence of clinician-patient communication about IPA range from 10% to slightly less than one third of all abused women.^2,8

Previous studies have shown that the low rates of clinician-patient communication about IPA result in part from a lack of direct questioning by many clinicians and because women rarely volunteer information about abuse without being asked. Less than 15% of women patients in primary care settings report being asked about abuse by health care professionals.^2,4,6,7,9 A recent statewide study of primary care clinicians in California found that only 10% reported routine screening for abuse among new patients, and 9% reported such screening at periodic checkups.¹⁰ Yet the majority of women patients report that they favor direct questioning by clinicians about IPA and would reveal abuse histories if asked directly.^6,7

Despite these studies there is much that remains unknown about abuse-related communication patterns and patient attitudes about communication in the medical setting. We examined the prevalence and determinants of clinician-patient communication about intimate partner abuse by interviewing an ethnically diverse group of abused women primary care patients to determine whether differences in disclosure of abuse were related to any of the following: age, ethnicity, education, language, and immigrant status of the patient, as well as clinician sex and ethnicity and the presence of an established clinician-patient relationship. We also looked into patients’ perceived barriers to communication about IPA, including lack of direct clinician questioning about abuse, perceptions about clinicians’ lack of time or interest in discussing abuse, fears about involving the police and courts, embarrassment, concerns about confidentiality, fear of shaming the family, and fear that the patient’s partner might hurt or kill her.

Methods

Study Population

Our sample consisted of women seen at 3 primary care outpatient clinics at San Francisco General Hospital in California.¹¹ Each year these family medicine, general internal medicine, and obstetrics/gynecology clinics serve nearly 100,000 ethnically and socioeconomically diverse women aged 18 to 45 years. During the 3-year period preceding our study, many staff members at the 3 clinics received training to encourage identification and management of IPA in the medical setting. The training incorporated lectures and continuing medical education.

We selected the sample from a computerized patient utilization database for the 3 clinics during 1997. Selection criteria included: (1) female sex; (2) race/ethnicity African American, non-Latina white, or Latina; (3) age 18 to 45 years; and (4) receipt of care in 1 of the 3 primary care clinics in the previous 6 months. Women were selected for participation in this study because they are much more likely to have been abused by an intimate partner than are men. Only women who reported histories of abuse were included in this analysis.

Patients were considered eligible if they met all the selection criteria, spoke English or Spanish, had verifiable phone numbers, and were mentally and physically capable of completing the survey.

Survey Instrument

We developed the survey instrument through a review of the literature, including the results from some of the authors’ previous qualitative research, consultation with domestic violence researchers and advocates, and discussions with a focus group of 6 abused women. Final survey modifications were made following expert review and pilot testing with 75 women, 25 from each target ethnic group. The instrument included questions about patients’ social, health, and demographic characteristics; clinic and medical clinician utilization; and IPA experiences. Women who indicated histories of IPA were questioned about their experiences in obtaining abuse-related help in the medical system, the barriers to IPA communication with medical clinicians, and clinician demographics. The questionnaire was prepared in English and translated to Spanish using standard translation methods.¹²

Questions about abuse were adapted from the 4-question Abuse Assessment Screen, which has been validated in multiethnic populations.¹³ These questions asked whether the participants had ever experienced physical, sexual, or psychological abuse. For each positive response, women indicated whether the abuse had occurred in the past 12 months (recent abuse) or in the more distant past.

Prevalence of communication with clinicians about abuse was assessed by asking participants if they had ever mentioned or discussed abuse with a physician: (1) in response to direct clinician questioning or (2) in the absence of direct clinician questioning.

Data Collection

The survey was administered to the sample by computer-assisted telephone interview between October 1997 and March 1998. An introductory letter was mailed to the homes of all potential participants (to ensure safety the topic of abuse was not mentioned in this letter). Following this, trained women interviewers contacted potential participants by telephone. After confirming eligibility, privacy, and safety and obtaining verbal consent, interviews lasting approximately 25 minutes were conducted in English or Spanish. The study protocol was approved by the Committee for Human Research at the University of California, San Francisco.

Data Analyses

We analyzed the data using SPSS statistical software.14 IPA was defined as having ever been exposed as an adult to physical abuse, sexual abuse, or threats/fear of abuse. The principal outcome variable was previous communication with a medical clinician about IPA experiences. Predictor variables included age, ethnicity, birthplace, language, employment and medical insurance status, and education, as well as clinician sex and ethnicity, direct clinician questioning about abuse, and presence of an established relationship with a clinician (regular clinician). Additional predictor variables included patients’ perceived barriers to communication.

We used multiple logistic regression analysis to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the factors associated with clinician-patient communication about abuse. Our final model includes variables of primary interest to our study (patient age, ethnicity, education, and presence of a regular clinician), as well as those variables that significantly influenced abuse-related communication (birthplace, direct questioning by a clinician, perceptions that clinicians lack time and interest in discussing abuse, and concerns about confidentiality). For cross tabulations, statistical significance was determined using the Pearson chi-square test. Statistical significance was defined as P less than .05.

Results

Sample Description

Of the 1390 patients selected from the database, 992 (71%) met the eligibility criteria. Of the 398 ineligible women, 315 (23%) did not have verifiable phone numbers, and 83 (6%) either did not speak English or Spanish, were incapable of completing the survey, or did not meet the original selection criteria. The overall collaboration rate was 74% (734/992) of the available eligible participants. Of the women interviewed, 51% (375) reported having ever been abused by an intimate partner as an adult. Further descriptive analyses are reported elsewhere.¹¹ Among the 375 participants who reported a history of abuse: 88% (328) reported having experienced physical abuse; 33% (122) reported having experienced sexual abuse; and 66% (246) reported having experienced threats or fear of IPA. There was substantial overlap between abuse categories for most participants, and almost all women reporting a history of sexual abuse also reported a history of physical abuse. However, 7% (28) of the participants reported previous threats or fear of IPA in the absence of physical or sexual abuse.

Sample characteristics of all study participants with histories of abuse are summarized in Table 1. The mean age was 34.3 years (standard deviation [SD]=7.3 years). The study participants were primarily of lower socioeconomic status. Years of education ranged from none to postgraduate, with a mean of 11.9 years (SD=3.5 years).

Prevalence of Clinician-Patient Communication About Abuse

Summary prevalence data relating to clinician-patient communication are provided in Table 2. Among the 375 abused participants, 42% (159) reported communicating with a clinician about IPA. Among the 347 participants with a history of physical or sexual abuse, 45% (155) reported communicating with a clinician about IPA. Communication rates were significantly lower, however, among the 7% (28) of the participants who reported threats or fear of IPA in the absence of physical or sexual abuse (P <.05). Only 14% of the participants in this group reported having ever communicated with a clinician about abuse.

Overall, 28% of the participants reported direct questioning by a medical clinician about abuse; however, 85% of those who were questioned reported that they had disclosed the abuse when directly asked by their physicians. In the absence of direct questioning, only 25% of participants reported disclosing abuse to a physician. Rates of clinician inquiry about IPA did not vary significantly across ethnic groups.

There were no significant differences in frequency of communication between women reporting abuse in the past 12 months and women reporting abuse in the more distant past. Other variables not significantly associated with communication included employment, language, medical insurance status, primary care clinic, and clinician’s sex or ethnicity. In addition, having been asked directly about abuse by a clinician was not associated with age, ethnicity, birthplace, education, insurance status, or primary clinic site. However, on bivariate analysis, having been asked was significantly associated with having a regular physician (33% vs 21%, P=.02) and having been married (36% vs 23%, P=.01).

Barriers to Communication

Barriers that hindered patients’ desire to communicate included beliefs that clinicians do not ask directly about IPA and that clinicians lack time for and interest in discussing abuse. Participants were also asked whether their communication with clinicians was hindered by any of the following factors: concerns about confidentiality, fear of involving the police and courts, embarrassment, fear of shaming family, and fear that their partners would hurt or kill them.

Table 3 lists each of the perceived barriers by frequency of agreement according to participants’ abuse communication status (never communicated vs ever communicated). All of the factors (with the exception of one) were reported with greater frequency among women who had never disclosed abuse to a medical clinician than among those who had.

To determine if there were significant differences in the frequency of reported barriers according to communication status, we conducted cross-tabulations and determined statistical significance using the Pearson chi-square test. Statistical significance was defined as P less than .05. We obtained significant differences for each of the following barriers: beliefs that clinicians do not ask directly (P <.001), concerns about confidentiality (P <.001), beliefs that clinicians lack time for (P=.002) and interest in (P=.001) discussing abuse, and fear of involving the police and courts (P=.042).

Among the 108 abused Latina patients, 34% identified language barriers, and 21% reported concerns about the immigration authorities.

Predictors of Communication

To better understand the variables associated with clinician-patient communication about abuse, we used multivariate logistic regression Table 4. We found that the most significant predictor of communication was the presence of direct clinician questioning about abuse. Women who had been directly asked about abuse were much more likely to discuss it than were those who were not asked directly (OR=4.53; 95% CI, 3.20-6.40). Ethnicity also had an important effect on communication, with African American women more likely to communicate about abuse than white women (OR=1.77; 95% CI, 1.08-2.92). Immigrant status was also an important predictor. Patients born outside the United States were less likely than US-born women to have communicated about abuse (OR=0.57; 95% CI, 0.33-0.99). Also, women with concerns about confidentiality were less likely to discuss abuse with medical clinicians (OR=0.68; 95% CI, 0.48-0.94). Although age, formal education, regular clinician status, and perceptions about clinicians’ time and interest in discussing abuse had some impact on communication outcomes, none of these variables reached statistical significance.

Although each of the attitudinal barriers had an influence on the likelihood of communicating about abuse, only concerns about confidentiality reached statistical significance in the multivariate model.

Discussion

Our study is one of the first to quantitatively examine the patterns of IPA communication between an ethnically diverse group of abused women and their medical clinicians. Overall, the prevalence of IPA communication in our study (42%) was substantially higher than we had anticipated. In spite of this, most of the women (58%) had never disclosed abuse to a medical clinician. This suggests that improved efforts to identify and reduce barriers to IPA communication in the medical setting are still needed.

We found important differences in communication patterns between participants who had experienced threats or fear of IPA only (in the absence of physical or sexual abuse) and participants who had experienced physical or sexual abuse (14% vs 45%, respectively). Given the significant effects on physical health associated with psychological abuse, these findings suggest a need for greater clinician inquiry about psychological forms of IPA in addition to physical and sexual IPA. Our findings also underscore the importance of direct clinician questioning about IPA.^6,7 In our study, less than one third (28%) of all participants reported having ever been directly questioned by a clinician about abuse. Among those who had been directly questioned, 85% had disclosed their abuse to a clinician, compared with only 25% of those who had never been directly questioned by a clinician. These findings support current recommendations for direct clinician inquiry about intimate partner abuse.⁵

We also found that birthplace is an important determinant of clinician-patient communication about abuse. In our study, women born outside the United States were much less likely to have disclosed abuse to a medical clinician than women born in the United States. Overall, 32% of immigrant participants reported previous communication with clinicians about abuse, compared with 46% of US-born participants. Low levels of communication among immigrant women (most of whom were Latina) may be found because foreign-born women and Latinas face numerous barriers to seeking medical help and communication with clinicians. These barriers include low levels of acculturation,¹⁵ discrimination, and language.¹⁶ It is clear that there is a need for special efforts to encourage communication about abuse among immigrant and Latina patients.¹⁷ Increased use of interpreters might be one means of addressing these barriers,¹⁸ in addition to greater sensitivity and attention to sociocultural and sociopolitical differences between patients and clinicians.¹⁹ These findings underscore the importance of cultural and linguistic competency when caring for the Latina population.

We identified a number of important barriers to clinician-patient communication. One is the belief that clinicians lack the time to discuss abuse. Fifty-three percent of the participants in our study felt that clinicians do not have time to discuss abuse (compared with 40% of women who had previously discussed abuse). This is consistent with previous research in which physicians noted time constraints as one of the deterrents to IPA communication with patients.²⁰ One means of eliminating this barrier might involve delegating responsibility for abuse screenings to other medical professionals, such as nurses and physician assistants. Another barrier identified was patients’ fear of involving the police and courts. This finding is also consistent with previous research¹⁹ and reiterates questions about the utility of mandatory IPA reporting requirements.^21,22

We also found that patients’ perceptions that clinicians lack interest in discussing abuse and concerns about confidentiality pose significant barriers to communication. Specifically among women who had never communicated with a medical clinician about abuse, 38% believed that clinicians lack interest in discussing it (compared with 25% of women who had previously communicated), and 37% had concerns about confidentiality (compared with 21% of women who had previously communicated with a clinician). This suggests the need for mechanisms to reduce these barriers during the abuse screening process. Even though clinician education about intimate partner abuse has been found to improve IPA screening practices,^10,23-25 the most effective training modalities and follow-up mechanisms have not been identified.

We note that our findings indicate a lack of clinician’s sex/ethnicity effect, suggesting that these demographic differences may be less important than other factors in facilitating abuse-related communication.

Limitations

Our findings are subject to limitations. The sample consisted primarily of low-income women in an urban setting, and therefore our results may not apply to all ethnically diverse abused women attending primary care clinics. Also, our study did not include any women from Asian ethnic groups. We relied on self-reporting of an extremely sensitive issue that may have led to underidentification of IPA and inaccurate reporting of communication patterns because of recall bias and desirability effects. We were also unable to compare the degree of communication or reported barriers with other measures, such as clinician report or documentation of the medical record. Although our study had a very good response rate, we were unable to sample patients who did not have telephones, and resultant unrecognized selection bias may have occurred.

One final limitation pertains to the high rates of clinician-patient communication obtained in this study. Our findings may be disproportionately high because of greater-than-average levels of awareness about IPA among clinicians at the 3 clinics involved in this study. Many of these clinicians received training related to the detection of IPA before the study began. As a result, our findings may not accurately reflect the frequency of communication among demographically similar populations of abused women patients in other medical settings.

Suggestions for future research

Although our findings support the need for direct clinician inquiry about IPA among all women patients in the medical setting, there is a need for more information about how to most effectively screen patients, particularly among demographically diverse populations. There is also a need for clarification around the meaning of “routine screening” and for information about the extent to which differences in screening practices might affect communication outcomes. These differences include factors such as the type of clinician doing the screening and the frequency of screenings (ie, screenings at every visit vs annually vs only if the patient is in a new relationship).

Relatively little is known about clinician-patient communication patterns among different immigrant groups in the United States. Although our study examined the general influence of birthplace on communication outcomes, most of the immigrant women in our study were from Spanish-speaking countries, and immigration was not a focus of our study. Future research might look specifically at determinants of communication among various immigrant groups in the United States, in particular, Asian women, about whom relatively little is known regarding abuse-related communication.

Finally, we were unable to specifically examine the determinants of decreased IPA communication among immigrant women. It is possible that decreased communication within this population may have resulted from less contact with the medical system or from differential treatment by medical clinicians. Future research might look more closely at this issue.

Acknowledgements

Our research was supported by the Commonwealth Foundation and by a grant under the Resource Centers for Minority Aging Research Program by the National Institute on Aging, the National Institute of Nursing, and the Office of Research on Minority Health, National Institute of Health, grant # 1 P30 AG15272. Dr Rodriguez was a Picker/Commonwealth Scholar when this work was completed. We wish to thank Drs Kevin Grumbach and Elizabeth McLoughlin for assistance with study design, Dr Liza Pressor for data collection, and Gregory Nah for data management. In addition, we thank the many San Francisco advocates against domestic violence for their input into the survey content and design, and we thank the women who participated in our study.

Related resources

• National Domestic Violence Hotline http://www.ndvh.org, 1-800-799-SAFE (7233), 1-800-787-3224 (TDD)
• The Family Violence Prevention Fund http://www.fvpf.org/
• Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Healthcare Providers http://www.cdc.gov/ncipc/pub-res/pdf/newguide.pdf
• American Medical Association Violence Prevention Website http://www.ama-assn.org/ama/pub/category/3242.html