"Are You Safe in Your Home?" -- Medical Screening for Domestic Violence Should Be Routine

Gwen Mayes, JD, MMSc

Disclosures

August 18, 2003

Introduction

We don't elect a President in this country without turning around and immediately speculating about the next. A hot issue for the 2004 Presidential election is women's health, most notably access to reproductive health services and abortion. Pro-choice advocates fear the overthrow of Roe vs Wade, as pro-lifers push the most politically conservative agenda in recent history.

But where do the women stand on these issues? Are they as concerned as the pundits in Washington wish us to believe?

Maybe not. According to a recent survey by the Center for the Advancement of Women, led by former Planned Parenthood president, Faye Wattleton, reducing domestic violence and sexual assault, not securing access to abortion, is the chief concern of American women. Of the 3300 women surveyed by Princeton Survey Research Associates over a recent 2-year period, 92% cited reducing violence against women as their top priority, whereas only 41% of those surveyed identified keeping abortion legal as a top priority.[1]

The survey findings should not surprise you. Approximately 20% to 30% of the women in this country will experience domestic violence at some point in their lives.[2] The federal Agency for Healthcare Research and Quality (AHRQ) estimates that 2% to 4% of all women seen in hospital emergency departments have acute trauma associated with domestic violence and another 10% to 12% of women have a recent history of domestic violence. Although most are classified as superficial, an estimated 73,000 hospitalizations and 1500 deaths among women are attributed to domestic violence each year.[3]

Yet, despite the prevalence of domestic violence, most women are not asked about their safety during an annual exam or visit to the hospital. An article appearing in the August 1999 issue of JAMA reported that fewer than 10% of primary care physicians routinely screen for domestic violence during regular office visits.[4] Similar findings have been reported for other healthcare settings.[5]

But ultimately, research shows that the individual practitioner's commitment to routine screening for domestic violence, either motivated by extensive training and education or through repeated exposure to the problem, is the greatest indicator that women will actually be screened and referred for services. According to The Family Violence Prevention Fund, routine and multiple screenings by skilled healthcare providers, when conducted face-to-face, markedly increase the identification of domestic violence.[6] The individual practitioner's commitment seems to be key.

On a facilities level, hospitals can do their part to instill practices that encourage routine screening. Last fall, the AHRQ released an evaluation tool that hospitals can use to assess the quality and effectiveness of their domestic violence programs. According to Dr. Jeffrey H. Coben, Director of the Center for Violence and Injury Control at Allegheny General Hospital in Pittsburgh, Pennsylvania, and AHRQ's former Domestic Violence Senior Scholar-in-Residence, the tool has been "well received by the research community and hospital domestic violence programs." (Personal communication, Jeffrey H. Coben, MD, Professor of Emergency Medicine, Drexel University College of Medicine; Director, Center for Violence and Injury Control, Allegheny-Singer Research Institute, Allegheny General Hospital, Aug. 7, 2003.) The underlying premise in the development of the tool is that hospitals with good structures in place are more likely to have the processes in place that lead to effective, routine, screening practices. Not just when it's visually apparent or suspected, but on each and every visit. The tool provides hospitals with performance measures and recommendations in 9 critical areas: policies and procedures, physical environment, hospital culture, training, safety assessment, documentation, intervention, evaluation activities, and collaboration. "Researchers are using the tool to measure program performance, and hospitals are using it to provide benchmarks for achievement," says Coben. The tool can be downloaded at the Agency's Web site at https://www.ahrq.gov/research/domesticviol/.[7]

New federal legislation may also encourage participation for healthcare providers. Earlier this year, Rep. Lois Capps [D-CA-23], a former school nurse in Santa Barbara County for 20 years, introduced the Domestic Violence Screening, Treatment, and Prevention Act of 2003 (H.R. 1267), which, if enacted, would provide research on the health impact and prevention of family violence; training for health professionals, behavioral and public health staff; community health centers for the identification and treatment of victims of violence; and coverage for domestic violence treatment through various federal programs and to federal workers through their health plans. "With this legislation, we can bring the medical profession into the overall plan for addressing domestic violence," says Brigid O'Brien, press secretary for Rep. Capps. (Personal communication, Brigid O'Brien, press secretary for Rep. Lois Capps [D-CA], Aug. 4, 2003.) "Generally, domestic violence has been a law enforcement issue, but there's a strong need for intervention by the medical community. Not just by physicians, but nurses, technicians and other providers."

What's the strategy for getting the bill passed? "We will be working with providers to make sure the reimbursement and training needs of physicians are met with this legislation," says Capps. But more importantly, Capps needs to find cosponsors and a Senate sponsor for the bill to stay alive. "The key to moving this bill is educating our colleagues about the need for medical intervention in domestic violence," concludes O'Brien. "They think screening is standard protocol, but it's not."

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