Introduction

Top Abstract Introduction Participants and methods Results Discussion References

Physical injury, mental health problems, and complications of pregnancy are some of the health consequences that result from violence inflicted on women by their male partners or former partners. Because domestic violence is common, serious, and often not identified, a recent British government publication recommended that health professionals should consider routinely asking all women, or selected groups of women, about a history of domestic violence.¹ Ten years ago, the American Medical Association recommended screening all women presenting to primary care and many secondary care specialties²; recently, this policy has been questioned.³ Research findings do not clarify whether screening women for domestic violence meets accepted criteria for a valid screening procedure.⁴

Little research in the primary care setting has investigated domestic violence against women in the United Kingdom. Two small studies reported lifetime prevalences of domestic violence against women of 39% and 60%. ^{5 6} A community survey found that 23% of women had ever been physically assaulted by a partner or former partner, with 4% experiencing violence within the previous 12 months.⁷ Recent primary care studies from outside the United Kingdom have reported rates of lifetime experience of domestic violence ranging from 12% to 46%^8-10 and prevalences over the previous 12 months of 6% and 28%. ^{11 12} The differences in prevalence are explained, in part, by the different definitions of domestic violence used in the studies.

We do not know if screening for domestic violence in primary care is acceptable to women. Some evidence, mostly from community surveys, indicates that women want to be asked about domestic violence.¹³

Our study had four objectives: to measure the prevalence of domestic violence among women attending general practice; to try to establish whether there is a high risk group of women for whom screening might be more appropriate; to measure the proportion of women experiencing domestic violence that is not detected; and to explore women's attitudes to being questioned about domestic violence by general practitioners or practice nurses.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

Between January and December 1999, we surveyed women (16 years or over) in 13 randomly selected general practices in the east London borough of Hackney. We designed a self administered questionnaire that looked at different aspects of domestic violence and incorporated questions used in a primary care study.¹⁴ For each question, the woman was asked to consider whether she had to be careful about what she said or did as a result of the man's behaviour. We also asked about the woman's attitude to being questioned by her general practitioner or practice nurse about abuse by her partner.

The sample consisted of consecutive women attending the practices during time periods randomly selected for data collection. Women were eligible to participate if they were registered with the practice, were over 15 years old, and were able to read English, Turkish, or Bengali (the three languages in which the questionnaire was available). Those who were holding an infant or who were too unwell to complete the questionnaire were ineligible. Research assistants recruited women in the surgeries' waiting areas, and the women completed the questionnaire in the waiting areas.

We collected data on any disclosure or suspicion of domestic violence that was documented in the medical records.

Statistical methods
We report univariate analyses performed with the ² test for frequencies. Logistic regression analyses were used to identify demographic variables that were significantly related to domestic violence. For the purpose of this analysis, we included any woman who had ever experienced any type of physical violence, including forced sex from a partner or former partner. We defined current domestic violence as physical violence experienced during the past 12 months.

We calculated that we needed to recruit 913 women to have 90% power to show a 15% difference in a range of demographic variables and to be significant at the 0.05 level between women who had experienced physical violence within the previous 12 months and those who had not. We assumed that 15% of women in the community had experienced domestic violence within the previous 12 months.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

In total, 1207 (55%) women were recruited (figure), comprising data collected from 5% of all registered women in 11 of the 13 practices. We aimed to review the patient's medical records for one in three randomly selected questionnaires. However, in only 258 of these randomly chosen questionnaires had the woman completing the questionnaire given consent for her medical records to be reviewed. The characteristics of the recruited women are shown in table 1.

View larger version (24K): [in this window] [in a new window]   Recruitment of participants

Prevalence of domestic violence
Overall, 425 (41%) of 1035 women had ever experienced physical violence from a partner or former partner (table 2). In total, 789 (74%) of 1060 women had experienced any form of controlling behaviour by their partner and 441 (46%) of 967 had been threatened. Based on responses from 1040 women, 222 (21%) women had ever had injuries, including bruises or more serious injuries, from violence. Of the 222 women who had experienced injury, 110 (50%) had sought medical attention for their injuries. Domestic violence during pregnancy was reported by 15% (101/677) of respondents who had ever been pregnant; of these, 26/103 (25%) women reported that this violence was worse than when they were not pregnant and 31/106 (29%) stated that it had caused a miscarriage.

Risk factors
Physical violence within the past 12 months was significantly associated with being divorced or separated (compared to being married; adjusted odds ratio 3.37, 95% confidence interval 1.89 to 6.01), pregnant in the past year (2.11, 1.39 to 3.19), and unemployed (1.71, 1.04 to 2.81). Women aged 45 years or over were significantly less likely to have experienced physical violence within the past 12 months (0.40, 0.19 to 0.85). Being divorced or separated, single or cohabiting, having children, being pregnant in the past year, and being born in the United Kingdom were significantly associated with ever experiencing physical violence. Black women were least likely to have ever experienced physical violence.

Recording of domestic violence in patients' records
The medical records of 258 women were reviewed. Of the 226 who had completed the section of the questionnaire on physical violence, 90 (40%) reported that they had ever experienced physical violence from a partner. Definite or suspected domestic violence was recorded in the records of 15 (17%) of these. In total, domestic violence was identified, or thought likely, and documented in 27 (10%) of the 258 sets of notes that we examined. Data extraction was validated in 107 sets of medical records. The true rate of recording of domestic violence in the medical records of women was calculated as 7% (95% exact binomial confidence interval 3% to 14%).

Attitudes to questioning
Overall, 34 (4%) women reported that they had ever been asked by their general practitioner if they had been hit, injured, or abused by a partner or former partner and 11 (1%) if they had been forced to have sex. Of those who had experienced physical violence, 64 (32%) reported they had told their doctor. In total, 202 (20%) women reported that they would mind being asked by their general practitioner about abuse or violence in their relationship if they had come about something else, with 234 (23%) objecting to a nurse asking the same question (3% difference, 0.8% to 5.3%). The acceptability of being asked was not significantly different between women who were and were not currently experiencing domestic violence (data not shown). Overall, 432 (42%) women reported that they would find it easier to discuss these issues with a female doctor and 31 (3%) with a male doctor.

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

Prevalence of domestic violence
The number of women in our study who had ever experienced physical violence was towards the upper end of the range found in other surveys in primary care. ^{8 9 11 15} We do not know whether the low response rate in our study produced an overestimate or underestimate of prevalence. Even if all non-responders were women who had not experienced abuse, one in five women attending these general practices would have experienced physical violence from a partner or former partner; this shows that, in a sample of women visiting their general practitioners, domestic violence is a common problem. This finding, taken with results from other studies, means that domestic violence fulfils one of the criteria for screening in general practicethat the condition is an important health problem.

Identifying women who are experiencing violence
A prerequisite for preventing further morbidity is being able to identify women experiencing current violence. We found that divorced or separated women, those under 45, and unemployed women were at higher risk of current physical violence from a partner or former partner. Some of our findings are consistent with those of Mirrlees-Black, who found that the risks for physical assault were highest over the past 12 months in women aged 16-24, separated women, council tenants, and those in poor health or financial difficulty.⁷

Pregnancy and domestic violence
We found that pregnancy within the past 12 months doubled the risk of physical violence. The association between pregnancy and current violence is no greater than that for several other demographic factors in our study. Pregnancy is distinguished from other situations by the broader health consequences of violencebecause the fetus is also at risk¹⁶and the more severe violence that women experience during pregnancy. Regular contact with health professionals during pregnancy may make it easier for women to report the problem and for health professionals to provide support. The Department of Health recommends that routine questioning about domestic violence should be included as part of antenatal care.¹⁷ Our findings show that pregnant women are at high risk and that screening could be more appropriate for this group of women than for other groups.

Underidentification of domestic violence
Our results agree with other studies, which show that most women experiencing domestic violence are not identified in their medical records. These indicate that general practitioners do not document a history of domestic violence in about three quarters of women who have experienced it.

Women's attitudes to screening
About one in five women in our survey objected to the idea of routine questioning; this finding is comparable with those from other surveys, which showed that similar ^{18 19} or higher²⁰ proportions of women were opposed to screening. A survey in the United Kingdom has shown that the majority of primary care health professionals do not wish to engage in screening²¹; this concurs with the results of one North American study.¹⁸

Conclusion
A recent review concludes that women experiencing domestic violence are best identified by universal screening.²² The limited acceptability and, in particular, the absence of evidence of a benefit to women of screening for domestic violence in healthcare settings²² means that its introduction would be premature. In the meantime, health professionals should not ignore the seriousness of domestic violence. We need to be aware of the possibility of violence in the lives of our patients and to offer support as well as general advice and information about agencies that can provide help.