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Domestic violence management in Malaysia: A survey on the primary health care providers

Domestic violence management in Malaysia: A survey on the primary health care providers Aim: To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting. Method: A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire. Results: Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence. Conclusion: Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence. in their lives [1]. In Malaysia, 39% of women above 15 Introduction Domestic violence is a major social and medical problem. years of age were estimated to have been physically beaten It occurs in all countries irrespective of social, economic, by their partner [2]. A study in the outpatient clinic of the cultural or religious values. The World Health Organiza- University Malaya Medical Centre (UMMC) revealed that tion (WHO) has reported that population studies around one in seven female patients attending the clinic had a the world have found 10 to 69% of women reported being background of domestic violence [3]. physically assaulted by an intimate partner at some point Page 1 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 The impact of domestic violence is alarming. Fatalities are The medical practitioner's personal value system and related to partner homicides or women committing sui- beliefs about domestic violence also play an important cide [1,4,5]. Morbidity as the consequences of domestic role. A study in an emergency department in Hong Kong violence comes in the form of poor health status, poor reported that the doctors found it difficult to optimally quality of life and high use of health services [6,7]. Many manage victims of domestic violence because of the belief abused women suffer acute physical injuries and many in the importance of maintaining family unity and that other chronic health problems that present as ambiguous domestic violence is a private issue [29]. Fewer doctors symptoms and physical findings [8,9]. Psychosomatic were found to screen for domestic violence compared complains and non-specific chronic pains are common with other behavioral risks, such as alcohol and drug con- [9]. These presentations may be treated in health care sumption, and risk of HIV/AIDS [30]. More doctors also facilities without identification of the underlying cause, believed that domestic violence intervention was less suc- leaving the patient at risk for subsequent episodes of cessful than intervention for tobacco and HIV/AIDS risks abuse [10-14]. [30]. Abuse usually escalates during pregnancy and represents a The aim of this study was to assess the knowledge, attitude significant risk to the health of both mother and infant and practices of primary health care (PHC) provider [15]. Abused pregnant women have been reported to have teams (clinicians and nursing staff) related to the identifi- late and poor antenatal check-up when compared to preg- cation and management of domestic violence. The infor- nant women without an abusive background [16]. The mation gathered hopefully may assist in the development impacts of domestic violence also extend to children of of appropriate intervention strategies that lead to the abused women. A survey by Women Safety Australia improvements in the management of domestic violence. (1996) found that 60% of the abused women have chil- dren under their care during the abuse and 38% of them Method reported that their children witness the violence episodes Setting and study participants [17]. These children suffered injury when they were A cross-sectional study was carried out at three PHC clin- caught between their fighting parents [18]. Children ics of University Malaya Medical Centre (UMMC) from brought up in a home where domestic violence occurs October to December of 2002. The patients make their have the tendency to develop behavioral or psychological first contact with health care providers at these PHC clin- problems, with risk of poor health in later life [19]. There ics. These clinics are managed by the Primary Care Medi- is a close association between domestic violence and child cine/Outpatient department (PMC), the Accident and abuse and it is estimated that child abuse occurs in 50% Emergency department (A&E), and the Obstetric and of families with domestic violence [17]. Gynecology department (O&G). Studies have shown that most of the abused women will All health care providers who were working at any of the keep their experiences to themselves [20-22]. Those who three clinics during the survey time were invited to partic- sought help were most likely to disclose their experience ipate. They consisted of the clinicians (consultants, spe- to their close relatives or friends for help [17]. In view of cialists and medical officers (MOs) who were either their poor health, these abused women were noted to be master students or servicing doctors) and nursing staff frequent attendees to health care facilities [15]. However, (sisters, staff nurses and assistant nurses and medical only a small proportion of these victims were successfully assistants). identified. It was noted that the lifetime disclosure rate for abuse women to be around 30% and a low general practi- Questionnaire tioners' inquiry rate of 13% despite high levels of preva- The survey instrument was a questionnaire, adapted from lence among those attending health care facilities [23,24]. a study by Sugg et al (1999), that seek to find different responses from the participants on various aspects of Factors such as shame, embarrassment, fear of partner's domestic violence management [31]. Six different main retaliation and perception that it is not the doctor's role to categories of responses were assessed by the question- intervene are factors that prevent abused women from naire: seeking help from health care providers [12,25]. Con- versely, primary issues like lack of time, inadequate train- • Frequency of domestic violence screening ing, uncertainty about how to respond and perceptions of patient non-compliance affect professional response to � Provider self-efficacy domestic violence from these doctors [26-28]. � Safety concerns Page 2 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 � Blaming the abused person Results Out of 188 staff available at the time of the study, only � Concern of offending the patients 108 responded to the questionnaires. The clinicians were made up of 61 respondents with response rate of 72.6%. � Perceived system support. They consisted of 18 consultants/physicians and 43 MOs. The rest of the respondents were from the nursing staff Questions on screening frequency and provider self-effi- and consisted of 42 nurses and five medical assistants. The cacy using a 5-point Likert scale, ranging from strongly low response rate (45%) of the nursing staff has been con- negative to strongly positive to categorize the responses. tributed by difficulty in making contact with the partici- The questionnaires for the nursing staff have a slight vari- pants in view of shift working time and perhaps minimal ation from those to the clinicians. Questions specific to research culture exposure among them. Sixty-eight per- clinician's medical consultation that were outside the cent of the participants were female and nearly all boundary of nursing tasks were omitted for the nursing (98.7%) of the participants had been in service for five staff. This study was initially piloted for its suitability with years or more. Three of the clinicians (5%) and two of the the community studied before it was fully conducted. nursing staff (4%) had personal experience of domestic violence at some point in their lives. Procedure Ethics approval for the study was granted by the Medical Perceived prevalence of the problem Ethics Committee of UMMC. After distribution of the Table 1 shows that majority of the respondents (62.3% of questionnaires, the participants were given time to com- the clinicians and 65.9% of the nursing staff) perceived plete the questionnaire and to return it via internal mail. that domestic violence within the patients attending their Written informed consent was taken from the partici- clinic was either very rare or rare. pants. The participants were not asked of their name in order to ensure anonymity. However, all the question- As shown in Table 2, 77% of the clinicians and 63.6% of naires were individually numbered to allow tracking of the nursing staff had identified at least once a patient with non-responses. To ensure confidentiality of the partici- domestic violence experience in their work. Of these pants, a research assistant carrying out the tracking was the health care providers, 64% of the clinicians and 71.4% only one who had the access to the list of individuals. The had identified at least one patient who had been abused non-responders were followed-up with three successive in the past year. Only 32.8% of the clinicians and 15.6% phone calls. of the nursing staff had ever identified a perpetrator/ abuser. Data Analysis The questionnaire responses were coded and the frequen- Most of the respondents (86.7% of the clinicians and cies were tabulated. The participants were divided into 73.9% of the nursing staff) believed that they had a role to two groups based on their job description: the 'clinician play in the management of domestic violence. group' and the 'nursing group' Data analyses were carried out separately on each group. The χ tests of goodness of Self-reported asking about abuse fit were used to determine whether the distributions of While the majority of clinicians (68.9%) reported asking about abuse to their patients at 'times', 26.2% had never responses to the specific questions departed significantly from chance. The result is significant with p < 0.05. Type I screened any of their patients for domestic violence. error rate was set at 0.05 for each test. Frequency of asking about domestic violence The frequency of clinicians in asking about domestic vio- lence when seeing various clinical presentations is shown Table 1: Perceived prevalence of domestic violence among patients † Perceived prevalence of domestic violence among patients‡ Very rare Rare Common Very common Clinicians (n = 61) 13.1 49.2 36.1 1.6 Nursing staff (n = 47) 17 48.9 31.9 2.1 † Clinicians and nursing staff were asked the question, 'What do you think of the prevalence of domestic violence among patients attending your clinic?' ‡ Observed values are given as percentage of clinicians and nursing staffs Page 3 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 Table 2: Identification of abused victims or perpetrators/abusers Identification of abused victims or perpetrators/abusers †‡ Clinicians Nursing staff (n = 61) (n = 47) Ever identified an abused victim 77 63.6 Have identified at least an abused victim the past one year 64 71.4 Have ever identified a perpetrator/abuser 32.8 15.6 † Observed values are given as percentage of clinicians and nursing staff ‡ Missing values are not included in Table 3. When seeing someone with injuries, 52.5% of tations. Overall, clinicians felt more confidence in asking clinicians almost always/always ask about abuse. Patients about high risk behaviors than about different types of with chronic pelvic pain, headache, irritable bowel syn- abuse. There was no significant departure from chance in drome, unexplained intrauterine growth retardation the distribution of responses on physical and sexual (IUGR) and those lack prenatal care were seldom/never abuse. asked regarding abuse by more than 50% of clinicians. Concern about safety With the exception of the question on depression or anx- iety, all other observed distributions of responses differed A very small percentage of participants (6.6% of clinicians significantly from chance. and 17.8% of nursing staff) expressed concern about their own safety when asking about domestic violence. How- Barriers to asking violence ever, 41% of the clinicians and 13% of the nursing staff Barriers to asking about domestic violence have been expressed concern that it may increase the risk of further reported to be lack of time (65.6% of clinicians), afraid of abuse of patients with a background of domestic violence. offending their patients (52.5% of the clinicians) and Blaming the abused person unsure of how to ask (32.8% of the clinicians). Of those clinicians who reported being afraid of offending their Twenty-eight percent of the clinicians and 51.1% of the patients, 71.4% were O&G clinicians, 62.5% were A&E cli- nursing staff endorsed the item stating that 'the abuse per- nicians and 28% were outpatient clinicians. The concern son usually has done something that would trigger the of offending the patients was only present in 30% of the perpetrator to abuse them'. nursing staff. Making police report Confidence in asking Of all the participants who answered the question 'Would Clinicians' confidence in asking about various health you make a police report of domestic violence even if your issues is shown in Table 4. A high proportion of clinicians patient objects to it?' 32.8% of the clinicians and 24.4% of reported being very confident when asking about smok- the nursing staff answered 'yes'. ing and alcohol compared to asking other health presen- Table 3: Frequency of clinicians asking about abuse (n = 61) † Frequency of clinicians asking about abuse ‡ Almost always or Always Sometimes Seldom or Never Statistical test value p value Injury 52.5 29.5 18.0 11.25 0.005 <p < 0.0005 Depression or anxiety 41.0 26.2 32.8 1.99 NS Chronic pelvic pain 6.6 31.1 62.3 28.56 0.005 <p < 0.0005 Headache 8.2 34.4 57.4 22.16 0.005 <p < 0.0005 Irritable bowel syndrome 3.3 19.7 77 54.9 0.005 <p < 0.0005 Unexplained IUGR 6.6 16.4 77 53.35 0.005 <p < 0.0005 Premature labor 8.2 14.8 77 52.86 0.005 <p < 0.0005 Lack prenatal care 16.4 31.1 52.5 12 0.005 <p < 0.0005 † Clinicians were asked the question 'How frequent do you asked about domestic violence when seeing a patient with these conditions?' ‡ Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Page 4 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 Table 4: Confidence of clinicians in asking about various health presentations (n = 57) † Confidence levels of clinicians ‡§ Not at all or Slightly Moderately Very confident Statistical test value p value Smoking 3.5 12.3 84.2 67.0 0.005 <p < 0.0005 Alcohol 5.3 21.1 73.7 43.9 0.005 <p < 0.0005 Sexual behavior 17.5 49.1 33.3 8.5 0.025 > p > 0.01 Emotional abuse 40.4 43.9 15.8 8.0 0.025 > p > 0.01 Physical abuse 24.6 42.1 33.3 2.6 NS Sexual abuse 42.1 38.6 19.3 5.16 NS † Clinicians were asked 'How confident are you in asking the following?' ‡ Missing values are not included. § Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Perceived self-efficacy NGO Providers' self-efficacy in managing domestic violence is Less than half of the participants knew of any non-govern- shown in Table 5. Most clinicians (53.4%) reported hav- mental organizations that help support domestic violence ing minimal or no strategies with only 45% of them victims. reported having moderate efficacy to help abused women. Eighty percent of clinicians reported having few or no Previous education on domestic violence strategies to help the abusers. Very few clinicians per- Only 20% of the clinicians and 6.8% of the nursing staff ceived themselves as having effective strategies in the had ever attended any educational program. Of these, one management of domestic violence. In all cases, the third of the clinicians and none of the nursing staff had observed distributions differed significantly from the dis- attended a program in the past one year. tributions expected by chance alone. Discussion Perceived system support This study yielded important information about the cur- Aware of any written protocol rent perceptions and approaches of the health care provid- Less than a third of the participants (28.7%) reported ers in Malaysia towards the identification and knowing of any written protocol for the management of management of domestic violence in the primary care set- domestic violence victims. ting. The findings will be useful in guiding the develop- ment of appropriate clinical interventions to improve care Social worker in primary care settings in general as well as specifically in Ninety-three percent of the participants believe that hav- the UMMC. ing a social worker could support them in the manage- ment of domestic violence victims. However, only 72.1% However, caution should be taken when interpreting the reported having easy access to social worker. Around 10% results of this study in view of several limitations of this of the participants were unsure of the availability of social study. First, this study was a single study which was carried worker at their work place. out in a single primary care location. Thus, the findings Table 5: Perceived self-efficiency of clinicians in management of domestic violence (n = 60) † Perceived self-efficiency of clinicians ‡§ Not at all or Slightly Moderately Very efficient Statistical test value p value Strategies to help abused patients 53.4 45 1.7 27.7 0.005 <p < 0.0005 Strategies to help the abusers 80 20 0 62.4 0.005 <p < 0.0005 Confidence in referring abused patients 31.7 56.7 11.7 18.3 0.005 <p < 0.0005 Access to different management information 54.2 40.7 5.1 22.45 0.005 <p < 0.0005 † Clinicians were asked 'How efficient are you in different management of domestic violence' ‡ Missing values are not included § Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Page 5 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 may not be applicable to other medical settings, such as in nicians have not been fully equipped on how to deal with the inpatient or mental health settings. Second, the domestic violence cases during their undergraduate or UMMC is a large public tertiary teaching hospital with its postgraduate training. The results also suggest the clini- location in a suburban setting and because of this, the cians and the nursing staff received minimal or no train- findings may not be representative of smaller primary care ing on violence management during their service. settings such as the general practice clinics or other medi- cal facilities from non-urban locations. Third, since the Health care providers possess certain opinions and preju- data collection was based on self-reporting by the partici- dices based on their own upbringing, culture and religious pants, respond and recall bias may result in desirable beliefs. These biases can affect their professional behavior answer despite the confidential manner of the data collec- including their intention to ask about abuse and create tion. errors in clinical judgment in domestic violence cases. More than half of the clinicians and a third of the nursing As evident in this study, more than sixty percent of health staff reported a fear of offending patients in asking about care providers in UMMC believed that the prevalence of domestic violence. This may be related to the underlying domestic violence among patients attending their clinic to belief that domestic violence is a 'private matter' and not be low. This may be one of the many causes of low screen- within the scope of medical treatment [29]. Nearly a third ing for domestic violence cases. Seventy percents of clini- of clinicians and half of nurses endorsed the view that the cians have reported screening for their patients but at abused person must have done something to trigger the times only. There was only one doctor among the 61 cli- abuse. This 'blaming the victim' attitude is a very negative nicians who screened all his/her patients for domestic vio- way to address the person who has been victimized when lence. the abuser should be the one to be blamed for using vio- lence to resolve conflict [37]. Despite perception of low prevalence in domestic vio- lence cases, 65% of the clinicians identified an abused vic- Traditional beliefs regarding the family privacy, family tim within the past year. This is contrary to physicians' unity and gender role was found to have posed difficulties perception of low prevalence of domestic violence when to health care providers in their management of domestic the actual prevalence of domestic violence was found to violence [29]. However, many abused women do not be higher in those attending the health care facilities when mind being asked about violence and would like the compared to population [32]. The prevalence of domestic health care providers to be more pro-active in asking ques- violence cases among patients in various primary care set- tions on abuse [12,25,28,38]. Furthermore, health care tings varies from 8.5% to 41% [6,32-36]. providers need to be aware that domestic violence is indeed a major medical problem and they have important Physical injuries related to abuse may be one of the most roles to play in its detection and management [39]. obvious symptoms presented to medical facilities. How- ever, only half of the clinicians reported 'always or almost Having a safe environment will also enable the health care always' asking their patients for any underlying abuse providers to identify domestic violence. There should be a when treating cases of injury. This reported practice of place for the health care providers to have a private con- inquiring about abuse is higher when compared to the sultation with the victim without the presence of the study finding conducted by Sugg in 1999 [31]. Other pres- abuser. In this study, a very small proportion of the partic- entations of domestic violence related to psychological, ipants expressed concern on their safety but a large pro- psychosomatic or antenatal problems which are more portion was concerned about the safety of their patients subtle to its relation to domestic violence were asked with in a violent environment. regarding abuse by the clinicians in a much lesser fre- quency. This finding is similar the study by Sugg [31]. Cli- Perceived self-efficacy plays an important role in the man- nicians failing to identify and to offer abused women help agement of various medical conditions. Most clinicians in despite repeated presentations to health care facilities may this study were more confident in asking about smoking cause them further abuse when they are send home to the and alcohol intake rather than asking about different same abusive environment. kinds of abuse. Most of them perceived lack of self-efficacy in the overall management of domestic violence, includ- Most clinicians in this study reported lack of time as a bar- ing the use of strategies to help the abused person and a rier to ask for domestic violence. This finding is similar to lack of access to different management information. All that reported in Sugg et al [27]. Nearly a third of the clini- these negatively impact on the health care provider's abil- cians were still unsure on how to ask regarding domestic ity to adequately care for abused person or abusers. Fac- violence among their patients which should raise major tors, such as inadequate training or the perception of poor concern. It would seem reasonable to suggest that the cli- success in management of these cases are relevant [30]. Page 6 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 There is no mandatory reporting for domestic violence in provide a better understanding on specific issues brought Malaysia. However, in this study, a proportion of health up in this study. care providers have indicated that they would still report cases of abuse to police despite abused women's refusal to Competing interests give consent. Not respecting the patient's autonomy can The authors declare that they have no competing interests. be considered as unethical and may represent institu- tional victimization. There should be support for the Authors' contributions abused patients no matter what their decision is at that SO provided the initial concept of the study, conducted point of time. This will increase their self-esteem and con- data collection, performed the statistical analysis and fidence level, aspects of their self-image that may have drafted the manuscript. NAMA participated in the design been severely undermined by repeated abused by their of the study and data collection. Both authors read and partner [22]. approved the final manuscript. Within institutional settings, having enabling factors for Acknowledgements This study was carried out with a research grant from the Research and the management of domestic violence will make the Development Unit of the University of Malaya, Vote F 03652002B. The health care providers more inclined to manage these authors thank Professor Kim Tee Ng and Professor Leon Piterman for their cases. Less than three-quarters of the participants in this helpful suggestions on the manuscript; Ms. Fazilah Omar, Dr. Salleh Yahya study had access to a social worker, while 10% of the par- for their contribution to this study; and all the study participants for their ticipants were unsure of the availability of social workers time and co-operation to make this study a success. to help them manage domestic violence cases. Less than a third of the participants knew of any written protocol for References the management of domestic violence. Not even half of 1. WHO: Violence by Intimate Partner World Health Organization; 2002. 2. 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Cohn F, Salmon ME, Stobo JD: Confronting Chronic Neglect: The Educa- available free of charge to the entire biomedical community tion and Training of Health Professionals on Family Violence National Academy Press; 2002. peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Domestic violence management in Malaysia: A survey on the primary health care providers

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Springer Journals
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Copyright © 2008 by Othman and Adenan; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
DOI
10.1186/1447-056X-7-2
pmid
18973706
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Abstract

Aim: To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting. Method: A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire. Results: Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence. Conclusion: Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence. in their lives [1]. In Malaysia, 39% of women above 15 Introduction Domestic violence is a major social and medical problem. years of age were estimated to have been physically beaten It occurs in all countries irrespective of social, economic, by their partner [2]. A study in the outpatient clinic of the cultural or religious values. The World Health Organiza- University Malaya Medical Centre (UMMC) revealed that tion (WHO) has reported that population studies around one in seven female patients attending the clinic had a the world have found 10 to 69% of women reported being background of domestic violence [3]. physically assaulted by an intimate partner at some point Page 1 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 The impact of domestic violence is alarming. Fatalities are The medical practitioner's personal value system and related to partner homicides or women committing sui- beliefs about domestic violence also play an important cide [1,4,5]. Morbidity as the consequences of domestic role. A study in an emergency department in Hong Kong violence comes in the form of poor health status, poor reported that the doctors found it difficult to optimally quality of life and high use of health services [6,7]. Many manage victims of domestic violence because of the belief abused women suffer acute physical injuries and many in the importance of maintaining family unity and that other chronic health problems that present as ambiguous domestic violence is a private issue [29]. Fewer doctors symptoms and physical findings [8,9]. Psychosomatic were found to screen for domestic violence compared complains and non-specific chronic pains are common with other behavioral risks, such as alcohol and drug con- [9]. These presentations may be treated in health care sumption, and risk of HIV/AIDS [30]. More doctors also facilities without identification of the underlying cause, believed that domestic violence intervention was less suc- leaving the patient at risk for subsequent episodes of cessful than intervention for tobacco and HIV/AIDS risks abuse [10-14]. [30]. Abuse usually escalates during pregnancy and represents a The aim of this study was to assess the knowledge, attitude significant risk to the health of both mother and infant and practices of primary health care (PHC) provider [15]. Abused pregnant women have been reported to have teams (clinicians and nursing staff) related to the identifi- late and poor antenatal check-up when compared to preg- cation and management of domestic violence. The infor- nant women without an abusive background [16]. The mation gathered hopefully may assist in the development impacts of domestic violence also extend to children of of appropriate intervention strategies that lead to the abused women. A survey by Women Safety Australia improvements in the management of domestic violence. (1996) found that 60% of the abused women have chil- dren under their care during the abuse and 38% of them Method reported that their children witness the violence episodes Setting and study participants [17]. These children suffered injury when they were A cross-sectional study was carried out at three PHC clin- caught between their fighting parents [18]. Children ics of University Malaya Medical Centre (UMMC) from brought up in a home where domestic violence occurs October to December of 2002. The patients make their have the tendency to develop behavioral or psychological first contact with health care providers at these PHC clin- problems, with risk of poor health in later life [19]. There ics. These clinics are managed by the Primary Care Medi- is a close association between domestic violence and child cine/Outpatient department (PMC), the Accident and abuse and it is estimated that child abuse occurs in 50% Emergency department (A&E), and the Obstetric and of families with domestic violence [17]. Gynecology department (O&G). Studies have shown that most of the abused women will All health care providers who were working at any of the keep their experiences to themselves [20-22]. Those who three clinics during the survey time were invited to partic- sought help were most likely to disclose their experience ipate. They consisted of the clinicians (consultants, spe- to their close relatives or friends for help [17]. In view of cialists and medical officers (MOs) who were either their poor health, these abused women were noted to be master students or servicing doctors) and nursing staff frequent attendees to health care facilities [15]. However, (sisters, staff nurses and assistant nurses and medical only a small proportion of these victims were successfully assistants). identified. It was noted that the lifetime disclosure rate for abuse women to be around 30% and a low general practi- Questionnaire tioners' inquiry rate of 13% despite high levels of preva- The survey instrument was a questionnaire, adapted from lence among those attending health care facilities [23,24]. a study by Sugg et al (1999), that seek to find different responses from the participants on various aspects of Factors such as shame, embarrassment, fear of partner's domestic violence management [31]. Six different main retaliation and perception that it is not the doctor's role to categories of responses were assessed by the question- intervene are factors that prevent abused women from naire: seeking help from health care providers [12,25]. Con- versely, primary issues like lack of time, inadequate train- • Frequency of domestic violence screening ing, uncertainty about how to respond and perceptions of patient non-compliance affect professional response to � Provider self-efficacy domestic violence from these doctors [26-28]. � Safety concerns Page 2 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 � Blaming the abused person Results Out of 188 staff available at the time of the study, only � Concern of offending the patients 108 responded to the questionnaires. The clinicians were made up of 61 respondents with response rate of 72.6%. � Perceived system support. They consisted of 18 consultants/physicians and 43 MOs. The rest of the respondents were from the nursing staff Questions on screening frequency and provider self-effi- and consisted of 42 nurses and five medical assistants. The cacy using a 5-point Likert scale, ranging from strongly low response rate (45%) of the nursing staff has been con- negative to strongly positive to categorize the responses. tributed by difficulty in making contact with the partici- The questionnaires for the nursing staff have a slight vari- pants in view of shift working time and perhaps minimal ation from those to the clinicians. Questions specific to research culture exposure among them. Sixty-eight per- clinician's medical consultation that were outside the cent of the participants were female and nearly all boundary of nursing tasks were omitted for the nursing (98.7%) of the participants had been in service for five staff. This study was initially piloted for its suitability with years or more. Three of the clinicians (5%) and two of the the community studied before it was fully conducted. nursing staff (4%) had personal experience of domestic violence at some point in their lives. Procedure Ethics approval for the study was granted by the Medical Perceived prevalence of the problem Ethics Committee of UMMC. After distribution of the Table 1 shows that majority of the respondents (62.3% of questionnaires, the participants were given time to com- the clinicians and 65.9% of the nursing staff) perceived plete the questionnaire and to return it via internal mail. that domestic violence within the patients attending their Written informed consent was taken from the partici- clinic was either very rare or rare. pants. The participants were not asked of their name in order to ensure anonymity. However, all the question- As shown in Table 2, 77% of the clinicians and 63.6% of naires were individually numbered to allow tracking of the nursing staff had identified at least once a patient with non-responses. To ensure confidentiality of the partici- domestic violence experience in their work. Of these pants, a research assistant carrying out the tracking was the health care providers, 64% of the clinicians and 71.4% only one who had the access to the list of individuals. The had identified at least one patient who had been abused non-responders were followed-up with three successive in the past year. Only 32.8% of the clinicians and 15.6% phone calls. of the nursing staff had ever identified a perpetrator/ abuser. Data Analysis The questionnaire responses were coded and the frequen- Most of the respondents (86.7% of the clinicians and cies were tabulated. The participants were divided into 73.9% of the nursing staff) believed that they had a role to two groups based on their job description: the 'clinician play in the management of domestic violence. group' and the 'nursing group' Data analyses were carried out separately on each group. The χ tests of goodness of Self-reported asking about abuse fit were used to determine whether the distributions of While the majority of clinicians (68.9%) reported asking about abuse to their patients at 'times', 26.2% had never responses to the specific questions departed significantly from chance. The result is significant with p < 0.05. Type I screened any of their patients for domestic violence. error rate was set at 0.05 for each test. Frequency of asking about domestic violence The frequency of clinicians in asking about domestic vio- lence when seeing various clinical presentations is shown Table 1: Perceived prevalence of domestic violence among patients † Perceived prevalence of domestic violence among patients‡ Very rare Rare Common Very common Clinicians (n = 61) 13.1 49.2 36.1 1.6 Nursing staff (n = 47) 17 48.9 31.9 2.1 † Clinicians and nursing staff were asked the question, 'What do you think of the prevalence of domestic violence among patients attending your clinic?' ‡ Observed values are given as percentage of clinicians and nursing staffs Page 3 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 Table 2: Identification of abused victims or perpetrators/abusers Identification of abused victims or perpetrators/abusers †‡ Clinicians Nursing staff (n = 61) (n = 47) Ever identified an abused victim 77 63.6 Have identified at least an abused victim the past one year 64 71.4 Have ever identified a perpetrator/abuser 32.8 15.6 † Observed values are given as percentage of clinicians and nursing staff ‡ Missing values are not included in Table 3. When seeing someone with injuries, 52.5% of tations. Overall, clinicians felt more confidence in asking clinicians almost always/always ask about abuse. Patients about high risk behaviors than about different types of with chronic pelvic pain, headache, irritable bowel syn- abuse. There was no significant departure from chance in drome, unexplained intrauterine growth retardation the distribution of responses on physical and sexual (IUGR) and those lack prenatal care were seldom/never abuse. asked regarding abuse by more than 50% of clinicians. Concern about safety With the exception of the question on depression or anx- iety, all other observed distributions of responses differed A very small percentage of participants (6.6% of clinicians significantly from chance. and 17.8% of nursing staff) expressed concern about their own safety when asking about domestic violence. How- Barriers to asking violence ever, 41% of the clinicians and 13% of the nursing staff Barriers to asking about domestic violence have been expressed concern that it may increase the risk of further reported to be lack of time (65.6% of clinicians), afraid of abuse of patients with a background of domestic violence. offending their patients (52.5% of the clinicians) and Blaming the abused person unsure of how to ask (32.8% of the clinicians). Of those clinicians who reported being afraid of offending their Twenty-eight percent of the clinicians and 51.1% of the patients, 71.4% were O&G clinicians, 62.5% were A&E cli- nursing staff endorsed the item stating that 'the abuse per- nicians and 28% were outpatient clinicians. The concern son usually has done something that would trigger the of offending the patients was only present in 30% of the perpetrator to abuse them'. nursing staff. Making police report Confidence in asking Of all the participants who answered the question 'Would Clinicians' confidence in asking about various health you make a police report of domestic violence even if your issues is shown in Table 4. A high proportion of clinicians patient objects to it?' 32.8% of the clinicians and 24.4% of reported being very confident when asking about smok- the nursing staff answered 'yes'. ing and alcohol compared to asking other health presen- Table 3: Frequency of clinicians asking about abuse (n = 61) † Frequency of clinicians asking about abuse ‡ Almost always or Always Sometimes Seldom or Never Statistical test value p value Injury 52.5 29.5 18.0 11.25 0.005 <p < 0.0005 Depression or anxiety 41.0 26.2 32.8 1.99 NS Chronic pelvic pain 6.6 31.1 62.3 28.56 0.005 <p < 0.0005 Headache 8.2 34.4 57.4 22.16 0.005 <p < 0.0005 Irritable bowel syndrome 3.3 19.7 77 54.9 0.005 <p < 0.0005 Unexplained IUGR 6.6 16.4 77 53.35 0.005 <p < 0.0005 Premature labor 8.2 14.8 77 52.86 0.005 <p < 0.0005 Lack prenatal care 16.4 31.1 52.5 12 0.005 <p < 0.0005 † Clinicians were asked the question 'How frequent do you asked about domestic violence when seeing a patient with these conditions?' ‡ Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Page 4 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 Table 4: Confidence of clinicians in asking about various health presentations (n = 57) † Confidence levels of clinicians ‡§ Not at all or Slightly Moderately Very confident Statistical test value p value Smoking 3.5 12.3 84.2 67.0 0.005 <p < 0.0005 Alcohol 5.3 21.1 73.7 43.9 0.005 <p < 0.0005 Sexual behavior 17.5 49.1 33.3 8.5 0.025 > p > 0.01 Emotional abuse 40.4 43.9 15.8 8.0 0.025 > p > 0.01 Physical abuse 24.6 42.1 33.3 2.6 NS Sexual abuse 42.1 38.6 19.3 5.16 NS † Clinicians were asked 'How confident are you in asking the following?' ‡ Missing values are not included. § Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Perceived self-efficacy NGO Providers' self-efficacy in managing domestic violence is Less than half of the participants knew of any non-govern- shown in Table 5. Most clinicians (53.4%) reported hav- mental organizations that help support domestic violence ing minimal or no strategies with only 45% of them victims. reported having moderate efficacy to help abused women. Eighty percent of clinicians reported having few or no Previous education on domestic violence strategies to help the abusers. Very few clinicians per- Only 20% of the clinicians and 6.8% of the nursing staff ceived themselves as having effective strategies in the had ever attended any educational program. Of these, one management of domestic violence. In all cases, the third of the clinicians and none of the nursing staff had observed distributions differed significantly from the dis- attended a program in the past one year. tributions expected by chance alone. Discussion Perceived system support This study yielded important information about the cur- Aware of any written protocol rent perceptions and approaches of the health care provid- Less than a third of the participants (28.7%) reported ers in Malaysia towards the identification and knowing of any written protocol for the management of management of domestic violence in the primary care set- domestic violence victims. ting. The findings will be useful in guiding the develop- ment of appropriate clinical interventions to improve care Social worker in primary care settings in general as well as specifically in Ninety-three percent of the participants believe that hav- the UMMC. ing a social worker could support them in the manage- ment of domestic violence victims. However, only 72.1% However, caution should be taken when interpreting the reported having easy access to social worker. Around 10% results of this study in view of several limitations of this of the participants were unsure of the availability of social study. First, this study was a single study which was carried worker at their work place. out in a single primary care location. Thus, the findings Table 5: Perceived self-efficiency of clinicians in management of domestic violence (n = 60) † Perceived self-efficiency of clinicians ‡§ Not at all or Slightly Moderately Very efficient Statistical test value p value Strategies to help abused patients 53.4 45 1.7 27.7 0.005 <p < 0.0005 Strategies to help the abusers 80 20 0 62.4 0.005 <p < 0.0005 Confidence in referring abused patients 31.7 56.7 11.7 18.3 0.005 <p < 0.0005 Access to different management information 54.2 40.7 5.1 22.45 0.005 <p < 0.0005 † Clinicians were asked 'How efficient are you in different management of domestic violence' ‡ Missing values are not included § Observed values are given as percentage of clinicians. All expected percentages are 33.33%. Page 5 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 may not be applicable to other medical settings, such as in nicians have not been fully equipped on how to deal with the inpatient or mental health settings. Second, the domestic violence cases during their undergraduate or UMMC is a large public tertiary teaching hospital with its postgraduate training. The results also suggest the clini- location in a suburban setting and because of this, the cians and the nursing staff received minimal or no train- findings may not be representative of smaller primary care ing on violence management during their service. settings such as the general practice clinics or other medi- cal facilities from non-urban locations. Third, since the Health care providers possess certain opinions and preju- data collection was based on self-reporting by the partici- dices based on their own upbringing, culture and religious pants, respond and recall bias may result in desirable beliefs. These biases can affect their professional behavior answer despite the confidential manner of the data collec- including their intention to ask about abuse and create tion. errors in clinical judgment in domestic violence cases. More than half of the clinicians and a third of the nursing As evident in this study, more than sixty percent of health staff reported a fear of offending patients in asking about care providers in UMMC believed that the prevalence of domestic violence. This may be related to the underlying domestic violence among patients attending their clinic to belief that domestic violence is a 'private matter' and not be low. This may be one of the many causes of low screen- within the scope of medical treatment [29]. Nearly a third ing for domestic violence cases. Seventy percents of clini- of clinicians and half of nurses endorsed the view that the cians have reported screening for their patients but at abused person must have done something to trigger the times only. There was only one doctor among the 61 cli- abuse. This 'blaming the victim' attitude is a very negative nicians who screened all his/her patients for domestic vio- way to address the person who has been victimized when lence. the abuser should be the one to be blamed for using vio- lence to resolve conflict [37]. Despite perception of low prevalence in domestic vio- lence cases, 65% of the clinicians identified an abused vic- Traditional beliefs regarding the family privacy, family tim within the past year. This is contrary to physicians' unity and gender role was found to have posed difficulties perception of low prevalence of domestic violence when to health care providers in their management of domestic the actual prevalence of domestic violence was found to violence [29]. However, many abused women do not be higher in those attending the health care facilities when mind being asked about violence and would like the compared to population [32]. The prevalence of domestic health care providers to be more pro-active in asking ques- violence cases among patients in various primary care set- tions on abuse [12,25,28,38]. Furthermore, health care tings varies from 8.5% to 41% [6,32-36]. providers need to be aware that domestic violence is indeed a major medical problem and they have important Physical injuries related to abuse may be one of the most roles to play in its detection and management [39]. obvious symptoms presented to medical facilities. How- ever, only half of the clinicians reported 'always or almost Having a safe environment will also enable the health care always' asking their patients for any underlying abuse providers to identify domestic violence. There should be a when treating cases of injury. This reported practice of place for the health care providers to have a private con- inquiring about abuse is higher when compared to the sultation with the victim without the presence of the study finding conducted by Sugg in 1999 [31]. Other pres- abuser. In this study, a very small proportion of the partic- entations of domestic violence related to psychological, ipants expressed concern on their safety but a large pro- psychosomatic or antenatal problems which are more portion was concerned about the safety of their patients subtle to its relation to domestic violence were asked with in a violent environment. regarding abuse by the clinicians in a much lesser fre- quency. This finding is similar the study by Sugg [31]. Cli- Perceived self-efficacy plays an important role in the man- nicians failing to identify and to offer abused women help agement of various medical conditions. Most clinicians in despite repeated presentations to health care facilities may this study were more confident in asking about smoking cause them further abuse when they are send home to the and alcohol intake rather than asking about different same abusive environment. kinds of abuse. Most of them perceived lack of self-efficacy in the overall management of domestic violence, includ- Most clinicians in this study reported lack of time as a bar- ing the use of strategies to help the abused person and a rier to ask for domestic violence. This finding is similar to lack of access to different management information. All that reported in Sugg et al [27]. Nearly a third of the clini- these negatively impact on the health care provider's abil- cians were still unsure on how to ask regarding domestic ity to adequately care for abused person or abusers. Fac- violence among their patients which should raise major tors, such as inadequate training or the perception of poor concern. It would seem reasonable to suggest that the cli- success in management of these cases are relevant [30]. Page 6 of 8 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:2 http://www.apfmj.com/content/7/1/2 There is no mandatory reporting for domestic violence in provide a better understanding on specific issues brought Malaysia. However, in this study, a proportion of health up in this study. care providers have indicated that they would still report cases of abuse to police despite abused women's refusal to Competing interests give consent. Not respecting the patient's autonomy can The authors declare that they have no competing interests. be considered as unethical and may represent institu- tional victimization. There should be support for the Authors' contributions abused patients no matter what their decision is at that SO provided the initial concept of the study, conducted point of time. This will increase their self-esteem and con- data collection, performed the statistical analysis and fidence level, aspects of their self-image that may have drafted the manuscript. NAMA participated in the design been severely undermined by repeated abused by their of the study and data collection. Both authors read and partner [22]. approved the final manuscript. Within institutional settings, having enabling factors for Acknowledgements This study was carried out with a research grant from the Research and the management of domestic violence will make the Development Unit of the University of Malaya, Vote F 03652002B. The health care providers more inclined to manage these authors thank Professor Kim Tee Ng and Professor Leon Piterman for their cases. Less than three-quarters of the participants in this helpful suggestions on the manuscript; Ms. Fazilah Omar, Dr. Salleh Yahya study had access to a social worker, while 10% of the par- for their contribution to this study; and all the study participants for their ticipants were unsure of the availability of social workers time and co-operation to make this study a success. to help them manage domestic violence cases. Less than a third of the participants knew of any written protocol for References the management of domestic violence. Not even half of 1. WHO: Violence by Intimate Partner World Health Organization; 2002. 2. 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Cohn F, Salmon ME, Stobo JD: Confronting Chronic Neglect: The Educa- available free of charge to the entire biomedical community tion and Training of Health Professionals on Family Violence National Academy Press; 2002. peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes)

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Asia Pacific Family MedicineSpringer Journals

Published: Sep 29, 2008

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