- Email: [email protected]
Partner violence and medical encounters
Partner Violence and Medical Encounters African-American Women’s Perspectives Louise-Anne McNutt, PhD, Michelle van Ryn, PhD, MPH, Carla Clark, MPH, Idelle Fraiser, MPH Objective:
To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population.
Design:
Cross-sectional, self-administered, anonymous survey.
Setting:
Community-based, primary care center.
Patients:
Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter.
Measurements:
Patients’ perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV “in the past year.”
Results:
Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers.
Conclusions: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care. Medical Subject Headings (MeSH): blacks, domestic violence, primary health care, spouse abuse, women’s health (Am J Prev Med 2000;19(4):264 –269) © 2000 American Journal of Preventive Medicine
Introduction
A
mple evidence shows the importance of patient–provider relationships. The quality of physician–patient communication can influence appropriate clinical decision making,1,2 how patients cope with illness,3 adherence to medical regimens,4,5 health outcomes,6 –9 and patient satisfaction with care,3,10 –16 as well as trust in physician competence17 and level of stress or anxiety experienced during the encounter.18,19 Patient satisfaction, in turn, is associated with a wide variety of outcomes, including appropriFrom the Department of Epidemiology, School of Public Health, University at Albany (McNutt, Clark, Fraiser), Rensselaer, New York; Division of Epidemiology, School of Public Health, University of Minnesota and Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center (van Ryn), Minneapolis, Minnesota; and San Jose State University (Fraiser), San Jose, California Address correspondence and reprint requests to: Louise-Anne McNutt, PhD, Department of Epidemiology, School of Public Health, University at Albany, 1 University Place, Rensselaer, NY 12144. E-mail: [email protected].
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ate use of services,20 adherence,10,21 health behaviors,22 pain management,23 and health outcomes.24 The possibility that intimate partner violence (IPV) is associated with the quality of provider–patient communication and level of patient satisfaction has implications for both screening and referral interventions as well as for the general quality of medical care that IPV victims receive. Furthermore, owing to the complex physical and mental health consequences of violence,25–33 IPV victims are disproportionately represented in medical care settings.26,34 As a result, the quality of the provider–patient relationship may be especially important to this group. The effect of IPV on medical care encounters has received limited study. Most studies focus specifically on encounters related to abuse.35–39 This study builds on research conducted by Plichta and colleagues,40 who found that abused women were less satisfied with primary care encounters compared with other women, potentially because of poorer communication between patient and provider. In contrast to the Plichta and
Am J Prev Med 2000;19(4) 0749-3797/00/$–see front matter © 2000 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00233-6
colleagues study,40 a telephone survey that included predominantly white women (84%) with private health insurance (81%) and a regular physician (100%), the present study examines the relationship between IPV and patient satisfaction among an African-American population who received care from a community clinic, regardless of access to a telephone or regular provider.
harm her or her children, to hurt himself, or to disclose confidential information. Responses to these questions included “a lot,” “quite a bit,” “a little bit,” and “not at all.” We classified women as “current IPV victims” if they provided positive responses to any item in the Conflicts Tactics Scale, responded “yes” to the sexual violence question, or if they responded “quite a bit” or “a lot” to any one of the emotional abuse items.
Methods Sample Characteristics
Patient Satisfaction
We conducted the study at a community health center in an urban community in the northeastern region of the United States. The center has nine primary care providers, including five physicians and four nurse practitioners. We invited women who had been seen at the health center between February 2 and April 30, 1998, to participate in the study if they met the following study criteria: (1) aged 18 years or older, (2) African Americans, (3) medical visits during specific research periods, and (4) not accompanied during the visits (for safety reasons). We invited 173 women to participate in the study; 133 women agreed to participate (response rate⫽77%); of these, 102 provided sufficient information for researchers to assess their recent IPV experiences, patient–provider encounter experiences, and primary demographic characteristics (completion rate⫽59%). The health center’s administration and the Institutional Review Board at the University at Albany approved the study. Women who participated in the study received resource lists and $5 gift certificates to a supermarket.
Measures Study participants were given the choice of completing either a self-administered questionnaire (n⫽101) or an interview containing the same questions (n⫽1). The questionnaire collected information on IPV experiences, demographic characteristics, childhood abuse experiences, health care use, as well as questions about current health care providers and the most recent primary care encounter. Demographic information included age, relationship status, education, perceived economic hardship, and household occupants. Health status and health care information included self-perception of overall health and number and types of health care visits.
Abuse Status We assessed for physical violence using the physical aggression portion of the Conflicts Tactics Scale, a widely used tool in IPV studies with established reliability and validity.41– 43 The scale contains items that cover a range of physically aggressive behaviors. We assessed for sexual violence with a single question: “In the past twelve months, has an intimate partner forced you to have sex against your will?” We assessed for emotional abuse “in the past year” with eight questions that explored whether a woman’s partner had forced her to use drugs or alcohol; had limited her access to money, family, friends, or her spiritual community; or had threatened to
We assessed patients’ perceptions of their most recent primary care encounters through questions adapted from the Medical Interview Satisfaction Scale44 and the Consultation Satisfaction Questionnaire.45,46 We chose these scales because evidence shows their utility for assessing specific medical care encounters47– 49 and they previously have been validated and found highly comparable with interscale correlations of 0.82.48 Attitudes toward health care and provider– patient encounters vary by population and culture, however, so we adapted the scales to the research setting and population, consistent with appropriate measurement theory.47,50 In common Likert-scale format, we asked patients to indicate whether a series of statements about their most recent encounters were “completely false,” “somewhat false,” “somewhat true,” or “completely true.” The items assessed four underlying factors: positive affect during the encounter, negative affect, receptive communication, and expressive communication. Positive affect statements reflected warm feelings (such as being accepted and cared about) and general satisfaction with the encounter, for example, “I really felt understood by the doctor.” Cronbach ␣ coefficient, used to assess the internal consistency of the scale, was 0.92. Negative affect statements reflected negative feelings felt or expressed during the encounter, such as “At times, the doctor seemed irritated or annoyed.” Cronbach ␣ coefficient was 0.75. Expressive communication statements reflected a patient’s satisfaction with her ability to contribute information, requests, and ideas to the encounter, such as “The doctor gave me a chance to say what was on my mind.” Cronbach ␣ coefficient was 0.69. Receptive communication reflected a patient’s feelings about and satisfaction with the information and ideas that the physician communicated during the encounter, such as “I was very satisfied with the way the doctor answered my questions.” Cronbach ␣ coefficient was 0.89. Responses to each of the four scales had a skewed distribution with median scores ⬎3.5 on a scale of 1 to 4 (after reverse scoring was completed for some questions). These positively skewed distributions are consistent with other studies51 and may partially be a result of acquiscent response bias.52 Such scales are frequently recoded to compare the most satisfied with less satisfied groups.53,54 Thus, for the analyses presented below, we reduced the scales to dichotomous variables in which the two categories allow comparison of respondents who gave the most positive rating (mean score, ⱖ3.5) for the encounter characteristics with those who gave lower ratings.
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Table 1. Demographic characteristics by recent partner violence experiences Recent partner violence victim (nⴝ47) Factor Age 18–24 years 25–34 years 35 years or older Marital status Single Married Separated, divorced, widowed Live with partner Yes No Education 11th grade or less High school diploma College Insurance None Medicaid Health maintenance organization Fee for service Missing Economic hardship A great deal or some Just a little Not at all Children in the home Yes No
#
%
#
%
p value
14 27 6
29.8 57.4 12.8
18 27 10
32.7 49.1 18.2
0.645
34 10 3
72.3 21.3 6.4
35 10 10
63.6 18.2 18.2
0.204
29 18
61.7 38.3
30 25
54.5 45.5
0.466
18 15 14
38.3 31.9 29.8
22 17 16
40.0 30.9 29.1
0.985
7 25 11 1 3
15.9 56.8 25.0 2.3 —
5 25 18 4 3
9.6 48.1 34.6 7.7 —
0.365
18 10 19
38.3 21.3 40.4
9 24 22
16.4 43.6 40.0
0.015
36 11
76.6 23.4
47 8
85.5 14.5
0.252
Data Management and Analysis We conducted bivariate analyses of patients’ IPV experiences with demographic characteristics. We used logistic regression analyses to assess the relationship between recent IPV violence status and patients’ perceptions of their most recent medical encounters. These analyses were adjusted for potential confounding factors, including age, education level, marital status, presence of a partner or children in the home, perceived economic hardship, perception of overall health, history of childhood physical or sexual abuse, and depressive symptoms. We calculated maximum likelihood chi-square test statistics and their p values. We used standard plotting methods to check the fit of the models for both outliers and influential points.55
Results Of the 102 African-American women included in this analysis, 47 (46.1%) reported experiencing at least one act of IPV during the previous year. The vast majority of IPV victims experienced physical violence (n⫽44, 93.6%); eight of these women were also forced to have sex against their will. Four women experienced substantial emotional/psychological abuse in the absence of physical or sexual violence, all of whom reported multiple types of emotional abuse. Women participating in the study tended to be 266
No recent partner violence (nⴝ55)
young, single, and high school or college educated (Table 1). The majority were insured by Medicaid or had no medical insurance. Most women in the study reported three or more primary care visits in the year before the survey (Table 2). More than one half of both IPV victims and nonvictims reported using emergency department services during the prior year; IPV victims were more likely to have repeated emergency department visits than were other women studied. Women who were experiencing IPV reported less satisfaction with their most recent primary care encounter than did women not victimized (Table 3). Women who reported recent IPV victimization were less likely than other women to provide the highest ratings on positive affect (51% vs 71%, p⫽0.007) or on negative affect (62% vs 80%, p⫽0.070). Thus, women who were experiencing IPV were less likely to find it completely true that they felt respected and accepted during an encounter. Additionally, victims of partner violence were more likely than were other women to feel that their providers were annoyed or irritated with them. Recent violence victims were less likely than other women to provide the highest rating on receptive communication (66% vs 80%, p⫽0.019) and expressive communication (49% vs 58%, p⫽0.216).
American Journal of Preventive Medicine, Volume 19, Number 4
Table 2. Health and health care experiences by recent partner violence experiences Recent partner violence victim (nⴝ47) Factors Overall health Fair or poor Excellent to good Primary care visits (past year) Less than 2 2 3 or more Missing Emergency department visits Never Once Twice 3 or more Missing Provider Both family practice and OB/GYN Family practice only OB/GYN only Missing
No recent partner violence (nⴝ55)
#
%
#
%
p value
14 33
29.8 70.2
10 45
18.2 81.8
0.168
4 6 37 —
8.5 12.8 78.7 —
4 5 43 3
7.7 9.6 82.7 —
0.865
16 7 9 13 2
35.6 15.6 20.0 28.8 —
22 13 12 5 3
42.3 25.0 23.1 9.6 —
0.100
9 15 18 5
21.4 35.7 42.9 —
5 20 26 4
9.8 39.2 51.0 —
0.292
OB/GYN, obstetrician/gynecologist
Discussion In our survey of African-American women who were seen at an urban health center, we found that women who had recently been abused ranked all aspects of medical encounters as less satisfactory than did other women. Similar to previous research,37,38,56 results from this study suggest recent IPV victims find it more difficult than other women to discuss “what is on their minds” and “private thoughts” with their providers, and may be less likely to feel that providers give them a chance to discuss their problems. It is possible that the effect of IPV on satisfaction is mediated through the greater likelihood that abuse victims are struggling with emotional problems. Women with emotional problems
who see providers for behaviors that are not conducive to patient self-disclosure may be more dissatisfied than their counterparts who do not have pressing emotional problems, yet who experience the same provider behavior.57 Alternately, providers may respond differently to patients who are victims of IPV or other major stressors whose social cues indicate to the provider the potential for a lengthy encounter unless carefully managed. Both factors may be at work. The contribution of these factors both independently and in combination deserves more investigation. Only 15% of women reported that providers ever asked about IPV, a finding consistent with previous studies.27,56,58,59 Previous studies have also found that
Table 3. Patient experiences in primary care medical encounters, by recent partner violence experience Recent partner violence victim (nⴝ47) Factors Positive affect Low-moderate High Negative affect Low-moderate High Receptive communication Low-moderate High Expressive communication Low-moderate High
No recent partner violence (nⴝ55)
Maximum likelihood adjusted p values*
#
%
#
%
23 24
48.9 51.1
16 39
29.1 70.9
0.007
18 29
38.3 61.7
11 44
20.0 80.0
0.070
16 31
34.0 66.0
11 44
20.0 80.0
0.019
24 23
51.1 48.9
23 32
41.8 58.2
0.216
* Adjusted for age, marital status, whether living with the partner or not, economic hardship, childhood physical or sexual abuse, overall health, depression, and having children living in the home.
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physicians tend to underestimate the proportion of patients who experience IPV.60 – 62 Thus, the observed differences in medical encounter experiences are not likely to be a result of providers’ knowledge of IPV status in general. Several factors limit the interpretation of these findings. Although the study does adjust for many potential confounders, including depression,63 a woman’s perception of the medical encounter may be affected by factors not measured in this study, such as severity of depression, appointment type (scheduled vs same-day), length of encounter, familiarity with provider, reason for encounter, or a complex interplay between patient interaction style and physician behavior. Additionally, women could not adequately distinguish provider training well enough to adjust analyses. We cannot rule out the possibility that the findings are caused by selection bias (response rate 77%). Women not included in these analyses because of missing data were not primarily victims of violence. Including available data from these women does not meaningfully change the results presented. Another limitation is that the study was conducted in one health center; the need for additional studies in different primary care settings is clear. Previous studies of the medical encounter experiences of IPV victims have focused primarily on medical care directly related to the abuse. However, this study suggests that the experience of IPV may have an impact on general medical care experiences. Thus, future studies should be broadened to evaluate the general medical care that abused women receive. Incorporating methods to validate self-report (e.g., chart review) and including providers’ perceptions (e.g., provider questionnaire) would be logical next steps to enhance our understanding of abused women’s experiences in medical encounters and to improve educational programs. The Preventive Health Services Block Grant and Maternal and Child Health Block Grant, New York State Department of Health, and the Center for Minority Health, University at Albany provided funding for this study.
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To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population.
Design:
Cross-sectional, self-administered, anonymous survey.
Setting:
Community-based, primary care center.
Patients:
Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter.
Measurements:
Patients’ perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV “in the past year.”
Results:
Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers.
Conclusions: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care. Medical Subject Headings (MeSH): blacks, domestic violence, primary health care, spouse abuse, women’s health (Am J Prev Med 2000;19(4):264 –269) © 2000 American Journal of Preventive Medicine
Introduction
A
mple evidence shows the importance of patient–provider relationships. The quality of physician–patient communication can influence appropriate clinical decision making,1,2 how patients cope with illness,3 adherence to medical regimens,4,5 health outcomes,6 –9 and patient satisfaction with care,3,10 –16 as well as trust in physician competence17 and level of stress or anxiety experienced during the encounter.18,19 Patient satisfaction, in turn, is associated with a wide variety of outcomes, including appropriFrom the Department of Epidemiology, School of Public Health, University at Albany (McNutt, Clark, Fraiser), Rensselaer, New York; Division of Epidemiology, School of Public Health, University of Minnesota and Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center (van Ryn), Minneapolis, Minnesota; and San Jose State University (Fraiser), San Jose, California Address correspondence and reprint requests to: Louise-Anne McNutt, PhD, Department of Epidemiology, School of Public Health, University at Albany, 1 University Place, Rensselaer, NY 12144. E-mail: [email protected].
264
ate use of services,20 adherence,10,21 health behaviors,22 pain management,23 and health outcomes.24 The possibility that intimate partner violence (IPV) is associated with the quality of provider–patient communication and level of patient satisfaction has implications for both screening and referral interventions as well as for the general quality of medical care that IPV victims receive. Furthermore, owing to the complex physical and mental health consequences of violence,25–33 IPV victims are disproportionately represented in medical care settings.26,34 As a result, the quality of the provider–patient relationship may be especially important to this group. The effect of IPV on medical care encounters has received limited study. Most studies focus specifically on encounters related to abuse.35–39 This study builds on research conducted by Plichta and colleagues,40 who found that abused women were less satisfied with primary care encounters compared with other women, potentially because of poorer communication between patient and provider. In contrast to the Plichta and
Am J Prev Med 2000;19(4) 0749-3797/00/$–see front matter © 2000 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00233-6
colleagues study,40 a telephone survey that included predominantly white women (84%) with private health insurance (81%) and a regular physician (100%), the present study examines the relationship between IPV and patient satisfaction among an African-American population who received care from a community clinic, regardless of access to a telephone or regular provider.
harm her or her children, to hurt himself, or to disclose confidential information. Responses to these questions included “a lot,” “quite a bit,” “a little bit,” and “not at all.” We classified women as “current IPV victims” if they provided positive responses to any item in the Conflicts Tactics Scale, responded “yes” to the sexual violence question, or if they responded “quite a bit” or “a lot” to any one of the emotional abuse items.
Methods Sample Characteristics
Patient Satisfaction
We conducted the study at a community health center in an urban community in the northeastern region of the United States. The center has nine primary care providers, including five physicians and four nurse practitioners. We invited women who had been seen at the health center between February 2 and April 30, 1998, to participate in the study if they met the following study criteria: (1) aged 18 years or older, (2) African Americans, (3) medical visits during specific research periods, and (4) not accompanied during the visits (for safety reasons). We invited 173 women to participate in the study; 133 women agreed to participate (response rate⫽77%); of these, 102 provided sufficient information for researchers to assess their recent IPV experiences, patient–provider encounter experiences, and primary demographic characteristics (completion rate⫽59%). The health center’s administration and the Institutional Review Board at the University at Albany approved the study. Women who participated in the study received resource lists and $5 gift certificates to a supermarket.
Measures Study participants were given the choice of completing either a self-administered questionnaire (n⫽101) or an interview containing the same questions (n⫽1). The questionnaire collected information on IPV experiences, demographic characteristics, childhood abuse experiences, health care use, as well as questions about current health care providers and the most recent primary care encounter. Demographic information included age, relationship status, education, perceived economic hardship, and household occupants. Health status and health care information included self-perception of overall health and number and types of health care visits.
Abuse Status We assessed for physical violence using the physical aggression portion of the Conflicts Tactics Scale, a widely used tool in IPV studies with established reliability and validity.41– 43 The scale contains items that cover a range of physically aggressive behaviors. We assessed for sexual violence with a single question: “In the past twelve months, has an intimate partner forced you to have sex against your will?” We assessed for emotional abuse “in the past year” with eight questions that explored whether a woman’s partner had forced her to use drugs or alcohol; had limited her access to money, family, friends, or her spiritual community; or had threatened to
We assessed patients’ perceptions of their most recent primary care encounters through questions adapted from the Medical Interview Satisfaction Scale44 and the Consultation Satisfaction Questionnaire.45,46 We chose these scales because evidence shows their utility for assessing specific medical care encounters47– 49 and they previously have been validated and found highly comparable with interscale correlations of 0.82.48 Attitudes toward health care and provider– patient encounters vary by population and culture, however, so we adapted the scales to the research setting and population, consistent with appropriate measurement theory.47,50 In common Likert-scale format, we asked patients to indicate whether a series of statements about their most recent encounters were “completely false,” “somewhat false,” “somewhat true,” or “completely true.” The items assessed four underlying factors: positive affect during the encounter, negative affect, receptive communication, and expressive communication. Positive affect statements reflected warm feelings (such as being accepted and cared about) and general satisfaction with the encounter, for example, “I really felt understood by the doctor.” Cronbach ␣ coefficient, used to assess the internal consistency of the scale, was 0.92. Negative affect statements reflected negative feelings felt or expressed during the encounter, such as “At times, the doctor seemed irritated or annoyed.” Cronbach ␣ coefficient was 0.75. Expressive communication statements reflected a patient’s satisfaction with her ability to contribute information, requests, and ideas to the encounter, such as “The doctor gave me a chance to say what was on my mind.” Cronbach ␣ coefficient was 0.69. Receptive communication reflected a patient’s feelings about and satisfaction with the information and ideas that the physician communicated during the encounter, such as “I was very satisfied with the way the doctor answered my questions.” Cronbach ␣ coefficient was 0.89. Responses to each of the four scales had a skewed distribution with median scores ⬎3.5 on a scale of 1 to 4 (after reverse scoring was completed for some questions). These positively skewed distributions are consistent with other studies51 and may partially be a result of acquiscent response bias.52 Such scales are frequently recoded to compare the most satisfied with less satisfied groups.53,54 Thus, for the analyses presented below, we reduced the scales to dichotomous variables in which the two categories allow comparison of respondents who gave the most positive rating (mean score, ⱖ3.5) for the encounter characteristics with those who gave lower ratings.
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Table 1. Demographic characteristics by recent partner violence experiences Recent partner violence victim (nⴝ47) Factor Age 18–24 years 25–34 years 35 years or older Marital status Single Married Separated, divorced, widowed Live with partner Yes No Education 11th grade or less High school diploma College Insurance None Medicaid Health maintenance organization Fee for service Missing Economic hardship A great deal or some Just a little Not at all Children in the home Yes No
#
%
#
%
p value
14 27 6
29.8 57.4 12.8
18 27 10
32.7 49.1 18.2
0.645
34 10 3
72.3 21.3 6.4
35 10 10
63.6 18.2 18.2
0.204
29 18
61.7 38.3
30 25
54.5 45.5
0.466
18 15 14
38.3 31.9 29.8
22 17 16
40.0 30.9 29.1
0.985
7 25 11 1 3
15.9 56.8 25.0 2.3 —
5 25 18 4 3
9.6 48.1 34.6 7.7 —
0.365
18 10 19
38.3 21.3 40.4
9 24 22
16.4 43.6 40.0
0.015
36 11
76.6 23.4
47 8
85.5 14.5
0.252
Data Management and Analysis We conducted bivariate analyses of patients’ IPV experiences with demographic characteristics. We used logistic regression analyses to assess the relationship between recent IPV violence status and patients’ perceptions of their most recent medical encounters. These analyses were adjusted for potential confounding factors, including age, education level, marital status, presence of a partner or children in the home, perceived economic hardship, perception of overall health, history of childhood physical or sexual abuse, and depressive symptoms. We calculated maximum likelihood chi-square test statistics and their p values. We used standard plotting methods to check the fit of the models for both outliers and influential points.55
Results Of the 102 African-American women included in this analysis, 47 (46.1%) reported experiencing at least one act of IPV during the previous year. The vast majority of IPV victims experienced physical violence (n⫽44, 93.6%); eight of these women were also forced to have sex against their will. Four women experienced substantial emotional/psychological abuse in the absence of physical or sexual violence, all of whom reported multiple types of emotional abuse. Women participating in the study tended to be 266
No recent partner violence (nⴝ55)
young, single, and high school or college educated (Table 1). The majority were insured by Medicaid or had no medical insurance. Most women in the study reported three or more primary care visits in the year before the survey (Table 2). More than one half of both IPV victims and nonvictims reported using emergency department services during the prior year; IPV victims were more likely to have repeated emergency department visits than were other women studied. Women who were experiencing IPV reported less satisfaction with their most recent primary care encounter than did women not victimized (Table 3). Women who reported recent IPV victimization were less likely than other women to provide the highest ratings on positive affect (51% vs 71%, p⫽0.007) or on negative affect (62% vs 80%, p⫽0.070). Thus, women who were experiencing IPV were less likely to find it completely true that they felt respected and accepted during an encounter. Additionally, victims of partner violence were more likely than were other women to feel that their providers were annoyed or irritated with them. Recent violence victims were less likely than other women to provide the highest rating on receptive communication (66% vs 80%, p⫽0.019) and expressive communication (49% vs 58%, p⫽0.216).
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Table 2. Health and health care experiences by recent partner violence experiences Recent partner violence victim (nⴝ47) Factors Overall health Fair or poor Excellent to good Primary care visits (past year) Less than 2 2 3 or more Missing Emergency department visits Never Once Twice 3 or more Missing Provider Both family practice and OB/GYN Family practice only OB/GYN only Missing
No recent partner violence (nⴝ55)
#
%
#
%
p value
14 33
29.8 70.2
10 45
18.2 81.8
0.168
4 6 37 —
8.5 12.8 78.7 —
4 5 43 3
7.7 9.6 82.7 —
0.865
16 7 9 13 2
35.6 15.6 20.0 28.8 —
22 13 12 5 3
42.3 25.0 23.1 9.6 —
0.100
9 15 18 5
21.4 35.7 42.9 —
5 20 26 4
9.8 39.2 51.0 —
0.292
OB/GYN, obstetrician/gynecologist
Discussion In our survey of African-American women who were seen at an urban health center, we found that women who had recently been abused ranked all aspects of medical encounters as less satisfactory than did other women. Similar to previous research,37,38,56 results from this study suggest recent IPV victims find it more difficult than other women to discuss “what is on their minds” and “private thoughts” with their providers, and may be less likely to feel that providers give them a chance to discuss their problems. It is possible that the effect of IPV on satisfaction is mediated through the greater likelihood that abuse victims are struggling with emotional problems. Women with emotional problems
who see providers for behaviors that are not conducive to patient self-disclosure may be more dissatisfied than their counterparts who do not have pressing emotional problems, yet who experience the same provider behavior.57 Alternately, providers may respond differently to patients who are victims of IPV or other major stressors whose social cues indicate to the provider the potential for a lengthy encounter unless carefully managed. Both factors may be at work. The contribution of these factors both independently and in combination deserves more investigation. Only 15% of women reported that providers ever asked about IPV, a finding consistent with previous studies.27,56,58,59 Previous studies have also found that
Table 3. Patient experiences in primary care medical encounters, by recent partner violence experience Recent partner violence victim (nⴝ47) Factors Positive affect Low-moderate High Negative affect Low-moderate High Receptive communication Low-moderate High Expressive communication Low-moderate High
No recent partner violence (nⴝ55)
Maximum likelihood adjusted p values*
#
%
#
%
23 24
48.9 51.1
16 39
29.1 70.9
0.007
18 29
38.3 61.7
11 44
20.0 80.0
0.070
16 31
34.0 66.0
11 44
20.0 80.0
0.019
24 23
51.1 48.9
23 32
41.8 58.2
0.216
* Adjusted for age, marital status, whether living with the partner or not, economic hardship, childhood physical or sexual abuse, overall health, depression, and having children living in the home.
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physicians tend to underestimate the proportion of patients who experience IPV.60 – 62 Thus, the observed differences in medical encounter experiences are not likely to be a result of providers’ knowledge of IPV status in general. Several factors limit the interpretation of these findings. Although the study does adjust for many potential confounders, including depression,63 a woman’s perception of the medical encounter may be affected by factors not measured in this study, such as severity of depression, appointment type (scheduled vs same-day), length of encounter, familiarity with provider, reason for encounter, or a complex interplay between patient interaction style and physician behavior. Additionally, women could not adequately distinguish provider training well enough to adjust analyses. We cannot rule out the possibility that the findings are caused by selection bias (response rate 77%). Women not included in these analyses because of missing data were not primarily victims of violence. Including available data from these women does not meaningfully change the results presented. Another limitation is that the study was conducted in one health center; the need for additional studies in different primary care settings is clear. Previous studies of the medical encounter experiences of IPV victims have focused primarily on medical care directly related to the abuse. However, this study suggests that the experience of IPV may have an impact on general medical care experiences. Thus, future studies should be broadened to evaluate the general medical care that abused women receive. Incorporating methods to validate self-report (e.g., chart review) and including providers’ perceptions (e.g., provider questionnaire) would be logical next steps to enhance our understanding of abused women’s experiences in medical encounters and to improve educational programs. The Preventive Health Services Block Grant and Maternal and Child Health Block Grant, New York State Department of Health, and the Center for Minority Health, University at Albany provided funding for this study.
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