Domestic violence (DV) is a major health and human rights problem across the globe. In a multi-country study of intimate partner violence, the World Health Organization (WHO) found a lifetime prevalence of violence of at least 25% in 13 out of 15 sites, with six of those having a prevalence greater than 50% (Garcia-Moreno et al. 2006). In the USA, 25% of women will experience DV during her lifetime, while in Australia, that figure is even greater, over one third of women (Mouzos & Makkai 2004; Tjaden & Thoennes 2000). The WHO (Ellsberg et al. 2008) multi-country population-based study on women's health and DV found that DV causes serious mental and physical health consequences, regardless of a woman's culture or race, where she lives or the degree to which violence is accepted by her or her society (Ellsberg et al. 2008).
This is not news. Researchers, healthcare providers and much of the general public have been aware of the high prevalence of DV and its consequences for many years. The WHO has identified addressing violence against women as an urgent public health priority and essential for achieving Millennium Development Goal 3, the promotion of gender equality and empowerment of women. Regulatory agencies and accrediting organizations include universal screening among required standards for hospitals and ambulatory clinics.
Why then, are we still failing to identify women suffering from DV and provide them with the resources and care they need? In this issue of the International Nursing Review, Ben Natan and colleagues report on the results of their study of universal screening for DV in an obstetrics and gynaecology department in an Israel hospital. Once again, the findings indicate that healthcare providers are not screening. Only 57% of the doctors and nurses surveyed screened for and identified women who experienced DV. And even among them, screening was minimal; when asked how many of the over 100 women they treated in the prior month they had asked about DV, the average answer was eight.
The major barriers to screening identified in this study are the same ones found in research across populations and settings: lack of knowledge, negative attitudes towards violence, sociocultural norms and setting constraints. Healthcare providers claim they do not know how to ask or what to do if a woman does disclose DV. Many report, as 68% of the healthcare providers in this study did, that they never received education about DV in their formal education process.
Healthcare providers often report feeling uncomfortable asking women about DV. Yet, studies consistently find that routine questions about DV are acceptable to most women (Boyle & Jones 2006; Dowd et al. 2002) and findings from this study suggest that even those who do find it uncomfortable recognize and appreciate the importance of questioning. Though 58% of the women thought being asked about DV was embarrassing and 73% thought it was insulting, a greater majority still thought the questions were appropriate (82%) and helpful (79%).
The high percentage of women who reported reactions of embarrassment and feeling insulted also points to the continuing stigma surrounding DV. This is propagated by the persistence of negative attitudes among healthcare providers. Sixteen percent of doctors in this study believed that women are to blame for the violence perpetrated against them. This may sound like a relatively low percentage but it is unacceptably high. Getting this number as close to zero as possible is critical; victims of DV consistently report that they would discuss their experience with a healthcare provider if they are asked with respect and treated in a non-judgmental way (Dienemann et al. 2005; Shoultz et al. 2002). Eliminating victim blaming is a realistic goal, as evidenced by the low percentage of nurses in this study who thought women were to blame – only 1%.
This leads to another important finding in this study: the striking differences between doctors and nurses in attitude towards, screening for and management of DV. Along with the above finding, 30% of doctors vs. 2.5% of nurses agreed with the statement that there are more important issues than DV and 45% of doctors vs. 11.5% of nurses reported they did not have enough time to assess for abuse. A much higher proportion of nurses than doctors reported providing follow-up care for battered women, including providing information on help and counselling services (85% vs. 40%, respectively) and setting up follow-up appointments (75% vs. 45%, respectively). The authors postulate that this finding is related to gender rather than profession as 90% of the doctors were men and 75% of the nurses were women. Based on the data presented, it is not possible to know how much of the difference is directly attributable to gender and how much could be a result of the differences in role socialization between nurses and doctors. Certainly, traditional gender roles and sociocultural norms support the interpretation that this is a reflection of the greater acceptance by men of violence against women (Flood & Pease 2009). However, the focus of doctors on curing as a goal may also be a factor in their attitudes towards and management of a health problem that is so difficult to ‘cure’. These findings warrant further study.
Questions persist about the effectiveness of universal screening in preventing further violence or improving health quality of life. However, screening on its own can not be expected to improve outcomes no more than colonoscopies would lower rates of colon cancer if patients were made to feel ashamed of positive results and appropriate follow-up was not done. Screening must be part of an evidence-based approach that includes immediate and long-term follow-up and linking women to needed physical, mental health and protective services.
The authors make some excellent recommendations for the future, including research on the effect of gender and culture on attitudes and screening, the use of simulation in educating healthcare providers and the development of culturally sensitive screening tools. To these, I would add examining how we are educating doctors and nurses and holding healthcare organizations accountable for removing setting constraints.
It is time to move forward. We know healthcare providers are not screening for DV and we know why. Now it is time to focus on how we educate healthcare providers about DV, including increasing their understanding of and sensitivity to the complex nature of this phenomenon; and on developing comprehensive, evidence-based interventions for women experiencing domestic violence.