Abstract
Background:Â
From 1999 to 2004, an estimated 653,000 women in Canada were either physically or sexually abused by their current or previous intimate partners. We aimed to determine the proportion of women presenting to orthopaedic fracture clinics for the treatment of musculoskeletal injuries who had experienced intimate partner violence, defined as physical, sexual, or emotional abuse, within the past twelve months.
Methods:Â
We completed a cross-sectional study of 282 injured women attending two Level-I trauma centers in Canada. Female patients presenting to the orthopaedic fracture clinics anonymously completed two previously developed self-reported written questionnaires, the Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS), to determine the prevalence of intimate partner violence. The questionnaire also contained questions that pertain to the participant's demographic characteristics, fracture characteristics, and experiences with health-care utilization.
Results:Â
The overall prevalence of intimate partner violence (emotional, physical, and sexual abuse) within the last twelve months was 32% (95% confidence interval, 26.4% to 37.2%). Twenty-four (8.5%) of the injured women disclosed a history of physical abuse in the past year. Seven women indicated that the cause for their current visit was directly related to physical abuse. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse. Of the twenty-four women who reported physical abuse, only four had been asked about intimate partner violence by a physician; none of these physicians were the treating orthopaedic surgeons.
Conclusions:Â
Our study suggests a high prevalence of intimate partner violence among female patients with injuries who presented to two orthopaedic fracture clinics in Ontario. Surgeons and health-care personnel in fracture clinics should consider intimate partner violence when interacting with injured women.
Intimate partner violence (IPV) is described by the American Medical Association as "a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation, and intimidation."1 From 1999 to 2004, an estimated 653,000 women in Canada were either physically or sexually abused by their current or previous intimate partners2. Of those who seek medical attention, only 24% disclose intimate partner violence in the emergency department setting3.
Injuries associated with physical abuse often require referral to orthopaedic surgeons. A recent study demonstrated that sprains, dislocations, fractures, and foot injuries accounted for 28% of all clinical manifestations of abuse among women who were identified over a two-year period by the Minnesota Domestic Abuse Program4. The importance of the role of orthopaedic surgeons in identifying intimate partner violence recently has been recognized by national organizations, including the Canadian Orthopaedic Association5.
Our primary objective was to estimate the prevalence of intimate partner violence within a twelve-month period among women who presented to orthopaedic fracture clinics for the treatment of musculoskeletal injuries by asking direct questions about physical, sexual, and emotional abuse. Our secondary objectives were (1) to estimate the prevalence of intimate partner violence within a twelve-month period among women who presented to orthopaedic fracture clinics for the treatment of orthopaedic injuries with use of two previously developed questionnaires, (2) to determine what proportion of women presented to orthopaedic clinics for the treatment of an injury that was the direct result of intimate partner violence from a current or previous relationship, and (3) to investigate patients’ previous experiences, knowledge, and perceptions with regard to approaching health-care professionals about intimate partner violence.
We conducted a cross-sectional observational study at two Level-I trauma centers in Ontario (Hamilton Health Sciences—General Site, Hamilton, and St. Michael's Hospital, Toronto, Ontario, Canada). Approval was obtained from the local Research Ethic Boards (Hamilton Health Sciences/McMaster University Research Ethics Board #08-369 and St. Michael's Hospital Research Ethics Board #09-047).
Participants
All women who presented to the two participating centers were screened for eligibility by a female study coordinator. Patients may have presented to the fracture clinic for the immediate treatment of an injury (after being seen in the emergency department) or for follow-up after an injury. In order to be considered for inclusion in the study, the patient (1) had to present to the fracture clinic for her own appointment; (2) had to be eighteen years of age or older; (3) had to be able to read, understand, and write in English; (4) had to be seen at the fracture clinic for the treatment of a musculoskeletal injury; and (5) had to be able to separate herself from anyone who accompanied her to the clinic to ensure that she could complete the questionnaire in privacy. We excluded patients who were too ill, injured, or cognitively impaired to participate, although we did interview some patients who recovered sufficiently and consented at the time of follow-up visits. We also excluded patients who presented to the clinics because of chronic pain, arthritis, or wear-and-tear issues. We recorded the number of patients who were screened and the reasons for ineligibility. Once a patient was deemed eligible, the study coordinator obtained informed consent and provided the participant with the self-reported written questionnaire, which was completed anonymously (Fig. 1). The patient was provided with an intimate partner violence resource sheet for the local area if she chose to take it.
Primary Outcome Measure
To measure the overall prevalence of intimate partner violence, our anonymous questionnaire directly asked each patient if her partner had abused her physically, emotionally, or sexually in the past twelve months. The three direct questions were taken from the Woman Abuse Screening Tool (WAST), developed by Brown et al.6. The questions "Have you been abused physically/emotionally/sexually by an intimate partner?" had possible responses of "often," "sometimes," and "never." Responses of "sometimes" or "often" constituted a positive screen for these questions. These direct questions have not been independently validated but were chosen because they are intuitive and easy to understand.
Secondary Outcome Measures
We also asked all participants to anonymously complete two validated questionnaires that were designed for the assessment of intimate partner violence status in health-care settings. We selected the WAST and the Partner Violence Screen (PVS) for their psychometric properties, reliability, and specificity in identifying intimate partner violence6-8.
The WAST consists of eight questions pertaining to a woman's experience in her intimate relationship for the past twelve months6 (Table I). We analyzed the WAST according to a 2008 revision of the original WAST7, which was originally created and validated by Brown et al.6. MacMillan et al. reported a sensitivity of 47% and a specificity of 96% when the WAST was compared with the Composite Abuse Scale (CAS), which is commonly used to screen for intimate partner violence9.
The PVS consists of three questions. The first question asks if the woman has been hit, kicked, punched, or otherwise hurt by someone in the past year and, if so, by whom. The second two questions assess the woman's perception of safety8 (Table I). The PVS was scored according to the developers’ guidelines8. When compared with the Index of Spouse Abuse, the sensitivity of the PVS in detecting partner abuse was 64.5% and the specificity was 80.3%8. When compared with the Conflict Tactics Scale, the sensitivity of the PVS was 71.4% and the specificity was 84.4%8.
Demographics, Injury Characteristics, and Perceptions About Intimate Partner Violence
The questionnaire included demographic questions and questions about the characteristics of each participant's injury. The questionnaire also asked about the patient's previous experiences and perceptions about discussing and reporting intimate partner violence with health-care professionals.
Sample Size
According to a recent survey of orthopaedic surgeons in Canada10, 87% of all respondents believed that the prevalence of intimate partner violence within their practice was <1%, with almost all of the remaining respondents believing that the prevalence of intimate partner violence in their practice was between 5% and 10%. Using an estimated intimate partner violence prevalence of 5% within orthopaedic clinics and standard statistical formulae for estimating the sample size of prevalence studies, we calculated that a sample size of 278 women would be necessary for our study to provide an estimate of the prevalence of intimate partner violence with a 95% confidence interval of between 2.78% and 8.31%, an interval that should bolster support for a more comprehensive study. If the point-estimate of the prevalence of intimate partner violence within orthopaedic clinics is higher than 5%, the proportion of the margin of error relative to the estimated prevalence will be lower.
Statistical Analysis
Data are reported as the number of participants and as proportions, with corresponding confidence intervals to estimate precision. Continuous data are presented as means and medians. The answers and overall scores for both the PVS and the WAST are presented with use of descriptive data. We conducted chi-square tests to determine if there were any differences in reported outcomes between the two clinical sites. Patients who completed part of the questionnaire were included in our analyses. The PVS has a positive cutoff score of 1, and the WAST has a positive cutoff score of 13. If these cutoff scores were reached, the patient was considered to have a positive score on that questionnaire, regardless of whether she completed all questions on the questionnaire. No statistical extrapolation process was carried out for missing information.
Source of Funding
The P.R.A.I.S.E. Investigators received no funding for this study. Dr. Bhandari is funded, in part, by a Canada Research Chair. This funding is unrelated to the P.R.A.I.S.E. study.
Recruitment
Six hundred and ninety patients were screened for participation in the present study, and 295 patients were deemed ineligible. Of the 395 patients who met our eligibility criteria, 282 patients provided informed consent and completed all or part of the questionnaire (Fig. 1).
Characteristics of Included Women
The majority of women in this study were white (85.1%; 240 of 282), over the age of forty years (62.8%; 177 of 282), and had an annual income of less than $40,000 (59.6%; 168 of 282) (see Appendix). Demographic characteristics were similar across participating sites except for annual income (p < 0.05), which was higher for the St. Michael's Hospital site. We did not collect data on the characteristics of women who did not participate in this study.
Injury Characteristics
Fractures were the most common type of injury (73%; 206 of 282). The most commonly reported cause of injury was a fall (47.9%; seventy-nine of 165), and most injuries involved the lower extremity (59.6%; 168 of 282) (see Appendix).
Prevalence of Intimate Partner Violence in the Past Twelve Months: Primary Measure
The overall prevalence of intimate partner violence (emotional, physical, and sexual abuse) on the basis of direct questions was 31.6% (eighty-nine of 282) (Table II). Twenty-four women (8.5%) experienced physical abuse, eighty-six (30.5%) experienced emotional abuse, and nine (3.2%) experienced sexual abuse. The eighty-nine women who screened positive for intimate partner violence when directly asked spanned different ages, ethnicities, income levels, and education levels (see Appendix). The lengths of their current relationships also varied from less than one year to more than forty years. No specific injury patterns were noted among women disclosing abusive relationships.
Prevalence of Intimate Partner Violence in the Past Twelve Months: Secondary Measures
Thirty-five women (15.4%) screened positive for intimate partner violence with use of the WAST (Table III). Twenty-six women (9.2%) screened positive for intimate partner violence with use of the PVS tool (Table IV). Seven women (2.5%) indicated that the reason for the visit to the orthopaedic clinic was directly related to a physical injury caused by her intimate partner. Five of these women were being treated for a fracture, one was unsure about her diagnosis, and one was being treated for an unspecified injury. These women spanned all ages, ethnicities, and educational levels.
Previous Screening
Twelve (7.6%) of 157 women responded that they had been previously screened by health-care professionals other than their treating surgeon. Of the twenty-four victims of intimate partner violence who had experienced physical abuse, four (16.7%) had been asked by another health-care professional about intimate partner violence. In addition, of the twenty-four women who had experienced physical abuse, nine (37.5%) indicated that they believed that health-care providers should ask about intimate partner violence. Of all women screened, 36.2% indicated that they believed that health-care providers should ask about intimate partner violence.
Our principal findings suggest that 31.6% of women who presented to fracture clinics had experienced some form of intimate partner violence within the last year, that 8.5% of women had experienced physical abuse in the past year, and that 2.5% of women reported that the reason for their fracture clinic visit was directly related to a serious injury caused by an intimate partner. We did not identify any patient characteristics unique to those women who had experienced intimate partner violence.
Strengths and Limitations
The present study has several important strengths, including the use of previously developed screening questionnaires and direct questions, broad eligibility criteria, the use of female study coordinators in order to maximize enrollment, the completion of self-administered questionnaires in a private location, and the assurance of anonymity of the respondents. The use of multiple screening tools may help to identify patients who have experienced forms of abuse that may not be screened for with use of only one tool. However, there is a possibility that broadening the definition of intimate partner violence creates a higher risk of false-positive results. Female study coordinators were used to recruit and survey the patients so that abused women would feel safer and more at ease. Many women have reported that it is difficult to talk to male health-care providers about their experiences with intimate partner violence11.
The decision to use a self-administered questionnaire is supported by studies that have suggested improved acceptability by women9,10. However, the use of a self-administered questionnaire led to some incomplete responses. For example, a large number of the women who had been hit, kicked, punched, or otherwise hurt in the past year declined to indicate how the current injury had been caused. Since the survey was anonymous, we were unable to link the surveys to a patient chart to obtain the missing information. This finding may indicate that intimate partner violence was underreported.
Despite our efforts to maximize enrollment, 113 women declined to participate in the study. It remains plausible that nonparticipants differed from participants in terms of the prevalence of abuse. Patients may have been less likely to participate if they were a victim of intimate partner violence, resulting in a lower prevalence of intimate partner violence in our study. Alternatively, some patients may have declined to participate because they were not victims of intimate partner violence and as such believed that the issue was not relevant to them.
In Ontario, in 2006, the median age was thirty-nine years12, the median household income was $62,40013, and 77.2% of the population was white14. Our population was, on average, older than the general Ontario population and had a higher percentage of low-income and white individuals. The generalizability of our findings may be limited only to fracture clinics with similar processes inherent in the triage and referral of patients in our study. Level-I trauma centers in other locations may have different referral procedures.
Relevant Literature
A recent survey of 186 Canadian orthopaedic surgeons suggested that 87% of the respondents believed that the prevalence of intimate partner violence within their practice was <1%10. Our findings support a much higher prevalence of intimate partner violence among women attending orthopaedic fracture clinics. The finding of most concern was the 2.5% prevalence of severe orthopaedic injuries, such as fractures, that were directly reported as the reason for the woman's visit to the surgical fracture clinic. Our findings support those of an American-based audit of musculoskeletal injuries sustained by women attending a domestic abuse treatment and counseling center, the Minneapolis Domestic Abuse Project4. That study demonstrated that head and neck and musculoskeletal injuries were the most common manifestations of intimate partner violence and that the spectrum of musculoskeletal injuries included sprains, fractures, dislocations, and foot injuries4. Similarly, Spedding et al. reported that multiple injuries (especially those involving the head and neck), fractures, loss of consciousness, abdominal injuries, and injuries occurring on stairs were markers of domestic violence in women presenting to the emergency department15.
Our overall estimate of intimate partner violence was higher than previously reported rates of intimate partner violence in other medical specialties, including emergency medicine, obstetrics and gynecology, primary care, internal medicine, and pediatrics (Fig. 2)16,17. However, the reported prevalence of intimate partner violence in patients with musculoskeletal injuries was similar to the prevalence of intimate partner violence in a hospital-based addiction-recovery unit16. The varying prevalences across medical disciplines may also reflect differing definitions of intimate partner violence. The high prevalence of intimate partner violence in orthopaedic fracture clinics as compared with other medical specialties confirms the need for orthopaedic surgeons to be aware of the issues related to intimate partner violence and to recognize opportunities to assist women experiencing intimate partner violence.
Our study included women who varied in terms of age, marital status, annual income, and education level. There was an array of injury types, causes of injury, and locations of injury. Similar to previous research18-20, our study demonstrated that women of all ages, ethnicities, socioeconomic status levels, and injury patterns may experience intimate partner violence. In a previous study, two of us (M.B. and S.D.) and colleagues identified several risk factors associated with increased frequency of physical abuse, including young age; a shorter duration of the relationship; the coexistence of emotional, psychological, and/or sexual abuse; and drug or alcohol dependency4.
Only one of seven women who indicated that the reason for the visit to the clinic was an injury directly resulting from intimate partner violence indicated that she had been previously asked about intimate partner violence by a health-care professional. These findings are consistent with those of other studies. A recent survey of >500 emergency department patients demonstrated that 86% of the patients believed that it is appropriate for all women to be asked if they had experienced violent or threatening behavior from someone close to them21. Similarly, Glass et al. found that the majority of both abused and nonabused women presenting to the emergency department supported routine screening for intimate partner violence16. The same study also demonstrated that the screening rates for women who had reported abuse in the prior year was only 13%16.
The most common barriers to reporting intimate partner violence include a lack of awareness of intimate partner violence resources, a perception that the situation was not major enough to seek help, a fear of retaliation from the abusive partner, concerns regarding the custody of children, financial issues, lack of trust in the health-care provider, shame and embarrassment, concern that physicians cannot help, social and language barriers, and the reluctance to talk to a male doctor11. A recent survey of Canadian orthopaedic surgeons found that almost one-third of the orthopaedic surgeons who responded felt personal discomfort about intimate partner violence and that more than half of the respondents indicated that there was a lack of knowledge and education regarding intimate partner violence10. In the same survey, 91% of surgeons believed that knowledge about intimate partner violence was relevant to their surgical practice and 30% supported educational programs for orthopaedic surgeons10.
The surgeon's role in identifying intimate partner violence has not gone unrecognized by national organizations. The American College of Surgeons position statement on intimate partner violence states that surgeons have the responsibility to identify intimate partner violence and to appropriately treat women who are at risk of further harm22. The Canadian Orthopaedic Association takes a similar stance, and its position statement declares that "orthopaedic surgeons are well positioned to identify patients living with IPV and initiate an intervention."5
Influence of Screening Tools on Prevalence of Intimate Partner Violence
In the present study, we used three direct questions as our primary measure of the prevalence of intimate partner violence. A substantially lower prevalence was obtained with the WAST and PVS as compared with the three direct questions. We believe that the differences in prevalence obtained with use of the different tools can be accounted for by looking at which type of abuse each tool is screening for. The majority of the women who had a positive score for intimate partner violence on the direct questions had experienced emotional abuse. A common challenge faced with intimate partner violence research is that emotional abuse is difficult to define and experiences are often interpreted differently across patients. The PVS focuses primarily on experiences with physical violence and feelings of safety. Women who experienced emotional or sexual abuse but not physical abuse may screen negatively on the PVS. Although the WAST asks about the three types of abuse, women who are experiencing only one type of abuse may answer the questions in such a way that they do not meet the positive cutoff score of 13. Given the limitations of the PVS and the WAST, we believe that our primary measure of directly asking about intimate partner violence provides the most accurate assessment of the prevalence of intimate partner violence.
Clinical Relevance
If our findings are generalizable to the practices of most general orthopaedic surgeons, the opportunities to identify and assist victims of intimate partner violence are numerous. Based on general clinic volumes, an orthopaedic surgeon sees approximately forty-five female patients per week (approximately 2340 female patients per year), half of whom will be new patients (1170 new female patients per year). Our findings suggest that screening all women would result in ninety-nine women (8.5%) disclosing physical abuse within the twelve months of that year and approximately twenty-nine women (2.5%) presenting to the orthopaedic surgeon's clinic for the treatment of injuries directly resulting from intimate partner violence.
We support the idea that primary-contact health-care professionals should be suitably trained in and aware of intimate partner violence to help women presenting to emergency and urgent care clinics across North America. There has been considerable research and focus to understand how women presenting to the first-contact health-care professional can be identified and assisted. As we understand, several challenges have emerged with this approach. When patients present to the emergency department, they are often frightened and in a great deal of pain. Previous reports have shown that this is not the optimal time to ask about intimate partner violence5. As orthopaedic surgeons see patients multiple times, can create trust, and are more likely than emergency department staff to see a patient in a calmer state, they are in a good position to identify victims of intimate partner violence5. Our study showed that, in some cases, the first time that a woman discloses intimate partner violence can be in the orthopaedic fracture clinic. This provides an opportunity to integrate hospital resources to ensure that appropriate referral from an orthopaedic clinic is possible. While not directly related to the musculoskeletal complaint that a woman may have when seeing her orthopaedic surgeon, her emotional well-being, compliance, and health will be impacted by intimate partner violence. The focus on quality of life in orthopaedic outcomes, and the common finding that psychological factors are important prognostic factors in recovery, could have direct relevance to the outcome of orthopaedic care. Finally, if surgeons ask about abuse, it may prevent the abuse from escalating to the point of physical violence and serious injury. This strategy would be relevant to the field for injury prevention.
Orthopaedic surgeons can help by having materials available on local shelters and toll-free help lines, screening patients for intimate partner violence in a private setting without the partner present, using direct questions to elicit a direct response, and respecting a women's choice to not disclose abuse if she is not ready to do so5. After a woman has disclosed abuse, the orthopaedic surgeon should be nonjudgmental and supportive, assess her safety, respect her decisions, take clear notes regarding the injury or injuries, and provide resources and referrals for help5.
While recent investigators have questioned the utility of universal screening, no reports to date have demonstrated harm resulting from a practice of universal screening of women23-27. In addition, Davis noted that "the long-term sequelae [of intimate partner violence] include health risks, posttraumatic stress disorder, depression, and the economic costs for health care, and the economic loss to victims" and also that the failure to diagnose intimate partner violence and intervene may have a detrimental outcome as 44% of domestic violence-related homicide victims had presented to an emergency department within two years before their death28.
Need for a Multinational Study
To our knowledge, the current study was the first to evaluate the prevalence of intimate partner violence in women presenting to orthopaedic fracture clinics in Ontario. This study included only two clinical centers in Ontario, both in urban settings, limiting the generalizability of our findings. To confirm local findings nationally and internationally, a larger, multinational study is required.
Given the high prevalence of intimate partner violence at the two orthopaedic fracture clinics, these results have implications for implementing intimate partner violence screening and providing further education for medical professionals. McCloskey et al. reported that screening or assessment for intimate partner violence prompted threefold more disclosure than might be volunteered spontaneously17. That study also demonstrated that 32% of abused women who were asked about partner violence by a provider received help contacting services, compared with 5% who were not asked17. Contrary to those findings, MacMillan et al. recently found that there continues to be a lack of evidence that universal screening alone improves health outcomes for survivors of intimate partner violence24. In an editorial in response to these findings, Moracco and Cole argued that universal screening with passive referrals to community services is an inadequate response to intimate partner violence29. They continue to stress that specific interventions to prevent the recurrence of abuse for women who are at risk of violence should be implemented and rigorously tested without further delay. This confirms the need for further studies on the outcomes of screening for intimate partner violence.
In conclusion, our study confirms that there is a high prevalence of intimate partner violence among female patients with injuries who are seen at orthopaedic clinics in Ontario. Similar to previous research, our study demonstrated that women of all ages, ethnicities, socioeconomic status levels, and injury patterns may experience intimate partner violence. Surgeons should consider screening all injured women for domestic violence in their clinics.
Tables presenting demographic and injury characteristics of the study population and the demographic characteristics of those screening positive for intimate partner violence can be found on our web site at www.jbjs.org (go to the article citation and click on "Supporting Data").
Note: Details regarding the authors and investigators are provided below.
Dr. Mohit Bhandari had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Writing Committee: Mohit Bhandari (Co-Chair), Sheila Sprague (Co-Chair), Sonia Dosanjh, Bradley Petrisor, Sarah Resendes, Kim Madden, and Emil H. Schemitsch.
Steering Committee: Mohit Bhandari (Chair), Gregory J. Della Rocca, Sonia Dosanjh, Kyle Jeray, David Matthews, Bradley Petrisor, Rudolf Poolman, Emil H. Schemitsch, and Sheila Sprague.
Intimate Partner Violence Expertise: Sonia Dosanjh, Clare Freeman, David Matthews, Diana Tikasz, and Harjeet Badwall.
Methods Center: Mohit Bhandari, Sheila Sprague, Victor Wu, Sarah Resendes, Alicia Cameron, Ivanna Ramnath, and Kim Madden.
Participating Clinical Sites: Bradley Petrisor, Krishan Rajaratnam, Dale Williams, Brian Drew, Ivan Wong, Desmond Kwok, Matthew Denkers, Alicia Cameron, Sarah Resendes, Ivanna Ramnath, Kim Madden (Hamilton Health Sciences—General Site); Victoria Avram (Hamilton Health Sciences—Chedoke Site); Femi Ayeni (Hamilton Health Sciences—McMaster Site); Emil H. Schemitsch, Jeremy Hall, Michael McKee, James Waddell, Daniel Whelan, Timothy Daniels, Milena Vicente, Lisa Wild (St. Michael's Hospital); David Puskas, Tina LeFrancois (Thunder Bay Regional Health Sciences Centre); Chad Coles, Kelly Trask, Gwendolyn Dobbin (Queen Elizabeth II Health Sciences Centre); Paul Duffy, Richard Buckley, Robert Korley, Shannon Puloski, Kelly Johnston, Kimberly Carcary (Foothills Medical Centre); Gregory J. Della Rocca, Linda Anderson, Leah Briggs, Kelly Sullivan (University of Missouri Hospital); Kyle Jeray, J. Scott Broderick, Stephanie L. Tanner, Rebecca G. Snider (Greenville Hospital System); Ole Brink (Aarhus University Hospital); Rudolf W. Poolman, Vanessa Scholtes (OLVG & JvG); J. Carel Goslings, Suzan Beerekamp (Academic Medical Center); and Susan Liew, Adam Dowrick, Zoe Murdoch (The Alfred).
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