Barriers to Screening and Possibilities for Active Detection of Family Medicine Attendees Exposed to Intimate Partner Violence

The study included ten family doctors of both genders who came from different health centres and worked in different regions, were of different ages and had different years of experience in family medicine. The age of the seven female and three male doctors varied from 29 to 62 years, the mean age was 45.9 years. Three of the participating doctors were specialists in general medicine, four specialists in family medicine and three were trainees in family medicine. Five doctors worked in urban environment, one came from a suburban clinic in and four from clinics in rural areas. Their working experience varied from two to 45 years, and all had already had experience with the detection of IPV. With this sample we were looking for a wide variety of viewpoints towards screening for violence and experience in detecting violence (28).

A semi-structured interview with pre-prepared questions was used, although free replies were also encouraged. The sub-questions were only implemented when trying to deepen or direct the content and themes relevant to the survey (29). All the interviews were conducted during July 2014.

Before commencing the interview, the participants were informed about the purpose and methods of the research, and were offered the possibility to withdraw from the study at any time. They all agreed to participate. The interviews were conducted in a private room, and lasted between 12 and 19 minutes. The interviewing phase was concluded when the data were saturated, i.e. until new codes within the given category were no longer emerging, which was achieved with the 10th interview. In order to respect the privacy of the participating physicians their names are not disclosed in the text.

The following issues were discussed: (1) According to you, how important a health problem is IPV? (2) What has been your experience in dealing with IPV in your patients? (3) What do you think about screening as a method of detecting domestic violence? (4) What are the barriers to screening? (5) How well qualified do you feel for the detection of domestic violence?

All the audio recordings of interviews were accurately transcribed. After completion, the transcription was rechecked for accuracy. The transcripts were analysed by two independent researchers; in cases of discrepancies in the analysis, the issues were discussed until agreement was achieved.

The transcripts of the interviews were analysed by qualitative content analysis and by deductive analysis, which is used when data are tested against known basic features in the new context. The categories and concepts were tested in the following steps (28):

This type of analysis is typified by a rapid reduction of the data. The categorisation matrix was formed according to data from the literature (28-37), and completed according to the results of our own original analysis. The subsequent text was analysed within the categorisation matrix.

The sample consisted of seven female and three male family doctors, aged between 29 and 65 years; the mean age was 45.9 years. Three of the participating physicians were specialists in general medicine, four were specialists in family medicine, and there were three residents/ trainees in family medicine. Five doctors came from urban clinics, one from a suburban clinic and four from clinics in rural areas.

Data are shown separately for the results of the analysis of screening and of the active detection of IPV, according to the definition of each mode of identification of victims ((19), (20)).

The current organization of work in family medicine clinics tends to reduce the potential for screening, due to limited time for each consultation and understaffing in this specialty ((38), (39)). The responses expose the fast pace of consultations (like a “conveyor belt”) and lack of time to deal with patients, while still carrying a large responsibility for them (Table 1). A cross-sectional study (40) which measured workload in the clinic, carried out among 50 family doctors in Slovenia, showed that the physicians have an average of only 6.93 minutes for each patient (39). This is due to the lack of family doctors in Slovenia compared with the European average, and consequently to an excessive number of patients per doctor (41).

It therefore seems reasonable that doctors are reluctant to take on screening as an additional burden, as they are aware that it is not a common topic in a typical consultation, and stressed that such conversations demand extra time (Table 1). This standpoint was shared by all participating doctors, regardless of their demographic data, mode of training (general medicine or family medicine), years of experience and their working environment. Lo Fo Wong notes that even 10-15 minutes, which is double the average time of consultation in Slovenia, is insufficient for screening and the consequent identification of potential victims of violence, where there are no known risk factors (42). Some studies have shown the inquiry should be repeated several times for the same individuals ((13), (43), (44)). Such a treatment plan, to detect IPV in multiple consecutive short conversations with prior preparation, taking account of the current limitations of consultation time in Slovenia, was also proposed by one of the interviewees. In a foreign qualitative research study (42), the desire for progressive detection was also expressed from the point of view of the victims; they expected more consecutive direct questioning, in order to prepare themselves for the disclosure.

Doctors have expressed difficulties in connection with the organizational peculiarities of work in family medicine (Table 1). The lack of doctors means a high turnover, and this reduces one of the most important competencies in family medicine – continuity. Doctors in family medicine have normally known and followed up their patients and their families over a long period of time (45). Because of their position, the ‘new’ doctors usually feel a lower confidence level than required in order to discuss violence (46). On the other hand, experienced physicians in this research recognized that their profession was the right place to detect IPV.

One of the participating physicians expressed the fear that dealing with violence meant an expansion of the health services program in the family medicine clinic (Table1). In their research, Zink and colleagues encountered a similar barrier in family doctors considering family violence; they thought that in their work “there is no need to look for new problems” (43). Lack of resources was also one of the major barriers to screening identified in a study by Lapidus (47). The participants in our interviews expected a clear definition of violence in order to carry out screening (Table 1). While they did not have any doubts or concerns about physical violence, they found the boundaries between certain specific behaviours and psychological violence less clearly defined. Psychological violence is more common than physical violence and has serious consequences, but its definition in different environments and cultures is problematic, as researchers have found, even in large studies (4, 48-50). In the context of the detection of violence, doctors presented a somewhat more flexible stance on its definition, taking into account the ethnic and cultural background, and, in particular, the position of the victim in the family (Table 2). If certain behaviour was perceived by victims as expected, acceptable and harmless, the doctors in the study did not consider it as violence.

The concern of the participating physicians with regard to screening as an effective and reliable instrument for the detection of IPV (Table 1) is consistent with previous findings, which could not confirm evidence-based support for the benefits of screening, and which may show that screening does not meet the criteria for secondary prevention (i.e. screening must, by definition, be an intervention which improves prognosis) (51). A recently published meta-analysis of several studies showed that more victims of violence are detected by screening, but that this proportion is still low compared to the frequency of violence; likewise, no improved outcomes for the victims following the screening could be demonstrated (22). The opinion of other researchers is that screening is justified because it detects violence as a risk factor responsible for a wide range of mental and physical problems (52). However, screening for violence, unfortunately, is not a simple diagnostic test with clear interpretation (42), as in the case of most chronic diseases. The sensitivity of the screening is also questionable in terms of falsenegative results, as it may occur during the period of denial, when the victim is not willing to disclose (53). In this regard, doctors were aware of their own limitations during consultation, as has been observed in several other publications (54-60).

The concern of doctors for their own safety in relation to retaliation by the perpetrator of violence was also mentioned while investigating IPV (Table 2). Doctors minding their own safety is understandable; a recent survey on violence against doctors in Slovenia showed considerable exposure on the one hand, and relatively rare or completely lacking mechanisms for protection on the other (61). This phenomenon is not specific to the Slovenian environment, as it has also been reported elsewhere (62).

Doctors highly value and protect the confidential doctorpatient relationship, as well as the privacy of their patients (Table 1, 2). While discussing violence, they have a sense of intrusion into the privacy of patients and are, therefore, reluctant to do it. They fear that, by asking about violence, they may hurt the patients’ feelings, arouse their suspicions or reduce their confidence (Table 1, 2). With these concerns, physicians demonstrate a highly ethical stance, particularly in protecting confidentiality and upholding the principle of do-no-harm to the patient (63). Similar dilemmas and obstacles to screening have also been reported by other authors (64-66). However, any harmful effects of screening have not been scientifically proven ((22), (64)). Doctors should have sufficient knowledge and skills for the screening, and be properly trained to respond professionally in the event of disclosure of violence ((11), (67)). Even the subjects in this qualitative research expressed fears within the meaning of the ‘Pandora’s Box’ phenomenon: merely asking about violence is not enough – there needs to be further action. Two recent studies, however, have found the importance of the disclosure of violence and subsequent participation in support programs: even the mere disclosure and subsequent clarification of the concept of violence helped victims to enter the 5-stage model of change ((43), (44)).

Although the participants of the study were not in favour of screening, they did suggest some urgent organizational conditions under which screening would be potentially feasible (Table 1).

Screening for only the most serious forms of physical violence was mentioned. It is known that different types of violence are interlinked, and therefore the victims of physical IPV are highly likely to be also exposed to mental and sexual violence (5). Screening with a single question about severe physical violence could perhaps identify high-risk victims, but the comprehensive treatment of victims would be neglected and the more frequent victims of psychological violence could be overlooked (5). The option proposed by two of the subjects in this study, of screening in the Slovenian model practices, has not been foreseen in the project program (68).

Notwithstanding the prevailing negative attitude towards screening, all the participants recognized the importance of adequate treatment of violence in a family medicine environment (Table 1, 2). They had all already been exposed to specific situations associated with IPV with their patients, had had experience of it, and been aware of the significance and frequency of domestic violence. The reluctance towards screening of the participating doctors is consistent with the results of research: screening should be implemented only to determine the frequency of violence in individual countries ((1), (6), (11)). It is primarily the environment of family medicine, as compared to all other environments, that allows the identification of the majority of the victims of IPV; research in family medicine practices (13, 21, 22, 64) in Australia, Ireland and the United Kingdom detected a higher incidence of IPV (between 37% and 40%) compared to studies in the general population in the same environment (an average of 30%) (4, 10, 12, 69, 70).

In our study, the physicians identified several obstacles to the active detection of IPV from the point of view of the patients: the powerlessness of victims of violence; their fear; a sense of stigma or shame; tolerance of violence; and even passivity and negative experiences with the healthcare system (Table 2). These findings are confirmed by patient-oriented research: the bullying of the victim by the perpetrator or the victim’s fear of reprisal undoubtedly reduce the possibility of the victim reporting IPV (67-71). Similarly to our study, the fear of stigma and shame, which appear due to self-accusation of the victims, and sometimes the attitude of the environment (e.g.: “He’s your own choice.”) were confirmed by other researchers ((13), (29), (32)). Observation of the helplessness of the victims and their bad experiences with services and institutions that deal with the treatment of violence, e.g. the police and social services in our study (Table 2), are consistent with the findings of other studies, in which the victims cited pressure from family and/or community, and the hope that the violence would cease, as important barriers to disclosure ((17), (37), (70)).

In connection with the discovery of IPV, the family doctors in the study mentioned relief, a deepening of the relationship with the patient, a better understanding of patients and their problems, solutions to unspecified health problems and an open field of sincere communication following the disclosure by the victim of violence (Table 2); so disclosure of violence brings many positive outcomes for both doctor and patient, not just the latter. Similar positive experiences of physicians are reported by other researchers ((42), (55), (56)).

Notwithstanding the negative attitude towards screening, which is consistent with current guidelines (36), all the participants expressed great interest in the identification of victims of violence in those with the recognized risk factors. Motivation for the active detection of violence was also recorded in their statements on the importance of awareness of IPV and its consequences (Table 2).

In the interviews with the doctors, a great desire and need was expressed for specific skills for communicating with patients on this subject, both in terms of screening and in active detection of violence (Table 1, 2). In their view, IPV screening requires different skills from those needed for treating chronic diseases and other risk factors. A desire and readiness to upgrade their skills in both verbal and non-verbal communication was stressed by all participants. Published research confirms that a lack of specific skills is a common reason for non-recognition of victims of violence ((16), (54)). The experience of the patients shows that an empathic manner when communicating with them reduces discomfort and increases the potential of disclosure of violence, irrespective of the gender of the doctor ((55), (56)).

In the context of educational activities, some authors do not address the views and attitudes of doctors towards violence ((19), (42)). In addition, the lack of knowledge of IPV can have negative consequences on the outcomes of screening, not only for patients, but also for doctors ((42), (57)). The concept of “creating an appropriate atmosphere to talk about violence” appears in the literature, which reports the viewpoint of female victims to screening; as in this Slovenian survey, the participating victims in the literature confirmed that an appropriate atmosphere helped them in overcoming denial, in addition to the doctor listening to them without prejudice or value judgments, showing empathy and allowing them time for decision-making (58-60). The participants in this study spontaneously listed most of these factors (Table 1, 2). They appreciated the trust of the patients while leaving them time and space to decide what to do, and the participating doctors emphasised their impartiality. Further research in this field would be useful, in particular into the performance of different strategies for the early detection of IPV.

The main limitation of the research is that it was carried out with only ten participating doctors, but saturation of data occurred even in this number of interviewees. Views on the barriers met by the patients could be better obtained not only indirectly from the observations of doctors, but also directly from some of the patients. However, it was the first qualitative IPV-related study in family medicine in Slovenia, identifying the obstacles as well as the enhancingfactors in the detection of IPV cases. Our findings provided a sufficiently thorough insight into the complexity of this threatening phenomenon, and could be used as basic knowledge for professionals preparing guidelines for family medicine practitioners dealing with patients exposed to IPV.