Effect of Type and Severity of Intimate Partner Violence on Women’s Health and Service Use

Abstract

Intimate partner violence (IPV) has major affects on women’s wellbeing. There has been limited investigation of the association between type and severity of IPV and health outcomes. This article describes socio-demographic characteristics, experiences of abuse, health, safety, and use of services in women enrolled in the Women’s Evaluation of Abuse and Violence Care (WEAVE) project. We explored associations between type and severity of abuse and women’s health, quality of life, and help seeking. Women (aged 16–50 years) attending 52 Australian general practices, reporting fear of partners in last 12 months were mailed a survey between June 2008 and May 2010. Response rate was 70.5% (272/386). In the last 12 months, one third (33.0%) experienced Severe Combined Abuse, 26.2% Physical and Emotional Abuse, 26.6% Emotional Abuse and/or Harassment only, 2.7% Physical Abuse only and 12.4% scored negative on the Composite Abuse Scale. A total of 31.6% of participants reported poor or fair health and 67.9% poor social support. In the last year, one third had seen a psychologist (36.6%) or had 5 or more general practitioner visits (34.3%); 14.7% contacted IPV services; and 24.4% had made a safety plan. Compared to other abuse groups, women with Severe Combined Abuse had poor quality of life and mental health, despite using more medications, counseling, and IPV services and were more likely to have days out of role because of emotional issues. In summary, women who were fearful of partners in the last year, have poor mental health and quality of life, attend health care services frequently, and domestic violence services infrequently. Those women experiencing severe combined physical, emotional, and sexual abuse have poorer quality of life and mental health than women experiencing other abuse types. Health practitioners should take a history of type and severity of abuse for women with mental health issues to assist access to appropriate specialist support.

Keywords

domestic violence anything related to domestic violence assessment intervention/treatment

Intimate partner violence (IPV) is common in the community (Abramsky et al., 2011; Australian Bureau of Statistics, 2005; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006) and clinical populations, particularly in primary care (Feder et al., 2009). It contributes to substantial physical and mental health burden among women in developing and developed parts of the world (Campbell, 2002; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008). In Australia, IPV is the leading cause of morbidity and mortality for women of child bearing age (Vos et al., 2006). Abused women use medical services more frequently because of increased rates of mental health issues (depression, anxiety, suicide, somatization, posttraumatic stress disorder, substance abuse; Golding, 1999; Rees et al., 2011) and physical health issues (chronic somatic complaints, reproductive problems and injuries; Campbell, 2002).

Despite the pervasive effects of IPV on societies, there are few trials of interventions for IPV in health care settings. Furthermore, there is a paucity of quantitative data on how different types and severity of abuse relate to women’s health, quality of life, and service use, with most data coming from the specialist service sector (e.g., Bonomi, Holt, Martin, & Thompson, 2006; Feder et al., 2009; Straus et al., 2009; Wuest et al., 2010). Gathering this data is hampered by most measures of IPV not characterizing type and severity of abuse (Hegarty, 2006). In studies that have made these distinctions, higher severity of abuse has been associated with lower mental and physical health status, quality of life, and higher levels of depression, posttraumatic stress disorder and chronic pain (Dutton, Kaltman, Goodman, Weinfurt, & Vankos, 2005; Straus et al., 2009; Wuest et al., 2010). The nature of these associations has differed according to the type of abuse experienced. For example, Wuest et al. found a relationship between chronic pain and severity of abuse, but only for psychological abuse. Dutton et al. found that women who had experienced more severe psychological and physical abuse were at greater risk of revictimization, but only if they had not also experienced severe sexual violence from their partners. Other studies have found that particular forms of abuse, such as harassment, put women at greater risk of revictimization, regardless of abuse severity (e.g., Cole, Logan, & Shannon, 2008). These studies show that the complex relationship between type and severity of abuse need to be taken into account when measuring IPV and related outcomes.

Many health organizations (e.g., American Medical Association, 2008; Joint Commission for the Accreditation of Healthcare Organizations [JCAHO], 2011) recommend screening for IPV in health care settings, although the evidence on whether screening does more good than harm is limited (Feder et al., 2009) with a recent Canadian trial showing no beneficial health outcomes from screening alone (MacMillan et al., 2009). The primary care setting has potential to facilitate early intervention given the high level of contact women have with family practice (Feder et al., 2011). The Women’s Evaluation of Abuse and Violence Care (WEAVE) project is the first family practice based trial testing the effect of screening plus intervention for IPV on women’s health and wellbeing (Hegarty et al., 2010). The trial protocol (Hegarty et al., 2010), intervention (Hegarty, O’Doherty, Gunn, Pierce, & Taft, 2008), and screening stage (Hegarty, O’Doherty, Astbury, & Gunn, 2012) have been described in detail elsewhere. In this article, we report an analysis of associations of type and severity of IPV with trial participants’ health and wellbeing, safety planning, and use of support and clinical services. This fills a gap in the literature examining associations specifically of type and severity of IPV with health outcomes.

Method

Between June 2008 and May 2010, women aged 16–50 years attending participating urban and rural general practitioners (GPs) in the previous 12 months were sent a postal screening survey. Women were excluded if the GP anticipated they may encounter difficulties in providing informed consent or understanding the surveys. The survey contained a series of items about lifestyle issues (Goodyear-Smith, Arroll, & Coupe, 2009), including an item about fear of partner to screen for IPV (Hegarty, Bush, & Sheehan, 2005). Women who indicated fear of a partner and supplied contact details were phoned by a research assistant and invited to participate in the trial. Additional exclusions were undertaken at this point if women had misinterpreted the fear item or been fearful more than 12 months ago, had moved, or had poor English language skills. Women willing to be involved were sent a baseline survey, an information leaflet and a resource services card to their nominated “safe” address.

The baseline survey was adapted from surveys used in the DIAMOND study (Gunn et al., 2008). The survey included socio-demographic items, childhood abuse (Child Maltreatment History Self-Report; MacMillan et al., 1997), quality of life (WHOQOL-Bref; Skevington, Lotfy, & O’Connell, 2004), physical and mental health status (Short-Form 12; SF-12; Ware, Kosinski, & Keller, 1996), safety (Safety-Promoting Behaviour Checklist; SPBC; McFarlane, Parker, Soeken, Silva, & Reel, 1998), anxiety and depression (Hospital Anxiety and Depression Scale; HADS; Zigmond & Snaith, 1983), posttraumatic stress disorder (Short Screening Scale for DSM-IV PTSD; Breslau, Peterson, Kessler, & Schultz, 1999), days out-of-role; alcohol use (Alcohol Use Disorders Identification Test; AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), smoking, and medication use.

IPV was measured using the Composite Abuse Scale (CAS; Hegarty et al., 2005), which categorizes respondents according to four different types of abuse experienced in the last 12 months: (i) Severe Combined Abuse, (ii) Physical and Emotional Abuse, (iii) Physical Abuse only, and (iv) Emotional Abuse and/or Harassment only. Women who did not meet the criteria for any of the abuse types on the CAS (e.g., because the abuse was longer than 12 months ago) were classified as fearful in the past 12 months but negative for IPV. The survey also measured GPs’ inquiry about safety of women and their children, service utilization, and visits to health care providers.

Once baseline surveys were returned, women were formally enrolled in the trial and GPs (and women) were randomly allocated to intervention or comparison groups. This article focuses on data emerging from the baseline assessment only. The study was granted ethics approval by the Human Research Ethics Committee of The University of Melbourne and is undertaken in accordance with CONSORT guidelines (Schulz, Altman, & Moher, 2010).

Data were summarized using frequencies and percentages for categorical data, and means and standard deviations for continuous data. Data met all assumptions for statistical tests performed. Marginal logistic regression was used to compare patient characteristics between the fearful women who agreed to enrol in the trial and those who did not. Women’s experiences of quality of life, health status, lifestyle, safety and help seeking behaviors and health care utilization were compared across the four abuse categories (namely, fearful but CAS-negative, Severe Combined Abuse, Physical and Emotional Abuse, and Emotional Abuse, and/or Harassment only). Women in the Physical Abuse only group were excluded from the analysis because there were only five women. The association between each of the outcome variables and type of abuse was tested using marginal linear and logistic regression models for continuous and binary outcomes, respectively. The marginal models were fitted using generalized estimating equations with information sandwich estimates of the standard errors to allow for the correlation between responses of the women that attend the same general practice.

Results were presented as mean score differences (95% confidence intervals, CI) for the continuous outcomes for each abuse category (Severe Combined Abuse, Physical and Emotional Abuse, and Emotional Abuse and/or Harassment only) compared to the group where women were fearful but CAS negative, which was chosen as the reference category for the analysis. Results were presented as odds ratios (OR) with 95% CIs for binary outcomes for each of the three CAS positive groupings compared to the reference group. Overall p-values that summarize the strength of the association between each outcome and abuse type were also reported. Estimates were also adjusted for age, marital status, income, and education based on a priori hypotheses of an independent association with abuse derived from the literature (Hegarty, Gunn, Chondros, & Small, 2004; Hegarty, Gunn, Chondros, & Taft, 2008). Data were analyzed using STATA, version 11.0 (StataCorp, 2009).

Results

Figure 1 shows the flow of patient participants up to enrolment in the baseline phase of the trial. Across 55 practices initially recruited into the study, 5,742/19,879 (28.9%) women returned a screening survey; 731/5,742 (12.7%) of them reported being afraid of a partner or ex-partner in the previous 12 months and 477/731 (65.3%) supplied contact details. Furthermore, 91 women were established as ineligible once they were contacted. Ultimately, 272/386 (70.5%) women from 52 practices completed the baseline assessment and enrolled in the trial. Three GPs were excluded from the analysis because none of their screened patients were eligible for participation. There was no difference between women who enrolled in the trial and fearful women who did not enrol, by age, employment, relationship status, or birthplace (see Table 1). However, trial enrolees were more often separated or divorced, had less school education, and were more likely to have English as their first language compared to fearful non-enrolees. Trial enrolees also experienced more fear of partner than fearful non-enrolees (52.2% versus 38.1% fearful some, most or all of the time).

Figure 1.

Flowchart of patient participation in the WEAVE trial before randomization of practices

Table 1.

Socio-Demographic Characteristics of Trial Enrolees (N = 272) and Non-Enrolees (N = 459)^a

	Enrolees, n (%)	Non-Enrolees, n (%)	OR (95% CI)^b	p Value
Age <30years	44 (16.2)	96 (21.2)	1.4 (0.9, 2.1)	.14
High school not completed	114 (42.2)	146 (32.2)	0.6 (0.4, 0.9)	<.01
Unemployed^c	73 (30.3)	105 (24.8)	0.8 (0.5, 1.1)	.15
Pension main source of income	61 (23.4)	82 (19.1)	0.8 (0.5, 1.1)	.15
Current intimate relationship	187 (68.8)	318 (69.7)	0.9 (0.7, 1.2)	.69
Lives with a partner	144 (52.9)	262 (57.7)	0.8 (0.7, 1.0)	.08
Marital status
Never married (base category)	86 (32.1)	158 (35.0)	—	—
Married	83 (30.9)	169 (37.5)	0.9 (0.6, 1.3)	.59
Separated/divorced/widowed	99 (36.9)	124 (27.5)	1.5 (1.1, 2.0)	.02
Not born in Australia	48 (17.7)	86 (1.8)	1.1 (0.7, 1.8)	.71
English not first language	15 (5.6)	51 (11.2)	2.1 (1.2, 4.0)	.02

Note. OR = odds ratio; CI = confidence interval.

Denominators vary because of missing data.

Calculated using logistic regression.

Includes those seeking and not seeking work.

Figure 2 shows the proportions of trial enrolees at baseline (N = 272) who experienced each type of abuse in the last 12 months. Severe Combined Abuse was the most common type of abuse experienced (33.0%), followed closely by Physical and Emotional Abuse (26.2%), and Emotional Abuse and/or Harassment only (26.6%); whereas only five participants (2.7%) had experienced Physical Abuse only. More than half (64.0%) of trial participants had experienced physical and/or sexual abuse as a child. Participants had fair or poor health (31.6%) and poor social support (67.9%). They had high levels of mental ill health, with one third of the women being on antidepressants (33.2%) or painkillers (32.1%) and were frequent users of health care services. However, in the past 12 months, only 11.2% had seen a social worker, 14.7% had sought help from a domestic violence service, 20.4% had contact with police, and 25.4% had contacted legal services. Around one quarter (24.4%) had ever made a safety plan.

Figure 2.

Women’s health, safety, and help seeking (N = 272^a)

Table 2 shows that trial enrolees had lower scores on all dimensions of quality of life (WHOQOL-Bref) and mental health (SF-12) compared to the Australian population (Australian Bureau of Statistics, 1997; Hawthorne, Herrman, & Murphy, 2006). Overall, women experiencing Severe Combined Abuse reported lower quality of life on the physical, psychological, and environmental dimensions of the WHOQOL-Bref compared to all other abuse categories. Although women experiencing some form of abuse (Severe Combined Abuse, Physical and Emotional Abuse, or Emotional Abuse and/or Harassment only) reported lower quality of life on the social dimension of the WHOQOL-Bref and lower mean mental health scores on SF-12 compared to the women who reported being fearful but CAS negative.

Table 2.

Participants’ Quality of Life and Health Status by Type of Abuse as Measured on the CAS (N = 262^a)

						Unadjusted Analyses				Adjusted Analysis^b
	Population means	CAS-neg (n = 33)	EA/H (n = 71)	PA&EA (n = 70)	SCA (n = 88)	EA/H	PA&EA	SCA		EA/H	PA&EA	SCA
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	β (95% CI)	β (95% CI)	β (95% CI)	p	β (95% CI)	β (95% CI)	β (95% CI)	p
WHO QOL-BREF
Physical	73 (17)	62.8 (21.1)	64.8 (15.8)	61.7 (15.7)	51.0 (20.9)	2.6 (−5.3, 10.4)	−0.6 (−9.0, 7.8)	−11.7 (−18.2, −5.1)	<.001	3.7 (−4.0, 11.3)	1.1 (−6.6, 8.8)	−8.9 (−15.8, −2.0)	<.001
Psychological	70.3 (13)	56.1 (17.2)	53.5 (15.3)	47.9 (18.0)	43.8 (19.0)	−2.5 (−8.7, 3.6)	−8.2 (−16.3, −0.1)	−12.2 (−17.9, −6.5)	<.07	−0.6 (−6.6, 5.3)	−5.8 (−13.4, 1.8)	−9.0 (−15.0, −3.0)	.01
Social	73.1 (17)	60.9 (23.2)	48.0 (22.9)	44.6 (25.0)	42.3 (23.0)	−9.6 (−19.6, −0.4)	−13.5 (−23.5, −3.5)	−17.2 (−25.4, −9.1)	<.001	−8.9 (−18.4, −0.6)	−12.9 (−22.2, −3.4)	−14.8 (−23.5, −6.1)	<.01
Environmental	74.8 (13)	65.0 (17.2)	61.3 (14.2)	60.5 (14.5)	53.5 (14.9)	−2.6 (−9.2, 3.9)	−3.4 (−10.8, 3.9)	−11.2 (−17.0, −5.3)	<.001	−1.3 (−7.8, 5.1)	−2.0 (−9.6, 5.5)	−8.3 (−14.2, −2.5)	<.01
SF-12
Physical scale	49.6 (10)	46.3 (10.7)	50.3 (9.5)	52.8 (8.6)	44.6 (12.3)	4.1 (−1.4, 9.6)	6.6 (2.2, 11.0)	−1.6 (−6.3, 3.1)	<.001	5.3 (0.8, 9.8)	6.9 (3.2, 10.7)	0.2 (−4.1, 4.4)	<.001
Mental scale	49.4 (10)	43.1 (12.1)	38.3 (11.4)	34.2 (10.8)	33.5 (11.6)	−4.4 (−7.8, −1.1)	−8.7 (−13.2, −4.2)	−9.7 (−13.4, −6.0)	<.001	−3.3 (−6.8, 0.2)	−7.6 (−12.0, −3.2)	−7.6 (−11.5, −3.8)	<.001

Note. Denominators for each measure vary because of missing data. Results are presented as score differences (95% confidence intervals) in linear regression models. The CAS groups were compared to the fearful but CAS-negative group on each of the outcomes.

CAS = Composite Abuse Scale; CAS-neg = fearful in past 12 months but did not meet cut-off score for abuse on the CAS; EA/H = Emotional Abuse and/or Harassment only; PA&EA = Physical Abuse and Emotional Abuse and/or Harassment; SCA = Severe Combined Abuse; WHOQOL-Bref = World Health Organization Quality of Life Bref; SF-12 = Short-Form 12.

Ten participants were excluded from analyses: five reported physical abuse only and five had missing data.

Adjusted for age, marital status, income and education, and clustering effect (at the general practice level).

Table 3 shows that women in the Severe Combined Abuse group were also more likely than the other abuse groups to report PTSD, anxiety symptoms, sedative, analgesic, and antidepressant use, and to experience days out-of-home duties because of emotional issues. Those experiencing Severe Combined Abuse or Physical and Emotional Abuse were also more likely than those in the other abuse groups to experience days off work because of emotional issues. As shown in Table 4, women experiencing Severe Combined Abuse were more likely than the fearful but CAS negative group to have ever made a safety plan and to have used safety-promoting behaviors in the last 6 months. Women in the Severe Combined Abuse and Physical and Emotional Abuse groups were more likely than the other groups to have visited a counselor, social worker, or psychologist in the past 12 months. In addition, there was a trend toward those in the Severe Combined Abuse group being somewhat more likely than the others to have been asked by a GP about their safety at home in the last 6 months.

Table 3.

Participants’ Physical and Mental Health and Lifestyle by Type of Abuse as Measured on the CAS (N = 262^a)

	CAS-neg (n = 33)	Emotional Abuse Only (n = 71)	Physical and Emotional Abuse (n = 70)	Severe Combined Abuse (n = 88)	Unadjusted Analyses				Adjusted Analysis^b
	CAS-neg (n = 33)	Emotional Abuse Only (n = 71)	Physical and Emotional Abuse (n = 70)	Severe Combined Abuse (n = 88)	EA/H	PA&EA	SCA	p	EA/H	PA&EA	SCA	p
	No. (%)	No. (%)	No. (%)	No. (%)	OR (95% CI)	OR (95% CI)	OR (95% CI)	p	OR (95% CI)	OR (95% CI)	OR (95% CI)	p
Positive PTSD	10 (30.3)	36 (52.9)	35 (50.0)	67 (77.9)	2.6 (1.1, 6.0)	2.3 (1.0, 5.1)	8.1 (3.3, 19.9)	<.001	2.1 (0.9, 4.7)	2.0 (0.9, 4.5)	5.5 (2.2, 13.8)	<.01
Moderate to severe anxiety (HADS)	12 (36.4)	30 (42.9)	35 (50.7)	59 (67.1)	1.3 (0.6, 2.9)	1.8 (0.8, 3.9)	3.5 (1.7, 7.4)	<.01	1.2 (0.5, 2.8)	1.6 (0.7, 3.4)	3.0 (1.4, 6.6)	.02
Moderate to severe depression (HADS)	5 (15.2)	10 (14.3)	14 (20.3)	26 (29.5)	0.9 (0.3, 2.7)	1.5 (0.5, 4.8)	2.5 (0.9, 6.5)	.04	0.8 (0.3, 2.3)	1.2 (0.3, 4.1)	1.9 (0.7, 5.2)	.11
Current use of sleeping medication >2 weeks	3 (10.0)	9 (13.9)	8 (12.1)	27 (34.6)	1.4 (0.4, 5.2)	1.2 (0.3, 4.6)	4.6 (1.4, 15.1)	<.01	1.3 (0.3, 5.1)	1.2 (0.3, 4.7)	4.2 (1.1, 15.7)	.01
Current use of pain medication >2 weeks	7 (21.9)	15 (23.4)	14 (20.9)	40 (50.6)	1.1 (0.4, 3.1)	1.0 (0.3, 2.9)	3.5 (1.4, 8.9)	<.001	1.4 (0.4, 4.7)	1.3 (0.4, 4.4)	4.5 (1.6, 12.4)	<.001
Current use of depression medication >2 weeks	10 (33.3)	15 (21.4)	19 (27.5)	38 (45.8)	0.5 (0.2, 1.2)	0.7 (0.3, 1.9)	1.4 (0.6, 3.2)	<.01	0.5 (0.2, 1.2)	0.7 (0.2, 2.0)	1.3 (0.5, 3.3)	.01
Currently smokes	9 (27.3)	17 (25.4)	16 (23.5)	41 (47.7)	0.9 (0.3, 2.6)	0.8 (0.3, 2.4)	2.4 (0.9, 6.2)	<.001	0.8 (0.3, 2.6)	0.7 (0.2, 2.1)	2.1 (0.7, 6.0)	<.01
Hazardous alcohol use, AUDIT	6 (19.4)	14 (20.9)	13 (19.4)	20 (24.4)	1.1 (0.4, 2.8)	1.0 (0.4, 2.7)	1.3 (0.5, 3.5)	.87	0.9 (0.3, 2.4)	0.9 (0.3, 2.5)	1.1 (0.4, 3.1)	.85
≥3 days out of work^d (because of physical issues)	6 (25.0)	16 (30.2)	12 (26.7)	24 (42.1)	1.3 (0.4, 4.1)	1.1 (0.3, 3.7)	2.2 (0.8, 6.7)	.19	1.1 (0.3, 3.6)	1.0 (0.3, 3.5)	2.2 (0.7, 6.9)	.17
≥3 days out of work^c (because of emotional issues)	2 (8.3)	9 (17.0)	19 (42.2)	18 (31.6)	2.3 (0.6, 9.0)	8.6 (2.0, 37.2)	5.3 (1.1, 24.8)	<.01	1.8 (0.4, 7.9)	7.2 (1.5, 34.8)	5.0 (1.0, 24.2)	.02
≥3 days out of home duties and study (physical)	10 (33.3)	19 (27.1)	16 (25.0)	33 (41.3)	0.7 (0.3, 1.9)	0.7 (0.3, 2.0)	1.4 (0.5, 3.7)	.05	0.6 (0.2, 1.4)	0.5 (0.2, 1.5)	1.1 (0.4, 3.0)	.11
≥3 days out of home duties and study (emotional)	8 (25.8)	28 (40.6)	33 (51.6)	46 (57.5)	2.0 (0.8, 5.4)	3.2 (1.1, 9.3)	3.8 (1.5, 9.4)	<.01	1.7 (0.6, 4.8)	2.6 (0.9, 7.8)	3.3 (1.2, 8.9)	.01

Note. Denominators vary because of missing data. Results are presented as odds ratios (with 95% confidence intervals) calculated using logistic regression. The CAS groups were compared to fearful but CAS-negative group on each of the outcomes.

OR = odds ratio; CI = confidence interval; CAS = Composite Abuse Scale; CAS-neg = fearful in past 12 months but did not meet cut-off score for abuse on the CAS; EA/H = Emotional Abuse and/or Harassment only; PA&EA = Physical Abuse and Emotional Abuse and/or Harassment; SCA = Severe Combined Abuse; PTSD = Posttraumatic Stress Disorder; HADS = Hospital Anxiety and Depression Scale; AUDIT = Alcohol Use Disorders Identification Test.

Ten participants were excluded from analyses: five reported physical abuse only and five had missing data.

Adjusted for age, marital status, income and education, and clustering effect (at the general practice level).

Applies to the 186 women who were currently working.

Table 4.

Safety, Help-Seeking and Health Care Utilization by Type of Abuse as Measured on the CAS (N = 262^a)

	CAS-neg (n = 33)	EA/H (n = 71)	PA&EA (n = 70)	SCA (n = 88)	Unadjusted Analyses				Adjusted Analysis^b
	CAS-neg (n = 33)	EA/H (n = 71)	PA&EA (n = 70)	SCA (n = 88)	EA/H	PA&EA	SCA	p	EA/H	PA&EA	SCA	p
	No. (%)	No. (%)	No. (%)	No. (%)	OR (95% CI)	OR (95% CI)	OR (95% CI)	p	OR (95% CI)	OR (95% CI)	OR (95% CI)	p
Ever made a safety plan	4 (12.1)	16 (22.5)	14 (20.0)	28 (32.6)	2.1 (0.6, 7.2)	1.8 (0.6, 5.7)	3.5 (1.2, 9.8)	.03	2.0 (0.6, 6.8)	1.6 (0.5, 5.2)	4.1 (1.5, 11.2)	.01
Used ≥6 safety behaviors in last 6 months, SBC	4 (12.1)	13 (18.6)	19 (27.1)	31 (36.5)	1.7 (0.5, 5.5)	2.7 (0.9, 8.6)	4.3 (1.2, 15.4)	.08	2.8 (0.6, 13.5)	4.2 (1.0, 17.4)	6.9 (1.6, 30.9)	.03
Visited GP ≥5 times in last 12 months	15 (45.5)	29 (41.4)	36 (51.4)	46 (53.5)	0.9 (0.4, 1.8)	1.3 (0.6, 2.7)	1.4 (0.6, 2.9)	.54	0.8 (0.3, 1.7)	1.1 (0.5, 2.5)	1.2 (0.5, 2.7)	.61
Visited psychiatrist ≥1 in last 12 months	2 (6.3)	9 (13.0)	10 (14.3)	17 (20.0)	2.3 (0.5, 10.5)	2.6 (0.6, 11.8)	3.8 (0.9, 16.2)	.30	2.1 (0.5, 9.8)	2.3 (0.5, 11.4)	3.3 (0.7, 15.3)	.44
Visited ED ≥1 times in last 12 months	7 (21.2)	22 (31.0)	18 (25.7)	28 (32.2)	1.6 (0.7, 4.1)	1.3 (0.5, 3.0)	1.8 (0.7, 4.2)	.54	1.5 (0.5, 3.9)	0.9 (0.3, 2.5)	1.4 (0.5, 3.7)	.57
Visited counselor, social worker, psychologist ≥1 times in last 12 months	10 (31.3)	29 (41.4)	45 (64.3)	50 (58.8)	1.6 (0.7, 3.9)	4.0 (1.7, 9.3)	3.2 (1.4, 7.1)	<.01	1.4 (0.5, 3.6)	3.5 (1.3, 9.3 )	2.9 (1.2, 6.7)	.02
Used a domestic violence support service ≥1 times in last 12 months	2 (6.3)	7 (10.1)	8 (11.9)	20 (22.7)	1.7 (0.3, 8.8)	2.0 (0.4, 10.0)	4.4 (1.0, 20.1)	.04	1.6 (0.2, 10.0)	2.2 (0.3, 14.1 )	4.7 (0.8, 28.9)	.07
GP enquired about safety of participant in last 6 months	1 (3.1)	11 (15.5)	14 (20.0)	22 (25.6)	5.9 (0.6, 53.3)	8.3 (1.0, 71.0)	11.6 (1.3, 101.2)	.05	4.9 (0.6, 42.6)	8.5 (1.1, 67.0)	10.3 (1.2, 91.0)	.08
GP enquired about safety of children under 18 at home^c	3 (15.0)	6 (14.6)	7 (16.3)	13 (27.7)	1.0 (0.2, 5.6)	1.2 (0.3, 5.3)	2.3 (0.6, 8.3)	0.2	1.8 (0.3, 11.9)	2.4 (0.4, 13.0)	4.1 (0.9, 19.6)	.17

OR = odds ratio; CI = confidence interval; CAS = Composite Abuse Scale; CAS-neg = fearful in past 12 months but did not meet cut-off score for abuse on the CAS; EA/H = Emotional Abuse and/or Harassment only; PA&EA = Physical Abuse and Emotional Abuse and/or Harassment; SCA = Severe Combined Abuse; SPBC = Safety-Promoting Behaviour Checklist; GP = general practitioner; ED = emergency department.

Ten participants were excluded from analyses: five reported physical abuse only and five had missing data.

Adjusted for age, marital status, income and education, and clustering effect (at the general practice level).

Denominator only includes participants with children under 18 years of age at home.

Discussion

Women experiencing IPV attend family practice frequently with mental and physical issues (Campbell, 2002; Hegarty, 2006). There is a paucity of evidence to inform how health practitioners should respond in primary care, particularly tailoring care to different experiences of abuse (Feder et al., 2009). The WEAVE project is the first family practice based trial testing the effect of screening plus intervention for IPV on women’s health and wellbeing (Hegarty et al., 2010). Our findings from the baseline survey, similar to other studies (Abramsky et al., 2011; Campbell, 2002), show participants report different types of abuse during their lifetime, and generally have poor mental health and quality of life (especially the social component on the WHOQOL-Bref). Participants also use medication and health care services frequently but specialist domestic violence services infrequently. In addition, this primary care sample data uniquely shows that women with severe combined physical, emotional, and sexual abuse are more likely to report poorer mental health and quality of life compared with women experiencing other types of abuse (Dutton et al., 2005; Wuest et al., 2010). This is despite the fact that these women are more likely to attend mental health services and specialist services, to have safety plans, and to be asked about safety by their general practitioner than women experiencing other types of abuse.

Limitations of the findings include the fact that women who come into a trial are not representative of women who attend primary care more generally. In particular, the low response rate from the screening survey makes any generalizations difficult. Furthermore, all data were collected using self-report measures, which may be subject to reporting error. The strength of the findings is that women attending primary care who were more fearful of their partner were more likely to participate in the trial.

The results raise several issues for health practitioners and for future research. Many women attending primary care who are experiencing IPV are offered or seek help from mainstream health services but may not be getting the right kind of support for their particular experience of abuse. For example, they may be getting treatment for their associated anxiety or depression, for example medication or counseling, instead of access to IPV services or IPV-specific support in health settings. Health practitioners may need to tailor their care and messages to women’s experiences of type and severity of abuse, similar to the care of people with depression in primary care (Gunn, Diggens, Hegarty, & Blashki, 2006). However, health practitioners need to understand that many women have not named or accepted that what they are experiencing is IPV and thus may find it hard to be referred to an IPV service or to report to police or take out legal action (Chang et al., 2010). Many women understand that violence affects negatively on their health and this understanding can be a useful starting point to use as a basis for tailored plans (Zink, Lloyd, Isham, Mathews, & Crowson, 2007).

There is a need for further research to better understand why so few women from the primary care setting access IPV-specific services. It may be that women are only ready to make an alliance with a health practitioner to deal with the health effects of IPV or that there is stigma attached to referrals to specialized services as women may need to see themselves as “domestic violence victims” to access such services. Exploration of the severity and types of abuse may allow practitioners to support women in choosing and accessing IPV-specific services appropriate to their safety needs and readiness to change (Chang et al., 2010). The WEAVE trial explores an intervention based around the use of tailored interventions by general practitioners (Hegarty, Gunn et al., 2008).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The WEAVE study is funded by the National Health and Medical Research Council (ID: 454532). SJB’s contribution to the weave project was supported by an NHMRC Career Development Fellowship and by the Victorian Government’s Operational Infrastructure Support Program. The funding bodies had no role in study design; the collection, analysis and interpretation of data; the writing of the manuscript; or the decision to submit this manuscript for publication.

Bios

Kelsey Hegarty leads the Abuse and Violence research program in the Primary Care Research Unit, Department of General Practice, The University of Melbourne, Australia, where she holds the position of associate professor. She is also Equity and Staff Development coordinator and Director of the Postgraduate Primary Care Nursing Course in the Department and works part-time in general practice. During the last decade, Kelsey has contributed at both national and international levels to the intimate partner violence field. She has developed a program of research in family violence, which commenced with her thesis. For this, she developed a new measure of domestic violence, the Composite Abuse Scale, which is the first validated multidimensional measure of partner abuse and is available in six languages. Kelsey currently leads the first large domestic violence screening and intervention trial (WEAVE) in general practice worldwide. She has co-edited a book on “Intimate partner abuse for health professionals” and is on two Cochrane systematic reviews of screening and advocacy interventions for domestic violence. She played a significant role in the development of the international guidelines on clinician management of all family members (available on the Royal Australian College of General Practice website). She has developed an innovative domestic violence curriculum for general practitioners and she regularly teaches domestic violence and mental health issues to undergraduates and postgraduate medical and nursing practitioners. She is currently chair of the management committee of the Domestic Violence Resource Centre Victoria, Australia.

Lorna O’Doherty is a research fellow within the Abuse and Violence program of the Primary Care Research Unit, Department of General Practice, The University of Melbourne, Australia. She is coordinator of the Women’s Evaluation of Abuse and Violence care in general practice (WEAVE) trial evaluating general practice interventions for partner violence since it commenced in 2007. She is also involved in a Cochrane review of screening for partner violence. Her additional research interests are ethical issues in trials, quality of life assessment and mental health. She has a PhD in health psychology from University College Dublin/Royal College of Surgeons in Ireland. Her PhD research focused on psychological adaptation and quality of life issues among individuals living with chronic neurological disorders.

Patty Chondros is a biostatistician providing statistical support and advice for the Primary Care Research Unit, Department of General Practice, The University of Melbourne, Australia, including for the Department’s Abuse and Violence research program. She also teaches in undergraduate and postgraduate courses, and has experience in statistical consulting. She undertook her PhD in the design and analysis of matched-pair cluster randomized trials.

Jodie Valpied is a research assistant within the Abuse and Violence program of the Primary Care Research Unit, Department of General Practice, The University of Melbourne, Australia. She is also completing a PhD in Psychology at the University of Melbourne, and has a decade of experience in both qualitative and quantitative methodologies. She holds a Master of Education degree and has taught in a range of settings, including higher education and professional development. Her additional research interests include mental health, depression, introversion, questionnaire development, and structural equation modeling.

Angela J. Taft is a principal research fellow/associate professor at the Mother and Child Health Research Centre, La Trobe University, Australia, and has been with the center since 1999. She is also an honorary senior fellow in the Department of General Practice, The University of Melbourne and the National Convenor of the Women’s Health Special Interest Group of the Public Health Association of Australia. She is a social scientist with a strong interest in rigorous combination of qualitative and quantitative methods to answer complex questions about women’s health. Over the last 10 years she has led a major competitively funded program of research at the Mother and Child Health Research Centre on intimate partner/gender-based violence. This has included analyzing the health impact of Intimate Partner Violence over time in the Australian Longitudinal Study of Women’s Health, Cochrane systematic reviews, and randomized trials of Intimate Partner Violence interventions in general practice and maternal and child health nursing. She is strongly interested in preventing gender based violence and prevention of unplanned and unwanted pregnancy.

Jill Astbury is adjunct principal research fellow in the School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia. Her research has focused on identifying the determinants of women’s mental health using a gender and human rights perspective. In particular, she is concerned with exploring the relationship between gender-based violence including sexual violence and gender disparities in mental health including increased rates of depression, anxiety, and posttraumatic stress disorder. She is currently the principal investigator on an Australian Development Research award to investigate gender-based violence, disability and other rights violations and access to related services amongst women in Cambodia. Her publications include “Crazy for You: The making of women’s madness” (Oxford University Press, 1996), “Women’s mental health: an evidence based review” (WHO, 2000), and “Gender disparities in Mental Health” (WHO, 2001).

Stephanie J. Brown has established an internationally recognized research program in maternal and perinatal epidemiology at the Murdoch Children’s Research Institute, Royal Children’s Hospital, Australia. She is the principal investigator for the Maternal Health Study: a prospective pregnancy cohort study investigating women’s psychological and physical health in pregnancy and after the birth of a first child. Her research has informed the development of maternity services and policy in Australia and has achieved international standing in relation to the development of population-based methods for assessing women’s views and experiences of maternity care, and investigation of maternal health after childbirth. Her current areas of research focus include: social, obstetric, and environmental factors affecting women’s physical and psychological health during and after pregnancy; health consequences of intimate partner violence; methods for evaluating complex interventions in primary care and community based settings; and strategies for improving Aboriginal maternal and child health outcomes. Stephanie’s research is underpinned by a strong commitment to bringing together stakeholders in research to work collaboratively across all stages of research. Stephanie has received a number of awards and fellowships in the field, including an Australian Research Council Future Fellowship (2012-2015), National Health & Medical Research Council Career Development Fellowship: Level 2 (2008–2011), BMC Award for Excellence in Medicine (2007), and VicHealth Public Health Research Fellowship (2002–2006).

Lisa Gold is a senior research fellow in Deakin Health Economics, Deakin University, Australia. Lisa is a health economist with particular expertise in the economic evaluation of health and social interventions that aim to improve population health and reduce health inequalities. Over the last 12 years, Lisa has designed and successfully conducted a large number of economic evaluations in public health related issues as well as systematic reviews of evidence and methodological development in economic evaluation in the UK and Australia. Lisa is currently providing the economic input to evaluations of a range of public health interventions in maternal and child health, including trials of caseload midwifery, early language development support, and obesity prevention in primary school-aged children.

Ann Taket holds a chair in health and social exclusion within the School of Health and Social Development, Deakin University, Australia, and is director of the Centre for Health through Action on Social Exclusion (CHASE). She supervises higher degree students and also teaches at postgraduate level. She is a highly active researcher in the field of public health, with particular interests in research directed at understanding the complex interactions between social exclusion and health, in the design and evaluation of interventions to reduce health inequities, violence and abuse, and the use of action research, mixed methods, participatory methods, and experiential learning.

Gene S. Feder is professor of primary health care in the School of Social and Community Medicine, Bristol University, UK. He also works as a general practitioner, and lectures in domestic violence, research methods and other aspects of primary health care. His current research programmes focus on stable angina and health care responses to domestic violence, with his main methodological expertise being randomized controlled trials and systematic reviews. He has lead numerous research programmes, including the first epidemiological study of domestic violence in primary care in Europe and two landmark systematic reviews, including a Department of Health commissioned systematic review on partner violence interventions in health care settings. In addition to his peer-reviewed papers, he is co-editor of a book on “Intimate partner abuse for health professionals.” Gene has chaired three NICE clinical guidelines, sat on the 2010 Department of Health task-force on responding to violence against women and children (chairing the domestic violence subgroup), is an expert advisor to the WHO on domestic violence and health, and in 2009 was short-listed for the BMJ group awards for outstanding achievement in evidence-based health care.

Jane Gunn is the Head of Department, inaugural Chair of Primary Care Research, and Director of the Primary Care Research Unit, Department of General Practice, The University of Melbourne, Australia. Her research interests include depression in primary care, perinatal care, women’s health, cancer screening, study design, and analysis within the primary care setting. She is particularly interested in randomized controlled trials and complex interventions. She has worked as an Academic GP since 1991 and has been heavily involved in research, teaching, and curriculum development. Her PhD investigated the role of general practice in the provision of care to mothers and babies in the year after birth and included the analysis of routinely collected Health Insurance Commission data, a State-wide survey of GPs, and a randomized controlled trial of an early postnatal visit. She has a special interest in combining quantitative and qualitative research methods to fully explore the questions that face the primary health care setting.

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