Exploring Mental Health Professionals’ Experiences of Intimate Partner Violence–Related Training: Results From a Global Survey

Abstract

Intimate partner violence (IPV) is a global public health problem that has been shown to lead to serious mental health consequences. Due to its frequent co-occurrence with psychiatric disorders, it is important to assess for IPV in mental health settings to improve treatment planning and referral. However, lack of training in how to identify and respond to IPV has been identified as a barrier for the assessment of IPV. The present study seeks to better understand this IPV-related training gap by assessing global mental health professionals’ experiences of IPV-related training and factors that contribute to their likelihood of receiving training. Participants were French-, Spanish-, and Japanese-speaking psychologists and psychiatrists (N = 321) from 24 nations differing on variables related to IPV, including IPV prevalence, IPV-related norms, and IPV-related laws. Participants responded to an online survey asking them to describe their experiences of IPV-related training (i.e., components and hours of training) and were asked to rate the frequency with which they encountered IPV in clinical practice and their level of knowledge and experience related to relationship problems; 53.1% of participants indicated that they had received IPV-related training. Clinicians from countries with relatively better implemented laws addressing IPV and those who encountered IPV more often in their regular practice were more likely to have received training. Participants who had received IPV-related training, relative to those without training, were more likely to report greater knowledge and experience related to relationship problems. Findings suggest that clinicians’ awareness of IPV and the institutional context in which they practice are related to training. Training, in turn, is associated with subjective appraisals of knowledge and experience related to relationship problems. Increasing institutional efforts to address IPV (e.g., implementing IPV legislation) may contribute to improved practices with regard to IPV in mental health settings.

Keywords

domestic violence assessment mental health and violence

Intimate partner violence (IPV) has been defined by Foran et al. (2015) as “physical, verbal/symbolic, or sexual acts that cause—or have reasonable potential to cause—harm to a partner” (p. 2). The World Health Organization (WHO, 2013a) adopted this definition in its 11th revision of the International Classification of Diseases (ICD-11) and identified IPV as a serious and widespread public health problem. Global prevalence studies estimate that 35% of ever-partnered women have experienced lifetime IPV (WHO, 2013a). IPV survivors are at increased risk of developing psychiatric disorders (Brown et al., 2009; Okuda et al., 2011; Rees et al., 2011). Notably, women who have ever been abused are more likely to experience emotional distress, depression, anxiety, posttraumatic stress disorder, eating disorders, substance use disorders, suicidal ideation, and suicide attempts compared with non-abused women (Ishida et al., 2010; Jonas et al., 2014; Stephenson et al., 2013; WHO, 2005). Prevalence rates for IPV are elevated in mental health settings, compared with other health care settings (Alhabib et al., 2010). In their systematic review of IPV prevalence studies, Oram et al. (2013) found that 16% to 94% of female and 18% to 48% of male psychiatric inpatients reported lifetime IPV. Specifically, in American surveys, 16% of female psychiatric inpatients reported sexual violence (Owens, 2007), 94% reported psychological violence (Sansone et al., 2007), and 18% of male psychiatric inpatients reported severe physical violence (Chang et al., 2011); 48% of male inpatients in a Canadian sample reported any form of IPV (Hoffman & Toner, 1988). These prevalence rates are consistent with national averages found in epidemiological surveys (e.g., Centers for Disease Control and Prevention’s [CDC] National Intimate Partner and Sexual Violence Survey; Smith et al., 2018).

Many professional societies and public health organizations recommend that mental health professionals assess for IPV, including the American Psychological Association (Koss et al., 1994), the Canadian Psychiatric Association (2012), the WHO (2013b), and the World Psychiatric Association (Stewart & Chandra, 2017). Research on IPV in mental health settings can lead to an improved understanding of the link between IPV and mental health problems and help to establish thresholds for clinical significance of mental health symptoms in the context of IPV (Foran et al., 2015). Importantly, distinguishing normal reactions to IPV from psychopathology improves treatment planning and/or referral to appropriate patient care pathways (e.g., psychosocial support vs. psychotropic medications).

However, despite apparent benefits of IPV identification, rates of IPV assessment in mental health clinical practice are low (Howard et al., 2010). Notably, in a survey of 216 Australian psychiatrists, only 44% of participants reported asking all new patients about experiences of IPV (Forsdike et al., 2019). Similarly, Nyame et al. (2013) found that among 131 U.K. mental health clinicians, only 39% reported assessing for IPV in patients who presented with symptoms associated with IPV.

Barriers to IPV assessment in clinical practice are multiple, including discomfort asking about IPV as well as lack of perceived expertise, confidence in addressing IPV, knowledge of resources for survivors, and training in how to identify and respond to IPV (Forsdike et al., 2019; Hultmann et al., 2013; Nyame et al., 2013; Trevillion et al., 2016). Importantly, studies examining health professionals’ experiences of IPV-related training suggest that clinicians who received training were less likely to report other barriers to assessment. Notably, clinicians who received training reported greater comfort asking about IPV (McColgan et al., 2010), increased IPV-related knowledge (Connor et al., 2013; Forsdike et al., 2019; Jayatilleke et al., 2015; McColgan et al., 2010; Trevillion et al., 2016), improved confidence in managing situations of IPV (Jayatilleke et al., 2015), and greater likelihood of screening for IPV (Waalen et al., 2000). In mental health settings, IPV-related training combined with the implementation of referral pathways to domestic violence advocacy services led to improved identification of IPV (Trevillion et al., 2014).

IPV-related training is often not a mandatory component of professional training programs, and its implementation may differ across settings and regions (Aksan & Aksu, 2007; Djikanovic et al., 2010; Kamimura et al., 2015). Mason and O’Rinn (2014) found that many studies recommended improved education and training on IPV-related issues, yet few practical recommendations on what should be included in training curricula were provided. In addition, in surveys of U.S. and U.K. mental health professionals (Campbell et al., 1999; Nyame et al., 2013), 41% to 46% reported not having received any form of IPV-related training. Among those who received training, length of training varied across clinicians, from less than 1 hr to more than 6 hr of training (Nyame et al., 2013).

Few studies have explored factors that contribute to clinicians’ experiences of IPV-related training. Campbell et al. (1999) found that, among 415 U.S. mental health professionals, those with IPV-related experience and those who considered themselves experts on violence against women were more likely to have received IPV-related training. Female, compared with male clinicians, were also more likely to have received training. In a more recent survey of 173 U.S. clinicians, demographic factors did not predict the likelihood of receiving IPV-related training (Murray et al., 2016). Clinicians’ likelihood of receiving training seems to be associated with the extent to which IPV is considered relevant to their clinical practice. Nonetheless, due to the high prevalence of IPV among psychiatric patients (Oram et al., 2013), it is reasonable to suggest that all mental health professionals, and not only those who consider themselves experts on IPV, should be trained on how to identify and respond to partner violence.

To address gaps in knowledge about health professionals’ IPV-related training needs, the WHO (2013b) issued recommendations based on a review of available evidence. These include providing training at both the pre-qualification and the professional level. The WHO also recommended that training should be multicomponent and include basic knowledge about IPV as well as skill-building components in assessing and responding to IPV. To date, there have been no studies assessing the extent to which mental health professionals’ training experiences follow these recommendations.

The present study sought to address this gap by exploring global clinicians’ experiences of IPV-related training, including the degree to which their training corresponds to WHO guidelines. In keeping with the current literature, it is expected that clinicians who received IPV-related training, compared with those who have not, will report greater knowledge and experience related to relationship problems. To the authors’ knowledge, this study represents the first cross-national survey of mental health professionals’ IPV-related training experiences and will expand on current knowledge on the subject. This study will also contribute to the literature regarding factors that affect clinicians’ likelihood of receiving IPV-related training by observing the relationship between training and proxies for country context related to IPV. It is expected that factors that are related to IPV will be associated with the likelihood of receiving IPV-related training.

This research was conducted in the context of developing the 11th revision of the Mental and Behavioural Disorders chapter of the WHO’s ICD-11. Throughout the revision process, proposed ICD-11 Relationship Problem and Maltreatment (RPM) guidelines, including descriptions of IPV, underwent extensive field testing with a global sample of clinicians to determine ratings of reliability and clinical utility (Reed et al., 2018). Data used in this study were collected during the Internet-based field testing of proposed RPM guidelines for ICD-11. See Heyman et al. (2018) for a complete description of the larger study.

Method

Participants

Participants were drawn from the WHO’s Global Clinical Practice Network (GCPN). The GCPN comprises more than 15,000 mental health professionals from 156 countries recruited to participate in the field trials for ICD-11 (Reed et al., 2015).

The current study was part of a larger field trial developed in English and translated into French, Spanish, and Japanese using forward and back translation. Translated versions of the study included additional questions related to participants’ experiences of IPV-related training which were not included in the English study. As IPV-related training is the subject of the present research, only data collected in French, Spanish, and Japanese were used for this study. Eligibility criteria included current provision of mental health services or engagement in clinical supervision and proficiency or fluency in one of the three study languages. Emails to solicit participation were sent to participants who met eligibility criteria (N = 3,233; French, n = 713; Spanish, n = 1,498; Japanese, n = 1,022), and reminder emails were sent 2 and 4 weeks later. Data collection lasted approximately 2 months for each sample. Participants (n = 604, 19% of total; French = 139, Spanish = 318, Japanese = 147) responded to the survey link and initiated the study. Of these, 24 reported not meeting eligibility criteria and were removed. A further 189 participants were removed due to non-completion of the study. As the analyses reported here focused only on psychiatrists and psychologists, participants from other professions (n = 56) were removed. Finally, participants from regions with low response rates in the available study languages (i.e., Africa, n = 7; Eastern Mediterranean, n = 5; North America, n = 2) were removed. In total, data from 321 participants from 24 countries were used for analyses (see Table 1). To determine the representativeness of the final sample, participants were compared with individuals with similar characteristics (i.e., psychologists and psychiatrists) who were invited to the study but did not participate (N = 2,114). Compared with those who were invited to the study but did not participate, completers did not differ in terms of gender, profession, region, or proportion of participants in each language of the survey. However, completers were slightly older (M = 49.64, SD = 10.99) than those who did not participate (M = 48.10, SD = 12.15); t(2447) = 2.175, p < .05, and had slightly more professional experience (M = 19.54, SD = 10.12) than non-participants (M = 18.12, SD = 11.00); t(2447) = 2.207, p < .05. The final sample (N = 321) was also compared with individuals who initiated the study but did not complete it (i.e., non-completers; n = 189). Participants were similar to non-completers in terms of gender, profession, region, and proportion of participants in each language of the survey. However, participants were slightly older (M = 49.64, SD = 10.99) than non-completers (M = 47.33, SD = 10.92); t(508) = 2.094, p < .05, and had slightly more professional experience (M = 19.54, SD = 10.12) than those who did not finish the survey (M = 17.62, SD = 9.27); t(508) = 2.085, p < .05.

Table 1.

Demographic Information (N = 321).

Variable	n (%)
Study language
Spanish	181 (56.4)
French	51 (15.9)
Japanese	89 (27.7)
WHO global region^a
South America	119 (37.1)
Europe	113 (35.2)
Asian West Pacific	89 (27.7)
Gender
Male	195 (60.7)
Female	126 (39.3)
Profession
Psychiatry	173 (53.9)
Psychology	148 (46.1)
Income level^b
High	206 (64.2)
Upper middle	110 (34.3)
Lower middle	5 (1.5)
	M (SD)
Age	49.78 (10.96)
Years of experience	19.81 (10.06)
National income^c	26,701.07 (16,355.95)

WHO = World Health Organization.

Participants were from the following countries in each global region—Asian West Pacific: Japan; Europe: Croatia, Cyprus, France, Poland, Portugal, Romania, Spain, and Switzerland; South America: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Peru, and Venezuela. ^bNational income level based on the World Bank list of analytical income classification of economies. There were no participants from low-income countries. ^cGross domestic product per capita in U.S. dollars.

Data and Variables

Demographic information

Demographic information was collected via an online survey during participants’ registration to the GCPN and again at the beginning of the current study. Participants provided information on a wide number of variables, including their gender, age, years of professional experience, profession, and country of residence. Based on their country of residence, they were classified into one of eight WHO regions. National income data were drawn from the World Bank database.

IPV-related variables

IPV-related norms, prevalence, and laws were drawn from the Organization for Economic Co-Operation and Development (OECD) Centre’s Gender, Institutions and Development (GID) Database (2019), which contains 60 indicators of gender discrimination across 160 countries. For each variable included in the GID, data were compiled and classified by country using national constitutions, legal frameworks, and primary publications, reports, or studies (OECD, 2014).

IPV-related norms

IPV-related norms represent the national percentage of women aged 15 to 49 who consider that a husband is justified in hitting his wife under certain circumstances (i.e., if his wife burns the food, argues with him, goes out without telling him, neglects the children, or refuses sexual relations). Among the 24 countries included in the study (see footnote in Table 1), the percentage of women who believed that IPV was sometimes justified ranged from 4% in Argentina to 34% in Peru (M = 12.37, SD = 4.24).

Prevalence of physical or sexual IPV

IPV prevalence is defined by the national percentage of women who have experienced lifetime physical or sexual violence in an intimate relationship. National prevalence rates of physical or sexual IPV among the 24 countries included in the study ranged from 10% in Switzerland to 64% in Bolivia (M = 24.83, SD = 13.95).

IPV-related laws

IPV-related laws represent the degree to which a country’s legal framework offers women protection against IPV. Laws were rated on a 5-point scale ranging from 1 (“There is specific legislation in place to address domestic violence; the law is adequate overall, and there are no reported problems of implementation”) to 5 (“There is no legislation in place to address domestic violence”). Most participants were from countries where IPV-related laws existed and were well implemented (Level 1; n = 207), and none of the participants were from regions where IPV-related laws did not exist (Levels 4 and 5). Due to low response rates (less than 5% of total sample) for Level 3 (“There is specific legislation in place to address domestic violence, but the law is inadequate”; n = 14), it was combined with Level 2 (“There is specific legislation in place to address domestic violence; the law is adequate overall, but there are reported problems of implementation”; n = 100) to form a new category describing countries where IPV-related laws existed yet were relatively less well implemented. The final “IPV-related laws” variable comprised two categories: 1 (“well-implemented laws”; n = 207) and 2 (“less well-implemented laws”; n = 114).

Frequency of IPV in clinical practice

Participants were asked to rate how often they used RPM codes, which describe instances of IPV, in their regular practice. Codes are alphanumeric codes found in diagnostic manuals and used to denote diagnoses and factors associated with consultation for health services. The use of codes represents an additional IPV-related variable: an estimate of how often participants encounter patients with IPV in their regular practice. Participants were asked, “How frequently do you use relationship problem and maltreatment codes in your practice? (i.e., ICD-10 Z codes, T codes, or Y codes; DSM-IV V codes, or DSM-5 V codes).” They responded using a 5-point scale, ranging from 1 (“Never”) to 5 (“Every day”). Due to a relatively low response frequency for Level 5 (“Every day”; n = 15), this level was combined with a conceptually similar adjacent level (Level 4; “A few times per week”). The final “Frequency of IPV in clinical practice” variable comprised four levels: 1 (“Never”; n = 77), 2 (“Once or less per month”; n = 114), 3 (“Once per week”; n = 51), and 4 (“Several times per week”; n = 79).

IPV-related training

Five questions were created to measure IPV-related training. The first question inquired about participation in formal IPV-related training (i.e., “Please indicate whether, at any point during your clinical training or professional career, you have received formal training [e.g., as a part of courses, workshops, continuing education programs] about how to detect or respond to intimate partner violence, including physical and psychological abuse.”). Response options were dichotomic (i.e., yes or no). Participants who responded “no” were not shown the following questions. The second question was based on IPV-related training recommendations for health care professionals made by the WHO (2013b). Participants were asked to select which components, from a list, were covered in the IPV-related training they received (i.e., definitions, laws, and risk factors related to IPV; support services for survivors of IPV; how and when to inquire about IPV with patients; and how to respond to survivors of IPV). The rationale for this question was to better understand the depth of IPV-related training that clinicians had received. The final three questions addressed participants’ total number of hours of training. Each was a text-entry question where participants could indicate the number of hours of IPV-related training that they had received during their professional training, after completing their professional training (e.g., in-service education), and in the past 5 years, respectively. These questions were included because IPV-related training has been found to be more effective when it is repeated and offered over longer periods of time (Buranosky et al., 2012).

Knowledge and experience of relationship problems

Participants’ level of knowledge and experience related to couples with relationship problems, which may include IPV, was assessed using the following question: “How would you describe your level of knowledge and experience related to couples with relationship problems?” Participants were asked to respond using a scale ranging from 1 (“None”) to 5 (“A great deal”). Categories 1 (n = 15) and 5 (n = 30) had low response frequencies (i.e., less than 10% of the total sample). To determine whether these categories could be combined with adjacent categories, two binary logistic regression models were generated which included all predictors and used categories as binary outcome variables (i.e., “1” vs. “2” and “4” vs. “5”; Osborne, 2017). In both cases, there were no significant predictor variables, indicating that categories were sufficiently similar to be combined. Thus, Category 1 (“None”) was combined with Category 2 (“A little bit”) to form the variable “Low” knowledge and experience. Category 5 (“A great deal”) was combined with Category 4 (“Quite a bit”) to form the variable “High” knowledge and experience. The final “Knowledge and experience of relationship problems” variable contained three categories: “Low,” n = 73; “Moderate,” n = 96; and “High,” n = 152.

Procedure

This study was exempted from review by the WHO Research Ethics Review Committee (Protocol ID RPC569) and by the Human Subjects Committee at the University of Kansas, Lawrence Campus (HSCL #20804).

Participants received an email invitation to participate in a larger study aimed at evaluating the accuracy and consistency of clinicians’ use of proposed diagnostic guidelines related to RPM for the ICD-11 as compared with the ICD-10. Participants who agreed to participate in the study followed an individualized link to an online survey, where they were randomly assigned to use either ICD-11 or revised ICD-10 RPM codes to rate a series of four clinical vignettes. Each vignette described a patient presenting with concerns concordant with one of four conditions of the study (i.e., IPV only, mental health symptoms only, both, or neither). See Heyman et al. (2018) for more information on the methodology of the larger RPM study. As a part of this study, participants rated their level of knowledge and experience related to couples with relationship problems, as well as their familiarity with RPM codes (i.e., the frequency with which they use these codes). They also responded to a series of five questions regarding their IPV-related training experiences, as described above.

Results

IPV-Related Training

Table 2 presents frequencies and descriptive statistics for IPV-related training by predictor. A little over half the participants (53.6%, n = 172) responded “Yes” when asked if they had received formal training about how to detect or respond to IPV. For these participants, IPV-related training experiences (i.e., components of training, time points at which they received training, and number of hours of training) are summarized in Table 3.

Table 2.

IPV-Related Training by Predictor.

Predictor	IPV-Related Training
	Yes		No
	n (%)		n (%)
Total	172 (53.6)		149 (46.4)
Language of survey
Spanish	140 (77.3)		41 (22.7)
French	22 (43.1)		29 (56.9)
Japanese	10 (11.2)		79 (88.8)
WHO global region
South America	98 (82.4)		21 (17.6)
Europe	64 (56.6)		49 (43.4)
Asian West Pacific	10 (11.2)		79 (88.8)
Gender
Male	86 (44.1)		109 (55.9)
Female	86 (68.3)		40 (31.7)
Profession
Psychiatrist	69 (39.9)		104 (60.1)
Psychologist	104 (69.6)		45 (30.4)
IPV-related laws
Well implemented	148 (71.5)		59 (28.5)
Less well implemented	24 (21.1)		90 (78.9)
Frequency of IPV in clinical practice
Never	22 (28.6)		55 (71.4)
Once or less per month	54 (47.4)		60 (52.6)
Once per week	31 (60.8)		20 (39.2)
Several times per week	65 (82.3)		14 (17.7)
	M	SD	M	SD
Age	49.09	11.75	50.57	9.94
Years of experience	19.85	10.60	19.76	9.43
National income^a	20,721.70	16,735.08	33,603.50	12,857.44
IPV norms (%)	12.40	4.65	12.33	3.73
Prevalence of physical or sexual IPV (%)	30.19	15.43	18.88	8.94

IPV = intimate partner violence; WHO = World Health Organization.

Gross domestic product per capita in U.S. dollars.

Table 3.

IPV-Related Training Experiences.

Component of Training	n (%)	Median	Interquartile Range
Basic information on IPV	152 (85.4)
Local support services for survivors	120 (67.4)
How and when to inquire about IPV	126 (70.8)
How to offer support to survivors	118 (66.3)
Other	36 (20.2)
Hours of Training	n (%)
During professional training	148 (88.6)	20.00	8.00–69.00
Since completing professional training	152 (92.7)	40.00	20.00–100.00
In the past 5 years	144 (89.4)	30.00	10.00–100.00

Note. Boxplots adjusted for skewed distributions (Walker et al., 2018) were used to detect and remove outliers for each “hours of training” variable, respectively (i.e., during professional training, n = 5; since completing professional training, n = 8; and in the past 5 years, n = 11). Outliers were only removed for analyses on “hours of training” variables and were retained for all other analyses. IPV = intimate partner violence.

The WHO recommends including four components (i.e., basic information on IPV, local support services for survivors, how and when to inquire about IPV, and how to offer support to survivors; WHO, 2013b) in IPV-related training protocols. Fewer than half of participants (49.4%, n = 85) reported that all four components were part of their training. Thirty-one participants (18.0%) reported that their training contained only one component, most commonly basic information on IPV (n = 15) or how and when to inquire about IPV (n = 10). Twenty-nine participants (16.9%) reported two components, most often basic information on IPV combined with information about local support services (n = 14). Twenty-nine clinicians (16.9%) reported three components, most commonly basic information on IPV combined with how and when to inquire about IPV and how to offer support to survivors (n = 11). The remaining four participants (2.3%) reported that their training contained none of these recommended components.

The WHO (2013b) and Buranosky et al. (2012) recommend that IPV-related training occurs both during and after professional training. Most participants (n = 149; 90.9%) reported that they had received IPV-related training at both of these time points. Four participants (2.4%) reported that they had only received training at the pre-qualification level, and the remaining 11 participants (6.7%) noted that they only received training post-qualification. Participants reported a wide range of training experiences, ranging from 1 to 500 hr of IPV-related training at each time point. To account for skewed distributions, median hours of training are reported in Table 3.

Binary logistic regression

Binary logistic regression was used to determine whether IPV-related variables (i. e., IPV-related laws, IPV-related norms, prevalence of physical or sexual IPV, and frequency of IPV in clinical practice) affected the likelihood that participants received IPV-related training. The regression model was constructed to investigate the relationship between predictors and a binary outcome variable (i.e., IPV-related training received—Yes, No). Demographic factors (i.e., gender, years of professional experience, profession, country income) were included as control variables. Due to multicollinearity (variance inflation factor [VIF] > 5), three demographic variables (i.e., language of survey, global region, and age) were not included in the regression.

The final regression model, compared with a model that included only control variables, significantly improved the fit between model and data, χ²(10, N = 321) = 117.65, Nagelkerke R² = .44, p < .001. IPV-related laws, χ²(1, N = 321) = 15.70, p < .001, and frequency of IPV in clinical practice, χ²(3, N = 321) = 7.89, p < .05, made statistically significant unique contributions to the final model. Table 4 presents the odds ratios for a model containing only control variables (Model 1) and the final regression model with predictors included (Model 2). As far as IPV-related laws are concerned, participants from regions where laws are relatively better implemented were more likely to have received training than participants from regions where laws were less well implemented. With regard to the frequency of IPV in clinical practice, participants who reported using IPV-related classification codes several times per week were more likely to have received training than those who never used these codes. IPV-related norms and prevalence of physical or sexual IPV were not significantly related to participants’ likelihood of receiving IPV-related training.

Table 4.

Binary Logistic Regression of IPV-Related Training, Models 1 (Control Variables Only) and 2 (IPV-Related Variables Added) (ORs).

Predictor	Yes Training^a
	Model 1		Model 2
	OR	SE	OR	SE
Years of experience	1.01	0.014	1.00	0.015
National income	0.95^***	0.010	1.00	0.013
Gender^b (male)	0.53^*	0.296	0.53	0.327
Profession^c (psychiatrist)	0.41^**	0.287	0.58	0.337
IPV-related laws^d (relatively better implemented laws)			8.84^***	0.550
IPV-related norms			1.16	0.070
Prevalence of physical or sexual IPV			1.01	0.020
Frequency of IPV in clinical practice^e
Once or less per month			1.71	0.391
Once per week			1.85	0.463
Several times per week			3.92^**	0.487

Note. IPV = intimate partner violence; ORs = odds ratios; SE = standard error.

Outcome variable category (n = 178); reference group = no training (n = 143). ^bFemale as reference. ^cPsychologist as reference. ^dRelatively less well-implemented laws as reference. ^eNever as reference.

p < .05 **p < .01 ***p < .001.

Linear regressions

Two multiple linear regressions were carried out to investigate the relationship between IPV-related variables and the number of hours of IPV-related training during professional training and after completing professional training, respectively. The effects of demographic variables were controlled for in the regression models. For both models, square root transformations of the outcome variables were performed, after which the scatterplot of standardized predicted values versus standardized residuals showed that the data met assumptions of homogeneity of variance and linearity, and the residuals were approximately normally distributed.

During professional training

Regression results indicated that participants who reported more frequent use of IPV-related classification codes were more likely to have received more hours of IPV-related training during their professional training (β = .29, p <.01). No other predictors were significant. A reduced regression model with only the significant predictor included was generated, and results show that participants’ use of RPM codes in their clinical practice explains 7.5% of the variance, R² = .075, F(1, 159) = 12.76, p < .001.

After completing professional training

Similar to the previous model, regression results showed that participants who reported more frequent use of IPV-related classification codes were more likely to have received more hours of IPV-related training after completing their professional training (β = .85, p < .05). No other predictors were significant. Results from a reduced regression model with only the significant predictor included indicated that participants’ self-rated use of RPM codes in their clinical practice explains 5.6% of the variance, R² = .056, F(1, 154) = 9.09, p < .01.

Knowledge and Experience of Relationship Problems

Table 5 presents frequencies and descriptive statistics for each predictor by level of knowledge and experience. A multinomial logistic regression examined the relationship between participants having IPV-related training (predictor) and their level of knowledge and experience of relationship problems (outcome variable; that is, “Low,” “Moderate,” or “High” knowledge/experience). “High knowledge/experience” was used as a reference category to which the other two categories were compared. The effects of all other variables (i.e., gender, years of professional experience, profession, country income, IPV-related laws, IPV-related norms, prevalence of physical or sexual IPV, and frequency of IPV in clinical practice) were controlled for in the model. Three demographic variables (i.e., language of survey, global region, and age) were not included in the analysis due to multicollinearity (VIF > 5).

Table 5.

Knowledge and Experience of Relationship Problems by Predictor.

Predictor	Knowledge and Experience
	Low		Moderate		High
	n (%)		n (%)		n (%)
Language of survey
Spanish	11 (6.1)		55 (30.4)		115 (63.5)
French	13 (25.5)		12 (23.5)		26 (51.0)
Japanese	49 (55.1)		29 (32.6)		11 (12.4)
WHO global region
South America	5 (4.2)		33 (27.7)		81 (68.1)
Europe	19 (16.8)		34 (30.1)		60 (53.1)
Asian West Pacific	49 (55.1)		29 (32.6)		11 (12.4)
Gender
Male	49 (25.1)		62 (31.8)		84 (43.1)
Female	24 (19.0)		34 (27.0)		68 (54.0)
Profession
Psychiatrist	50 (28.9)		55 (31.8)		68 (39.3)
Psychologist	23 (15.5)		41 (27.7)		84 (56.8)
IPV-related laws
Well implemented	20 (9.7)		61 (29.5)		126 (60.9)
Less well implemented	53 (46.5)		35 (30.7)		26 (22.8)
Frequency of IPV in clinical practice
Never	37 (48.1)		19 (24.7)		21 (27.3)
Once or less per month	30 (26.3)		45 (39.5)		39 (34.2)
Once per week	5 (9.8)		12 (23.5)		34 (66.7)
Several times per week	1 (1.3)		20 (25.3)		58 (73.4)
IPV-related training
Yes	11 (6.4)		42 (24.4)		119 (69.2)
No	62 (41.6)		54 (36.2)		33 (22.1)
	M	SD	M	SD	M	SD
Age	47.84	10.51	49.41	9.97	50.94	11.65
Years of experience	17.27	9.62	19.45	9.72	21.26	10.27
Income^a	37,071.90	11,913.61	25,725.10	12,833.74	22,336.80	17,995.80
IPV norms (%)	12.48	3.13	12.16	3.37	12.44	5.17
Prevalence of physical or sexual IPV (%)	16.92	6.53	24.53	13.75	29.12	15.10

WHO = World Health Organization. IPV = intimate partner violence; SD = standard deviation.

Gross domestic product per capita in U.S. dollars.

The final regression model, compared with a model that included only control variables, significantly improved the fit between model and data, χ²(22, N = 321) = 171.54, Nagelkerke R² = .50, p < .001. Four predictors made significant unique contributions to the final model: years of professional experience, χ²(2, N = 321) = 6.24, p < .05; IPV-related laws, χ²(2, N = 321) = 7.77, p < .05; frequency of IPV in clinical practice, χ²(6, N = 321) = 26.26, p < .001; and experiences of IPV-related training, χ²(2, N = 321) = 36.57, p < .001. Table 6 presents the odds ratios for a model containing only control variables (Model 1) and the final regression model with the predictor included (Model 2). Participants who had not received training were more likely to report low or moderate knowledge/experience, compared with high knowledge/experience, than those who had received training.

Table 6.

Multinomial Logistic Regression of Knowledge and Experience of Relationship Problems, Models 1 (Control Variables Only) and 2 (IPV-Related Training Added) (ORs).

Predictor	Model 1				Model 2
	Low Knowledge and Experience (n = 71)		Moderate Knowledge and Experience (n = 93)		Low Knowledge and Experience (n = 71)		Moderate Knowledge and Experience (n = 93)
	OR	SE	OR	SE	OR	SE	OR	SE
Years of experience	0.96^*	0.020	0.98	0.015	0.95^*	0.022	0.97	0.016
National income	0.99	0.016	0.97	0.016	1.00	0.017	0.97	0.017
Gender^a (male)	1.15	0.436	1.45	0.334	0.71	0.483	1.23	0.350
Profession^b (psychiatrist)	1.06	0.460	1.21	0.346	0.98	0.498	1.03	0.362
IPV-related laws^c (relatively better implemented laws)	0.03^***	0.831	0.23^**	0.573	0.09^**	0.897	0.39	0.573
IPV-related norms	0.71^**	0.110	0.89	0.067	0.80	0.116	0.91	0.059
Prevalence of physical or sexual IPV	1.00	0.030	0.99	0.020	1.01	0.032	0.99	0.020
Frequency of IPV in clinical practice^d
Once or less per month	0.75	0.444	1.59	0.431	1.04	0.491	1.94	0.465
Once per week	0.15^**	0.655	0.51	0.500	0.13^**	0.705	0.52	0.533
Several times per week	0.04^**	1.096	0.52	0.477	0.06^*	1.125	0.67	0.505
Training^e (no training)					13.13^***	0.517	5.49^***	0.378

Note. Reference group: High knowledge and experience (n = 138). IPV = intimate partner violence; OR = odds ratio; SE = standard error.

Female as reference. ^bPsychologist as reference. ^cRelatively less well-implemented laws as reference. ^dNever as reference. ^eYes training as reference.

p < .05. **p < .01. ***p < .001.

Discussion

This study provides a cross-national exploration of mental health professionals’ IPV-related training experiences. It expands on previous research on IPV-related training, typically conducted with participants from a single country (e.g., Campbell et al., 1999; Forsdike et al., 2019; Howard et al., 2010; Nyame et al., 2013), by assessing the training experiences of 321 mental health professionals in 24 countries across three global regions. Specifically, we used an online survey sent to members of the WHO’s GCPN (Reed et al., 2015) to explore the degree to which psychologists’ and psychiatrists’ IPV-related training experiences resemble training recommendations advanced by the WHO (2013b). In addition, we assessed whether IPV-related factors (i.e., prevalence, norms, laws, and use of IPV guidelines) are related to clinicians’ likelihood of receiving training and whether IPV-related training is linked to greater self-reported knowledge about relationship problems.

Our findings are consistent with what has been reported in the literature (Campbell et al., 1999; Nyame et al., 2013), in that global mental health professionals’ experiences of IPV-related training appear to be limited. Only a little over half the sample (53.6%; n = 172) reported ever receiving IPV-related training. Among these, less than half (49.4%; n = 85) indicated that their training resembled WHO recommendations (WHO, 2013b), and over one third (33.8%; n = 58) noted that their training contained only one or two of the four recommended components. Participants who received training also reported a large range of hours of training (1–550), with most participants reporting between 20 and 40 hr. Taken together, these results suggest that the content and depth of clinicians’ IPV-related training experiences vary widely. Nearly all participants who received IPV-related training (90.9%; n = 149) reported that training occurred more than once, both during and after professional qualification training. This suggests that clinicians who receive training once are likely to obtain further IPV-related training. This is encouraging, because multiple sources (Buranosky et al., 2012; WHO, 2013b) recommend that clinicians receive IPV-related training at several time points to maximize efficacy.

There are multiple benefits of IPV-related training, including improved identification of IPV in mental health settings (Trevillion et al., 2016) and improved self-reported knowledge and confidence in addressing IPV (Connor et al., 2013; Forsdike et al., 2019; Jayatilleke et al., 2015; McColgan et al., 2010; Trevillion et al., 2016). Identifying IPV in mental health settings is important because it can assist clinicians in distinguishing normal reactions to IPV from psychopathology and in providing referrals to appropriate care. For these reasons, it appears valuable to understand factors that are associated to clinicians’ likelihood of receiving IPV-related training. Results from this study suggest that mental health professionals who use ICD or DSM (Diagnostic and Statistical Manual of Mental Disorders) codes for IPV more regularly in their clinical practice and come from countries with relatively better implemented laws addressing IPV are more likely to have received training. Results from this study also show that clinicians who report using IPV codes are more likely to have received more hours of IPV-related training. This is in line with Campbell et al.’s (1999) study showing that clinicians who had experience working with IPV were more likely to have received IPV-related training. It is possible that clinicians who encounter IPV more often in clinical practice are motivated to seek out specific training to address the needs of their patients. Alternatively, as is suggested in the literature, it is also plausible that clinicians who have received IPV-related training are more likely to assess for IPV and thereby identify it more frequently in their practice (McColgan et al., 2010; Waalen et al., 2000). Furthermore, it seems that greater institutional efforts to address IPV (i.e., drafting and implementing legislation that provides consequences for IPV) are associated with improved clinical practices with regard to IPV. Some research suggests that health professionals’ perception of partner violence as a private family matter, rather than a public health issue, represents a barrier for IPV assessment (Colombini et al., 2013; Ribeiro, 2014). It is possible that laws addressing IPV may legitimize IPV as a serious public health problem and empower clinicians to address it in their regular practice.

Interestingly, our findings suggest that national prevalence rates for IPV and national IPV-related norms (i.e., the cultural acceptability of IPV) were not related to clinicians’ likelihood of receiving IPV-related training. It is possible that national prevalence rates do not reflect the relative frequency with which clinicians see patients presenting with IPV in their clinics, depending on the location and nature of their practice. As such, the likelihood that clinicians will encounter IPV in their personal practice is a stronger predictor of pursuing training than national prevalence rates. National IPV-related norms do not influence clinicians’ likelihood of receiving IPV-related training. However, national norms in this study were defined as the percentage of women aged 15 to 49 who agreed that physical IPV was acceptable under certain conditions (OECD, 2014). The OECD sample used to define these norms is not representative of the sample of clinicians found in this study (i.e., male and female clinicians aged 26–76). It seems plausible that participants’ personal attitudes toward IPV may not resemble those of the OECD sample. Research has shown that clinicians’ personal attitudes toward IPV predict their likelihood of assessing for IPV. Those who hold more negative beliefs about IPV survivors (e.g., perceive survivors as responsible for the abuse) are less likely to assess for IPV in their regular practice (Sprague et al., 2012). It is conceivable that clinicians’ personal attitudes toward IPV, which were not assessed, might more strongly predict their likelihood of receiving training compared with national norms.

As noted above, IPV-related training has been shown to improve clinicians’ ratings of their IPV-related knowledge (Jayatilleke et al., 2015). Concordantly, results from this study show that clinicians who received IPV-related training, relative to those without training, are more likely to report greater knowledge and experience related to relationship problems. Interpretation of this result must be made with caution, however, because it is unclear whether experiences of IPV-related training increase clinicians’ likelihood of reporting greater knowledge and experience of relationship problems, or, as Campbell et al. (1999) suggest, whether clinicians who report greater experience with relationship problems are more likely to pursue training. Clinical experience, frequency of IPV in clinical practice, and IPV-related laws were also significantly related to knowledge and experience of relationship problems. Clinicians with more years of experience and those who see patients with IPV more regularly (i.e., at least once per week) were more likely to report high knowledge and experience. Unsurprisingly, it seems that clinicians with greater clinical experience are more likely to provide higher ratings of their knowledge and experience with clinical issues such as relationship problems. Participants from countries with better implemented laws related to IPV, compared with less well-implemented laws, were also more likely to describe high knowledge and experience of relationship problems. As described earlier, it is possible that the implementation of IPV-related laws may validate the importance of addressing IPV in health contexts and contribute to clinicians gaining knowledge and experience related to these issues.

Limitations

The present study used a convenience sample, whereby participants were clinicians who volunteered to be members of the WHO’s GCPN and chose to respond to an online survey regarding the revision of ICD-11 RPM guidelines. Only 10% of GCPN members who were sent the survey composed the final sample. Therefore, it is possible that the sample represented a self-selected group of professionals who chose to participate because they had proficiency in the assessment and treatment of patients with relationship problems and maltreatment. These participants may have been more likely to report experiences of IPV-related training than the general population. Participants were psychologists and psychiatrists only, and no other mental health professionals (e.g., counselors, social workers, mental health nurses) were included. Participants were from high-income (64.2%), upper-middle-income (34.3%), and lower-middle-income (1.5%) countries; there were no participants from low-income countries. In addition, English data were not used in this study due to the absence of IPV-related training variables in the English version of the survey. This makes it difficult to compare study results with previous research on IPV-related training conducted in English-speaking countries, such as the United States (Campbell et al., 1999; Murray et al., 2016), the United Kingdom (Nyame et al., 2013), and Australia (Forsdike et al., 2019). Data for this study were collected in French, Japanese, and Spanish, and only participants from South America, Europe, and the Asian West Pacific region were included in analyses. Thus, results are a snapshot of psychologists’ and psychiatrists’ experiences in these regions and may not be representative of a broader global sample of diverse mental health professionals.

This study explores the association between national-level IPV variables and IPV-related training. It does not measure clinicians’ individual attitudes toward IPV, nor the norms, prevalence, or level of implementation of IPV-related laws in participants’ specific communities or regions of practice. Therefore, while results allow speculation about the relationship between elements of national culture and clinicians’ IPV-related training experiences, it is not possible to determine how individual or regional differences with regard to IPV affect training. As described earlier, IPV-related norms in this study are limited by their narrow definition (i.e., the national percentage of women aged 15–49 who indicated that physical IPV was sometimes acceptable) and are perhaps not representative of clinicians’ personal attitudes toward IPV. Furthermore, social norms are complex and dynamic concepts formed by social expectations and social influence (Mackie et al., 2015), and the one-dimensional measure of norms used in this study may not accurately capture the complexity of IPV-related norms within a given country. IPV prevalence was defined as the prevalence of physical and sexual violence toward women in intimate relationships and did not include instances of psychological violence or IPV perpetrated toward men. Thus, it is likely that prevalence rates are underrepresentative of IPV incidents as they are defined by the WHO (Foran et al., 2015; WHO, 2013a).

Proxy variables were used in this study to represent the frequency of IPV in clinical practice and participants’ level of knowledge and experience related to IPV. With regard to measuring the frequency of IPV in clinical practice, clinicians were asked to indicate the frequency with which they used IPV-related codes from diagnostic manuals (i.e., ICD or DSM) in their practice. Although it seems likely that clinicians who use these codes more often also encounter IPV more regularly, it is conceivable that some clinicians who see cases of IPV choose not to record them using diagnostic codes. Therefore, this variable may be more representative of clinicians’ likelihood of using IPV codes, rather than the frequency with which they see IPV in their practice. In addition, the authors considered that participants’ ratings of knowledge and experience relating to couples experiencing relationship problems approximated their knowledge and experience of IPV. While relationship problems encompass instances of IPV, they also represent milder forms of relational difficulties such as normative disagreements and dissatisfaction within romantic partnerships (Foran et al., 2015). Therefore, it is difficult to determine whether clinicians’ self-rated level of knowledge and experience related to relationship problems is truly representative of their experience with IPV.

Future Research

This study adds to our understanding of the gaps in global mental health professionals’ IPV-related training experiences. Although it appears that clinicians’ training experiences do not closely follow WHO recommendations for IPV-related training (WHO, 2013b), there has yet to be any research assessing whether adherence to WHO training recommendations improves clinician performance in assessing for IPV. Due to institutional and financial constraints that may limit the depth and length of IPV-related training available in many settings and regions, future research may evaluate whether comprehensive training (as is recommended by the WHO) is necessary to improve clinician outcomes in assessing for IPV. Particularly, it would be important to explore whether adherence to WHO recommendations leads to improved ability to correctly identify IPV in clinical practice.

Conclusion

This study represents a snapshot of global clinicians’ experiences of IPV-related training. Overall, it appears that training is limited across the 24 countries included in this study, and experiences of IPV-related training vary broadly. Certain factors (i.e., IPV-related laws and frequency of IPV in clinical practice) appear to increase clinicians’ likelihood of receiving training, and receiving training appears to improve the likelihood that clinicians will report greater knowledge and experience related to relationship problems. Findings suggest that clinicians’ awareness of IPV (e.g., experience working with those reporting IPV) and the greater institutional context in which they practice (i.e., whether IPV-related legislation is well implemented) are related to training. Improved institutional efforts to address IPV, such as implementing legislation and IPV awareness campaigns, may improve mental health professionals’ practices with regard to IPV.

Although this study only represents a subset of global mental health professionals, it includes data collected in three different languages across 24 countries and is therefore far more inclusive than previous similar research seeking to describe clinicians’ experiences of IPV-related training. It highlights the global challenges with regard to IPV-related training, which may include a lack of financial resources or infrastructure to support training. Further inquiry into the utility of comprehensive training for improving IPV identification in clinical practice, compared with less in-depth training, is an important next step as it will better inform best training practices.

Footnotes

Acknowledgments

The authors are grateful to the following individuals for their assistance with statistical consultation, translation, and testing of the study materials—statistical consultation: Jared Keeley; French translation: Stéphane Sabourin; Japanese translation: Yukiro Morino; and Spanish translation: Alejandra González Salas, Omar Hernández, Carolina Muñoz, and Juan F. Rodríguez-Testal.

Authors’ Note

The opinions contained in the article are those of its authors and, except as specifically stated, are not intended to represent the official policies or positions of the World Health Organization.

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Samantha C. Burns

Author Biographies

Samantha C. Burns, BA, is completing a PhD in clinical psychology at the University of Ottawa. Her research focuses on mental health professionals’ training and practices with regard to intimate partner violence, with the goal of improving clinicians’ assessment of and response to family maltreatment.

Cary S. Kogan, PhD, is professor of clinical psychology at the University of Ottawa. His research focuses on developmental neuroscience of neurodevelopmental disorders and classification of mental health conditions. Currently, in partnership with international collaborators, he is interested in the development and evaluation of the World Health Organization’s (WHO) International Classification of Diseases, 11th Edition (ICD-11) with the goal of improving identification of mental health and related conditions to reduce global disease burden.

Richard E. Heyman, PhD, is professor in the Faculty of Health at New York University and co-director of the Family Translational Research Group. His research program has focused on the development and maintenance of family problems, with a strong focus on family maltreatment and relationship distress. He also studies interventions at all stages of the translational research cycle.

Heather M. Foran, PhD, is professor of psychology at the Universität Klagenfurt in Austria. Her research focuses on models of family environment, mental health, and physical health. She is also involved in studies on assessment and prevention of family maltreatment with a focus on public health approaches.

Amy M. Smith Slep, PhD, is professor in the Faculty of Health at New York University and co-director of the Family Translational Research Group. Her research has focused on anger and aggression in families, and the interconnections of child and partner abuse. Her work emphasizes translation into prevention, as well as implementation science.

Tecelli Dominguez-Martinez, PhD, is medical science researcher at the Research Global Mental Health Center of the Direction of Epidemiology and Psychosocial Research at the National Institute of Psychiatry “Ramón de la Fuente Muñiz” in Mexico City. Her research focuses on psychosocial risk factors, diagnosis, classification, prevention, and intervention of mental disorders. She has worked on multiple field studies of the WHO to validate the Mental and Behavioural Disorders chapter from the 11th revision of the ICD.

Jean Grenier, PhD, is a clinical psychologist and researcher at the Montfort Hospital and Institut du Savoir Montfort in Ottawa, Canada. He is also professor of clinical psychology and assistant professor at the Department of Family Medicine at the University of Ottawa. His research focuses on the integration of psychological services in primary care and psychological interventions in the context of chronic health problems.

Chihiro Matsumoto, PhD, is national study coordinator for ICD-11 Field Studies at Japanese Society of Psychiatry and Neurology. She has helped implement a number of ICD-11-related field studies in Japan. Her interests also include training clinicians on diagnosis and classification of personality disorders, which is expected to be substantially different in the ICD-11 compared with the current classification system.

Geoffrey M. Reed, PhD, is professor of medical psychology at the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons. He is a consultant to the WHO and, beginning in 2008, served as senior project officer for the development of ICD-11 Mental, Behavioural and Neurodevelopmental Disorders in WHO’s Department of Mental Health and Substance Abuse.

References

Aksan

H. A.

Aksu

(2007). The training needs of Turkish emergency department personnel regarding intimate partner violence. BMC Public Health, 7. https://doi.org/10.1186/1471-2458-7-350

Alhabib

Nur

Jones

(2010). Domestic violence against women: Systematic review of prevalence studies. Journal of Family Violence, 25, 369–382. https://doi.org/10.1007/s10896-009-9298-4

Brown

Cosgrave

Killackey

Purcell

Buckby

Yung

A. R.

(2009). The longitudinal association of adolescent dating violence with psychiatric disorders and functioning. Journal of Interpersonal Violence, 24, 1964–1979. https://doi.org/10.1177/0886260508327700

Buranosky

Hess

McNeil

M. A.

Aiken

A. M.

Chang

J. C.

(2012). Once is not enough: Effective strategies for medical student education on intimate partner violence. Violence Against Women, 18, 1192–1212. https://doi.org/10.1177/1077801212465154

Campbell

Raja

Grining

P. L.

(1999). Training mental health professionals on violence against women. Journal of Interpersonal Violence, 14, 1003–1013.

Canadian Psychiatric Association. (2012). Intimate partner violence. The Canadian Journal of Psychiatry, 58, Insert 1–15, Encart 1–17.

Chang

J. C.

Cluss

P. A.

Burke

J. G.

Hawker

Dado

Goldstrohm

Scholle

S. H.

(2011). Partner violence screening in mental health. General Hospital Psychiatry, 33, 58–65. https://doi.org/10.1089/jwh.2014.4861

Colombini

Mayhew

Ali

S. H.

Shuib

Watts

(2013). “I feel it is not enough . . .” Health providers’ perspectives on services for victims of intimate partner violence in Malaysia. BMC Health Services Research, 13, 2–11. https://doi.org/10.1186/1472-6963-13-65

Connor

P. D.

Nouer

S. S.

Speck

P. M.

Mackey

S. N.

Tipton

N. G.

(2013). Nursing students and intimate partner violence education: Improving and integrating knowledge into health care curricula. Journal of Professional Nursing, 29, 233–239.

10.

Djikanovic

Celik

Simic

Matejic

Cucic

(2010). Health professionals’ perceptions of intimate partner violence against women in Serbia: Opportunities and barriers for response improvement. Patient Education and Counseling, 80, 88–93.

11.

Foran

H. M.

Beach

S. R. H.

Slep

A. M.

Heyman

R. E.

Wamboldt

M. Z.

(2015). Family problems and family violence: Reliable assessment and the ICD-11. Springer.

12.

Forsdike

O’Connor

Castle

Hegarty

(2019). Exploring Australian psychiatrists’ and psychiatric trainees’ knowledge, attitudes and preparedness in responding to adults experiencing domestic violence. Australasian Psychiatry, 27, 64–68. https://doi.org/10.1177/1039856218789778

13.

Heyman

R. E.

Kogan

C. S.

Foran

H. M.

Burns

S. C.

Slep

A. M. S.

Wodja

A. K.

Keeley

J. W.

Rebello

T. J.

Reed

G. M.

(2018). A case-controlled field study evaluating ICD-11 proposals for relational problems and intimate partner violence. International Journal of Clinical Health Psychology, 18, 113–123. https://doi.org/10.1016/j.ijchp.2018.03.001

14.

Hoffman

B. F.

Toner

(1988). The prevalence of spousal abuse in psychiatric in-patients: A preliminary study. Canadian Journal of Community Mental Health, 7, 53–60.

15.

Howard

L. M.

Trevillion

Khalifeh

Woodall

Agnew-Davies

Feder

(2010). Domestic violence and severe psychiatric disorders: Prevalence and interventions. Psychological Medicine, 40, 881–893. https://doi.org/10.1017/S0033291709991589

16.

Hultmann

Moller

Ormhaug

S. M.

Broberg

(2013). Asking routinely about intimate partner violence in a child and adolescent psychiatric clinic: A qualitative study. Journal of Family Violence, 29, 67–78. https://doi.org/10.1007/s10896-013-9554-5

17.

Ishida

Stupp

Melian

Serbanescu

Goodwin

(2010). Exploring the associations between intimate partner violence and women’s mental health: Evidence from a population-based study in Paraguay. Social Science and Medicine, 71, 1653–1661. https://doi.org/10.1016/j.socscimed.2010.08.007

18.

Jayatilleke

A. C.

Yoshikawa

Yasuoka

Poudel

K. C.

Fernando

Jayatilleke

A. U.

Jimba

(2015). Training Sri Lankan public health midwives on intimate partner violence: A pre- and post-intervention study. BMC Public Health, 15, Article 331. https://doi.org/10.1186/s12889-015-1674-9

19.

Jonas

Khalifeh

Bebbington

P. E.

McManus

Brugha

Meltzer

Howard

L. M.

(2014). Gender differences in intimate partner violence and psychiatric disorders in England: Results from the 2007 adult psychiatric morbidity survey. Epidemiology and Psychiatric Sciences, 23, 189–199. https://doi.org/10.1017/S2045796013000292

20.

Kamimura

Al-Obaydi

Nguyen

Trinh

H. N.

Doan

Franchek-Roa

(2015). Intimate partner violence education for medical students in the USA, Vietnam and China. Public Health, 129, 1452–1458.

21.

Koss

M. P.

Goodman

L. A.

Browne

Fitzgerald

L. F.

Keita

G. P.

Russo

N. F.

(1994). No safe haven: Male violence against women at home, at work, and in the community. American Psychological Association.

22.

Mackie

Moneti

Shakya

Denny

(2015). What are social norms? How are they measured? UNICEF. http://www.unicef.org/protection/files/4_09_30_Whole_What_are_Social_Norms.pdf

23.

Mason

O’Rinn

(2014). Co-occurring intimate partner violence, mental health, and substance use problems: A scoping review. Global Health Action, 7. https://doi.org/10.3402/gha.v7.24815

24.

McColgan

M. D.

Cruz

McKee

Dempsey

S. H.

Davis

M. B.

Barry

Yoder

A. L.

Giardino

A. P.

(2010). Results of a multifaceted intimate partner violence training program for pediatric residents. Child Abuse and Neglect, 34, 275–283.

25.

Murray

C. E.

Davis

Rudolph

Graves

K. N.

Colbert

Fryer

Mason

Thigpen

(2016). Domestic violence training experiences and needs among mental health professionals: Implications from a statewide survey. Violence & Victims, 31. https://doi.org/10.1891/0886-6708.VV-D-14-00092

26.

Nyame

Howard

L. M.

Feder

Trevillion

(2013). A survey of mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence. Journal of Mental Health, 22, 536–543. https://doi.org/10.3109/09638237.2013.841871

27.

Okuda

Olfson

Hasin

Grant

B. F.

Lin

Blanco

(2011). Mental health of victims of intimate partner violence: Results from a national epidemiologic survey. Psychiatric Services, 62, 959–962.

28.

Oram

Trevillion

Feder

Howard

L. M.

(2013). Prevalence of experiences of domestic violence among psychiatric patients: Systematic review. The British Journal of Psychiatry, 202, 94–99. https://doi.org/10.1192/bjp.bp.112.109934

29.

Organization for Economic Co-Operation and Development Centre. (2014). Social institutions and gender index 2014 synthesis report. http://www.oecd.org/dev/development-gender/BrochureSIGI2015-web.pdf

30.

Organization for Economic Co-Operation and Development Centre. (2019). Gender, Institutions and Development (Edition 2014). OECD International Development Statistics [Database]. https://doi.org/10.1787/data-00728-en

31.

Osborne

J. W.

(2017). Regression and linear modeling: Best practices and modern methods. SAGE.

32.

Owens

K. R.

(2007). Patient-centered provider behaviors and disclosure of intimate partner violence in a psychiatric emergency setting [Doctoral dissertation, University of Pittsburgh].

33.

Reed

G. M.

Rebello

T. J.

Pike

K. M.

Medina-Mara

M. E.

Gureje

Zhoa

Dai

Roberts

M. C.

Maruta

Matsumoto

Krasnov

V. N.

Kulygina

Lovell

A. M.

Stona

Sharan

Robles

Gaebel

Zielasek

Khoury

Saxena

(2015). WHO’s Global Clinical Practice Network for mental health. The Lancet, 2, 379–380.

34.

Reed

G. M.

Sharan

Rebello

T. J.

Keeley

J. W.

Elena Medina-Mora

Gureje

Luis Ayuso-Mateos

Kanba

Khoury

Kogan

C. S.

Krasnov

V. N.

Maj

de Jesus Mari

Stein

D. J.

Zhao

Akiyama

Andrews

H. F.

Asevedo

Cheour

Pike

K. M.

(2018). The ICD-11 developmental field study of reliability of diagnoses of high-burden mental disorders: Results among adult patients in mental health settings of 13 countries. World Psychiatry, 17, 174–186. https://doi.org/10.1002/wps.20524

35.

Rees

Silove

MAppStat

T. C.

Ivancic

Steel

Creamer

Teesson

Bryant

McFarlane

A. C.

Mills

K. L.

Slade

Carragher

O’Donnell

Forbes

(2011). Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function. Journal of American Medical Association, 306, 513–521.

36.

Ribeiro

A. P.

(2014). Perceptions and practices of Angolan health care professionals concerning intimate partner violence against women. Cadernos de Saúde Pública, 30, 1229–1238. https://doi.org/10.1590/0102-311X00103613

37.

Sansone

R. A.

Chu

Wiederman

(2007). Self-inflicted bodily harm among victims of intimate-partner violence. Clinical Psychology & Psychotherapy, 14, 352–357.

38.

Smith

S. G.

Zhang

Basile

K. C.

Merrick

M. T.

Wang

Kresnow

Chen

(2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 data brief—Updated release. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

39.

Sprague

Madden

Simunovic

Godin

Pham

N. K.

Bhandari

Goslings

J. C.

(2012). Barriers to screening for intimate partner violence. Women & Health, 52, 587–605. https://doi.org/10.1080/03630242.2012.690840

40.

Stephenson

Winter

Hindin

(2013). Frequency of intimate partner violence and rural women’s mental health in four Indian states. Violence Against Women, 19, 1133–1150. https://doi.org/10.1177/1077801213501898

41.

Stewart

D. E.

Chandra

P. B.

(2017). WPA international competency-based curriculum for mental health providers on intimate partner violence and sexual violence against women. World Psychiatry, 16, 223–224. https://doi.org/10.1002/wps.20432

42.

Trevillion

Byford

Cary

Rose

Oram

Feder

Agnew-Davies

Howard

(2014). Linking abuse and recovery through advocacy: An observational study. Epidemiology and Psychiatric Sciences, 23, 99–113. https://doi.org/10.1017/S2045796013000206

43.

Trevillion

Corker

Capron

L. E.

Oram

(2016). Improving mental health service responses to domestic violence and abuse. International Review of Psychiatry, 28, 423–432. https://doi.org/10.1080/09540261.2016.1201053

44.

Waalen

Goodwin

M. M.

Spitz

A. M.

Petersen

Sultzman

L. E.

(2000). Screening for intimate partner violence by health care providers: Barriers and interventions. American Journal or Preventive Medicine, 19, 230–237.

45.

Walker

M. L.

Dovoedo

Chakraborti

Hilton

C. W.

(2018). An improved boxplot for univariate data. The American Statistician, 72, 348–353. https://doi.org/10.1080/00031305.2018.1448891

46.

World Health Organization. (2005). WHO multi-country study on women’s health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women’s responses.

47.

World Health Organization. (2013a). Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence.

48.

World Health Organization. (2013b). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.