Prevalence of Intimate Partner Violence Across Medical and Surgical Health Care Settings

Abstract

Intimate partner violence (IPV) is a serious health problem and a leading cause of nonfatal injury in North American females. Prevalence of IPV has ranged from less than 20% to more than 50% across primary care, emergency medicine, and family medicine. We conducted a systematic review and meta-analysis of the literature to examine best estimates of IPV prevalence as opportunities for targeted interventions in health care specialties. We included 37 articles in this study. Based on our pooled data, best estimates of the lifetime prevalence of any type of IPV were 38% in family medicine and 40% in emergency medicine.

Keywords

intimate partner violence prevalence systematic review

Introduction

Intimate partner violence (IPV) against women has been identified as a serious health problem and is a leading cause of nonfatal injury in females in North America (Dannenberg, Baker, & Li, 1994; Kyriacou et al., 1999). IPV is described by the American Medical Association as “a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation, and intimidation” (McCloskey et al., 2007; p. 1067). These behaviors are perpetrated by someone who is in a private and personal relationship with another individual, such as a victim’s spouse, common-law partner, sexual partner, or dating partner.

Some studies have reported that as high as 54% of all women have experienced some form of IPV during the course of their life (Reisenhofer & Seibold, 2007). Women who are victims of IPV have been known to utilize health care services at higher rates than women who have not been abused (Campbell, 2002). They may present to a number of different medical specialists including emergency room physicians, orthopedic or trauma surgeons, family physicians, and specialists in obstetrics and gynecology, during routine appointments or for appointments specific to their injuries. Researchers and advocates have argued that health care providers can play a vital role in detecting IPV (Davidson et al., 2001).

Despite these recommendations for universal screening, the response from the medical community to address the issue of domestic violence has been characterized as “slow and inconsistent” (Davis, 2008). IPV is an underrecognized, recurrent part of trauma, present in at least one in five women who present to the Emergency Department, and physicians frequently fail to make this diagnosis (Davis, 2008). The failure to detect IPV contributes to recidivism and long-term health problems (Glass, Dearwater, & Campbell, 2001). In addition, when injuries resulting from IPV are not recorded in medical records, abused women are denied documentation of their injuries for future references in court cases (Glass et al., 2001). In addition, opportunities to provide education about prevention, lethality assessment, safety planning, and options for escaping an abusive situation and referrals to resources within the community may also be missed (Glass et al., 2001).

The reported rates of IPV vary across different subspecialties and may be underreported. While several studies have reported the prevalence rates of IPV in the health care setting, these estimates vary substantially. Best estimates of rates across various subspecialties are lacking. We therefore undertook a systematic review and meta-analysis of the published literature to determine the prevalence rates of IPV reported to different medical subspecialties including family medicine, emergency medicine, obstetrics and gynecology, internal medicine, addiction recovery clinics, and adults with child patients in pediatric clinics. The study has important implications for health care professionals in various settings. It will direct attention to medical practitioners in subspecialties where IPV is overlooked and will affect their interaction with and treatment of IPV victims as well as victims’ willingness to disclose. In addition, identification of health care settings with the highest prevalence rates will allow targeted research and focus toward improvement of the quality of life of IPV victims.

Method

This systematic review adheres to the reporting guidelines of the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) Statement (Stroup et al., 2000).

Eligibility Criteria

We identified articles in all languages that met the following eligibility criteria: (a) The study was published between January 1995 and July 2009, (b) the target population consisted of adult women between the ages of 16 and 65 years presenting to physicians of any medical specialty, and (c) the primary objective of the study was to determine the prevalence rates of IPV. We included all study designs including cross-sectional designs, surveys, and chart or medical record reviews. We excluded studies focusing on children, males, and special populations such as pregnant women, elderly patients, and patients suffering from a specific illness (i.e., depression, chronic gastroenterological disease). We also excluded review articles, letters, comments, case reports, and guidelines.

Identification of Studies

Two reviewers (C.H. and S. dM.) independently conducted a search of the electronic database PubMed for relevant articles published from January 1995 to July 2009 in all languages with the help of a professional librarian. Additional strategies used to identify studies included consultation with experts, a review of reference lists from articles that fulfilled our eligibility criteria, and use of the “related articles” feature in PubMed for all studies meeting our entry criteria.

Assessment of Study Eligibility

Two of the authors (C.H. and S. dM.) independently assessed all studies identified for full evaluation and resolved disagreements through discussion toward consensus. The eligibility was verified by two additional authors (S.S. and N.S.). Agreement between observers for study eligibility with regard to abstract and full-text review was examined using the κ (kappa) statistic. The interobserver agreement in methodological quality scores was evaluated using the intraclass correlation coefficient. We chose an a priori criterion of κ ≥ .65 for adequate agreement. The 95% confidence intervals were calculated using the generic formula: Estimate ± 1.96 × (Standard Error).

Assessment of Methodological Quality

Two reviewers (N.S. and S.S.), both with methodological expertise and one with content expertise (S.S.), independently graded the methodological quality of each included study using questions adapted from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement designed for cross-sectional studies (von Elm et al., 2008). The STROBE statement is a checklist of 22 items that are considered for good reporting of observational studies. The STROBE statement was developed to assist authors when writing analytic observational studies, to support editors and reviewers when considering such articles for publication, and to help readers critically appraise published research (von Elm et al., 2008).

The original authors emphasized that the STROBE statement was not developed as a tool for assessing the quality of published observational research (von Elm et al., 2008). Unfortunately, very few checklists exist for critically appraising cross-sectional studies (Katrak, Bialocerkowski, Massy-Westropp, Kumar, & Grimmer, 2004; Kelley, Clark, Brown, & Sitzia, 2003; Sanderson, Tatt, & Higgins, 2007), and we did not find that any of the previously developed checklists were appropriate for this study. Therefore, we adapted the STROBE statement to assess study quality. A priori we determined that studies that met at least 10 of the 13 reporting criteria within our modified STROBE criteria would be considered high quality; studies that met 7 to 9 reporting criteria would be considered medium quality; and studies that met 6 or fewer criteria would be classified as low quality.

Data Extraction

A structured data extraction form was developed and relevant data were extracted from each eligible study in duplicate (S.S. and N.S.) to ensure accuracy. Pertinent data included study characteristics (year and location), patient characteristics (age), type of medical subspeciality (emergency medicine, family medicine, obstetrics and gynecology, internal medicine, addiction recovery, pediatrics, and public health), method of data collection (survey, interview, chart review, other design), time frame (lifetime, 1 year, 2 years, and other), sample size, and response rate. We documented how the authors defined overall IPV as well as physical, emotional, and sexual abuse. Finally, we recorded the reported rates of overall IPV and of physical, emotional, and sexual abuse as reported by the authors.

Data Analysis

We provide pooled rates of lifetime and 1-year physical abuse, emotional abuse, and sexual abuse for emergency medicine, family medicine, and other specialties. Analyses were performed with Predictive Analytics SoftWare (PASW) Statistics version 18.0 (SPSS, Inc., Chicago, IL).

Evaluation of Heterogeneity

Before analyzing the data, we hypothesized that there would be a large degree of heterogeneity across the studies. Differences such as study methodology (e.g., survey vs. interview vs. other study designs), timelines of reported IPV (e.g., lifetime vs. 1 year), differences in screening tools used (e.g., Abuse Assessment Screen (AAS), Conflict Tactics Scale (CTS), Partner Violence Screen (PVS)), variability within and between populations (e.g., socioeconomic status, age, jurisdiction), differences in the definition of IPV perpetrator (e.g., male perpetrator vs. perpetrator of any gender, or spouse vs. any intimate partner), or variable study quality could contribute to the heterogeneity.

Results

Study Identification

Our literature search identified 894 potentially relevant citations, of which 32 were considered for inclusion after full-text review (Figure 1). Eighteen of these 32 studies were excluded after verification by additional reviewers (N.S. and S.S.) because of insufficient data on IPV prevalence, or they did not meet the eligibility criteria. Of 80 studies considered for inclusion based on review of bibliographies, 20 were included in this study. Three studies were identified and included after consultation with a content expert. In total, 37 studies were included in this review. The weighted kappa on overall agreement between reviewers when choosing articles for the full-text review was .70 (95% CI = [0.59, 0.82]), and for final study inclusion there was only one disagreement.

Figure 1.

Flowchart of study process.

Study Characteristics

Details of the selected studies are shown in Table 1. The mean age of participants in the included studies was between 28 and 65 years, with 17 studies not reporting mean age. Response rates ranged from 9% to 100% with most studies (24/37, 64.9%) reporting a response rate of 70% or greater. Twenty-five studies (67.6%) took place in the United States, 3 studies took place in each of Australia and the United Kingdom, and other locations (Canada, Spain, Iran, Israel, South Africa, and China) each having 1 study. Most studies took place in family medicine clinics (15/37, 40.5%) and emergency departments (12/37, 32.4%). Of the remaining studies, 3 took place in obstetrics and gynecology clinics, three took place in internal medicine clinics, and 4 studies had more than one specialty. Nineteen studies (51.4%) used written questionnaires to assess rates of IPV, 14 studies (37.8%) used an in-person interview, 1 study (2.7%) used a telephone survey, 1 study (2.7%) used a computer-based survey, and 2 studies (5.4%) used more than one method.

Table 1.

Characteristics of Included Studies.

Study	Year	Location	Medical specialty	Population	M age of participants (years)	Sample size	Method of data collection	Timelines presented	Response rate (%)	Quality score^a
Abbott, Johnson, Koziol-McLain, and Lowenstein	1995	United States	Emergency	English, Spanish, 18-86, 7% pregnant	34.0	648	Written survey	Lifetime, 1 year, acute, 1 month	77.8	High
Bauer, Rodriguez, and Perez-Stable	2000	United States	Family, ObGyn, Internal	18-46, 31% African American, 36% Latina, 31% White	33.5 (7.5)	734	Phone interview	Lifetime, 1 year	74.0	High
Caralis and Musialowski	1997	United States	Internal	Female veteran patients, English speaking	50.4 ± 16	406	In-person interview	Lifetime, 1 year, current	78.7	High
Cleary, Keniston, Havranek, and Albert	2008	United States	Internal	18-60, not pregnant, English/Spanish speaking	History of IPV: 44.0 ± 10 No history of IPV: 45.0 ± 12	72	Written survey	Lifetime, 1 year, current, most recent relationship, past relationship	92.3	High
Coker, Smith, McKeown, and King	2000	United States	Family	18-65, insured, in relationship for at least 6 months	37.6	1,401	In-person interview	Lifetime, current, past 5 years	87.3	High
Coker et al.	2007	United States	Family	Lower income women in rural clinics	39.5 ± 12.6	3,664	In-person interview	Lifetime, 1 year, current, acute	74.1	High
Cox et al.	2004	Canada	Emergency	16+, English or French speaking, able to communicate	41.0	983	Written survey	Lifetime, 1 year, current, acute	80.4	High
Dearwater et al.	1998	United States	Emergency	18+, English and Spanish speaking, able to communicate	Pennsylvania: 48 California: 41	3,455	In-person interview	Lifetime, 1 year, acute	74.4	High
El-Bassel et al.	2007	United States	Emergency	18+	37.1	799	In-person interview	Lifetime	63.9	High
Elliott and Johnson	1995	United States	Family	18-65, English speaking	NR	42	In-person interview	Lifetime, past relationship	65.6	Moderate
Ernst, Nick, Weiss, Houry, and Mills	1997	United States	Emergency	18+, inner city, English speaking, excluded if they never had a partner, men and women	35.0 ± 13	207	Written survey	Current, past relationship	NR	High
Faramarzi, Esmailzadeh, and Mosavi	2005	Iran	ObGyn	Iranian women, married	28.2 (6.6)	2,400	In-person interview	1 year	NR	Moderate
Glass, Dearwater, and Campbell	2001	United States	Emergency	18-65 English/Spanish speaking	NR	3,455	In-person interview, Chart review, Written survey	Lifetime, 1 year	73.7	High
Grynbaum, Biderman, Levy, and Petasne-Weinstock	2001	Israel	Family	Hebrew and Russian speaking, 18-60 years	39.2	133	Written survey	Lifetime, 1 year	95.7	Moderate
Hegarty	2002	Australia	Family	16+, English speaking, women presenting with child patients also included	NR	1,836	Written survey	Lifetime, 1 year, 5 years	78.5	High
Houry, Kemball, Rhodes, and Kaslow	2006	United States	Emergency	African American, 18-55, spoke English at grade 5 level	32.4	461	Computer survey	1 year	75.8	High
John, Johnson, Kukreja, Found, and Lindow	2004	United Kingdom	ObGyn	All women	NR	825	Written survey	Lifetime, 1 year	89.7	Moderate
D. Johnson	1997	United States	Family	18-94 years, rural	NR	280	Written survey	Lifetime, 1 year, current	NR	Moderate
M. Johnson and Elliott	1997	United States	Family	18+, English speaking, no dementia	65.0	127	In-person interview	Lifetime, current, past relationship	63.5	Moderate
Kramer, Lorenzon, and Mueller	2004	United States	Family, Emergency	18+, English and Spanish speaking	NR	1,268	Written survey	Lifetime, 1 year	9	High
Krishnan, Hilbert, and Pase	2001	United States	Emergency	18+, English and Spanish speaking	NR	87	In-person interview	Lifetime, current	70	Low
Marais, de Villiers, Moller, and Stein	1999	South Africa	Family	18+	NR	1,050	In-person interview	Lifetime	99	Moderate
Mazza, Dennerstein, and Ryan	1998	Australia	Family	18+	NR	2,181	Written survey	1 year	72.1	High
McCauley et al.	1995	United States	Internal	English-speaking adults, able to read, no mental diminishment, not acutely ill	NR	1,952	Written survey	Lifetime, 1 year	81.6	High
McCloskey et al.	2005	United States	Family, Emergency, ObGyn, Pediatrics, Addictions	English, Spanish, Chinese or Russian speaking, 18+, some pregnant women	35.0 ± 13.4	2,650	Written survey	Lifetime, 1 year	62.4	High
McFarlane, Groff, O’Brien, and Watson	2005	United States	Family	18-44, African American, White and Hispanic (predominant), English/Spanish speaking	NR	7,443	In-person interview	1 year	NR	Moderate
McLaughlin et al.	1999	United States	Emergency	18-50 years, English speaking	NR	421	In-person interview	Lifetime, 1 year	100	Moderate
Muelleman, Lenaghan, and Pakieser	1998	United States	Emergency	19-65 years, English speaking	NR	4,501	Written survey	Lifetime, current	73.3	Moderate
Newman, Sheehan, and Powell	2005	United States	Pediatric Emergency	English- and Spanish-speaking women with children	32.0 ± 10	451	Written survey	1 year	97.8	High
Paul, Smith, and Long	2006	Ireland	Family	18-65, women and men	NR	139	Written survey	Lifetime	77.2	High
Peralta and Fleming	2003	United States	Family	18-36, English speaking	NR	399	Written survey	Past 3 months	NR	High
Richardson et al.	2002	United Kingdom	Family	16+, English, Turkish or Bengali speaking	NR	1,207	Written survey	Lifetime, 1 year	55.1	High
Roberts, O’Toole, Raphael, Lawrence, and Ashby	1996	Australia	Emergency	16+, English speaking, men and women	45.1	533	Written survey	Lifetime	67.7	High
Roche, Moracco, Dixon, Stern, and Bowling	2007	United States	Emergency	18+, English/Spanish speaking, admitted to hospital	37.0	321	Phone interview, Written survey	Lifetime	75.1	High
Ruiz-Perez et al.	2006	Spain	Family	18-65, Spanish speaking, literate	38.8 (11.2)	1,402	Written survey	Lifetime	86.0	High
Wagner, Mongan, Hamrick, and Hendrick	1995	United States	Family	18+, urban and rural setting, White and African American	NR	407	In-person interview	Lifetime	86.2	High
Xu et al.	2005	China	ObGyn	18-60, Mandarin speaking	31.3 (7.5)	600	In-person interview	Lifetime, 1 year	87.6	High

The quality score is based on the STROBE Statement for cross-sectional studies. NR = not reported.

Study Quality

We judged 26 studies to be of high methodological quality, 10 studies to be of moderate quality, and the remaining 1 study to be of low quality (Table 1). The reviewers of methodological quality achieved moderate agreement (intraclass correlation coefficient, 0.65; 95% CI = [0.57, 0.71]).

Definition of IPV

The definition of IPV varied greatly among studies. The two most commonly used screening tools among the studies were the Abuse Assessment Screen (13 studies, 35.1%) and the Conflict Tactics Scales (5 studies, 13.5%), or modified versions of these tools. Many studies used gender-neutral language, such as “partner,” but others specified that the abuser must be male (8 studies, 21.6%). Most studies included only female victims, but a small number (3 studies, 8.1%) also included male victims.

IPV Prevalence

Twenty-nine of the included studies (78.4%) presented an overall rate of IPV. Overall pooled lifetime prevalence rates were similar across family medicine and emergency medicine (38% and 40%, respectively). Rates reported for other specialties, however, were considerably higher (59%; Table 4). Prevalence rates of IPV in the past year were also similar across studies in family practice and emergency clinics (19.9% vs. 19.5%, respectively; Tables 2 and 3). Between 2% and 4.3% of female patients presenting to emergency departments were reported to have injuries caused by a current or former intimate partner (Table 2). Based on a single study in each of pediatric emergency medicine and public health clinics, these specialties have lower rates of physical IPV than other specialties in the reviewed articles (Table 4). Please see Figure 2 for pooled prevalence rates of IPV across specialties.

Table 2.

Prevalence in Emergency Medicine.

Timeline	Study	Overall IPV rate (%)	Physical IPV rate (%)	Sexual IPV rate (%)	Emotional IPV rate (%)
Lifetime	Abbott, Johnson, Koziol-McLain, and Lowenstein (1995)	27.7 (23.4-32.2)	23.1	NR	NR
	Roberts, O’Toole, Raphael, Lawrence, and Ashby (1996)	16.1	NR	NR	NR
	Muelleman, Lenaghan, and Pakieser (1998)	NR	37	NR	NR
	McLaughlin et al. (1999)	47.3	NR	NR	NR
	Krishnan, Hilbert, and Pase (2001)	NR	20.7	5.7	23.0
	Cox et al. (2004)	51 (49-53)	NR	NR	NR
	Kramer, Lorenzon, and Mueller (2004)	NR	58.1	33.9	67.7
	McCloskey et al. (2005)	41^a	NR	NR	NR
	El-Bassel et al. (2007)	49.6	44.2	24.9	NR
	Roche, Moracco, Dixon, Stern, and Bowling (2007)	33.3	27.1	5.6	NR
Past year	Abbott, Johnson, Koziol-McLain, and Lowenstein (1995)	15.3 (12.6-18.3)	NR	NR	NR
	Dearwater et al. (1998)	14.4	12.6	4.6 (3.8-5.2)	NR
	McLaughlin et al. (1999)	12.1	NR	NR	NR
	Cox et al. (2004)	25 (23-39)	NR	NR	NR
	Kramer et al. (2004)	NR	20.4	6.5	37.8
	McCloskey et al. (2005)	16.5^a	NR	NR	NR
	Houry, Kemball, Rhodes, and Kaslow (2006)	36.0	22.0	8.9	32.1
Past 6 months	El-Bassel et al. (2007)	11.8	8.9	6.4	NR
Past month	Abbott et al. (1995)	11.9 (9.5-14.6)	6.5	NR	NR
Current relationship	Ernst, Nick, Weiss, Houry, and Mills (1997)	NR	18.8	NR	15.5
	Muelleman et al. (1998)	NR	5.9	NR	NR
	Krishnan et al. (2001)	18.2	NR	NR	NR
	Cox et al. (2004)	9 (7-12)	NR	NR	NR
Most recent relationship	Krishnan et al. (2001)	32.3	NR	NR	NR
Acute	Abbott et al. (1995)	NR	2.2	NR	NR
	Dearwater et al. (1998)	2.2	NR	NR	NR
	Glass, Dearwater, and Campbell (2001)	4.3	NR	NR	NR
	Cox et al. (2004)	2	NR	NR	NR
Past Relationship	Ernst et al. (1997)	NR	32.2	NR	22.3
Cumulative	Abbott et al. (1995)	54.2	NR	NR	NR

Rates are adjusted

Table 3.

Prevalence in Family Medicine.

Timeline	Study	Overall IPV rate (%)	Physical IPV rate (%)	Sexual IPV rate (%)	Emotional IPV rate (%)
Lifetime	Elliott and Johnson (1995)	45	31	19	31
	Wagner, Mongan, Hamrick, and Hendrick (1995)	66.1	38.8	24	55
	D. Johnson (1997)	NR	13.9	2.1	NR
	M. Johnson and Elliott (1997)	44.9	29.1	15.0	29.1
	Marais, de Villiers, Moller, and Stein (1999)	21.5	14.6	1.6	NR
	Coker, Smith, McKeown, and King (2000)	55.1	37.6	23.1	NR
	Grynbaum, Biderman, Levy, and Petasne-Weinstock (2001)	30.8	NR	NR	NR
	Richardson et al. (2002)	27.7 (25-30)	41.1 (38-44)	NR	NR
	Hegarty (2004)	37 (31-42)	23.3	10.6	33.9
	Kramer, Lorenzon, and Mueller (2004)	NR	53.8	24.2	54.2
	Paul, Smith, and Long (2006)	NR	43.2	NR	76
	Ruiz-Perez et al. (2006)	31.7	14.1	8.8	30.7
Past year	D. Johnson (1997)	NR	8.2	NR	NR
	Mazza, Dennerstein, and Ryan (1998)	28.9 (24-34)	22.4	NR	20.1 (16-24)
	Bauer, Rodriguez, and Perez-Stable (2000)	13	NR	NR	NR
	Grynbaum et al. (2001)	NR	9.8	NR	NR
	Hegarty (2002)	27.6	5.0	1.9	7.6
	Richardson et al. (2002)	NR	16.8 (14-19)	NR	NR
	Kramer et al. (2004)	NR	9.6	3.7	25.4
	McCloskey et al. (2005)	8.6^a	NR	NR	NR
Past 3 months	Peralta and Fleming (2003)	44.3	10.3	NR	40.6
Past 5 years	Coker et al. (2007)	25.6	10.1	24.3	NR
Over 5 years ago	Hegarty (2002)	41.5	NR	NR	NR
Current relationship	D. Johnson (1997)	NR	NR	NR	5.0
	M. Johnson and Elliott (1997)	20.5	NR	NR	NR
	Coker et al. (2000)	14.8	14.8	5.1	NR
	Coker et al. (2007)	13.3	16.3	13.3	NR
Most recent relationship	Coker et al. (2000)	33.0	18.9	14.4	NR
Past relationship	M. Johnson and Elliott (1997)	27.6	NR	NR	NR
	Coker et al. (2000)	46.0	32.0	17.3	10.1

Rates are adjusted.

Table 4.

Prevalence in Other Specialties.

Specialty	Timeline	Study	Overall IPV rate (%)	Physical IPV rate (%)	Sexual IPV rate (%)	Emotional IPV rate (%)
Obstetrics/gynecology	Lifetime	John, Johnson, Kukreja, Found, and Lindow (2004)	NR	20.7	NR	NR
		Xu et al. (2005)	43	38	16	NR
	Past year	Bauer, Rodriguez, and Perez-Stable (2000)	15	NR	NR	NR
		John et al. (2004)	NR	4.1	NR	13.1
		Faramarzi, Esmailzadeh, and Mosavi (2005)	NR	15.0	42.4	81.5
		Xu et al. (2005)	26	21	12	NR
Internal medicine	Lifetime	Cleary, Keniston, Havranek, and Albert (2008)	61.1	NR	NR	NR
	Past year	McCauley et al. (1995)	5.5	NR	NR	NR
		Caralis and Musialowski (1997)	NR	7	3	NR
		Bauer et al. (2000)	14	NR	NR	NR
		McCloskey et al. (2005)	12.7^a	NR	NR	NR
		Cleary et al. (2008)	22.2	NR	NR	NR
	Current relationship	Caralis and Musialowski (1997)	7	NR	NR	NR
Addiction recovery	Lifetime	McCloskey et al. (2005)	73^a	NR	NR	NR
	Past year	McCloskey et al. (2005)	16.5^a	NR	NR	NR
Pediatrics (adults accompanying pediatric patients)	Past year	McCloskey et al. (2005)	8.4^a	NR	NR	NR
Pediatric emergency (adults accompanying pediatric patients)	Past year	Newman, Sheehan, and Powell (2005)	11.1	4.2	<0.001	NR
Public health	Past year	McFarlane, Groff, O’Brien, and Watson (2005)	NR	4.1	<0.001	NR

Rates are adjusted.

Figure 2.

Pooled prevalence of IPV.

Discussion

Our systematic review and meta-analysis found that the pooled prevalence rates of IPV in emergency medicine and family medicine are similar for both lifetime and 1-year timelines. Pediatric emergency medicine and public health clinics had lower rates of physical IPV than other specialties, although there were fewer studies in these specialties than others. Physical IPV was more commonly reported than both emotional IPV and sexual IPV, and the rates of sexual abuse tend to be lower than physical and emotional abuse, with emotional abuse being the most common type of IPV.

Several strengths contributed to the quality of this study. A comprehensive search of the literature and a data abstraction from eligible studies were conducted by two independent reviewers to ensure accuracy, and the articles were screened thoroughly and systematically for inclusion criteria. There was a high degree of agreement between the two reviewers, and many studies of general high quality are included in the review. Also, the results can be highly generalized due to the broad eligibility criteria.

Despite these strengths, our study is limited by a large degree of heterogeneity across the included studies. Heterogeneity was likely a product of many factors including different methodology, populations, and definitions of IPV utilized across the eligible studies. The included studies had varying population characteristics and utilized several different screening tools, which likely contributed to the wide range in prevalence rates reported. Despite the large variations, our pooled data show that the prevalence of IPV in emergency medicine and family medicine are similar. Another limitation is the moderately low intraclass correlation coefficient for agreement on methodological quality. This is likely due to the chance for greater variability with an extensive 13-item checklist.

The definition of IPV used is essential to compare studies of IPV prevalence. Differences in definitions include the timeline reported, screening tool used, type(s) of IPV included, and definition of perpetrator and victim. Nine different timelines were presented by included studies (lifetime, 1 year, acute, 1 month, 3 months, most recent relationship, current relationship, past relationship, and past 5 years). The included studies also used a variety of screening tools that have been validated to differing degrees, or adaptations of screening tools that have not undergone validation studies. Rabin, Jennings, Campbell, and Bair-Merritt (2009) reported that even the most commonly studied screening tools are only validated in a small number of studies. Since no “gold standard” exists to screen for IPV in a clinical setting, comparing results across screening tools is a challenge. These differences in definition make IPV a difficult subject to fully understand without some sort of standardization.

Despite similar definitions, differences still occurred. There were three studies that used the AAS (the most common screening tool among included articles), similar definitions of physical IPV, and included a family medicine population (M. Johnson & Elliott, 1997; Kramer, Lorenzon, & Mueller, 2004; Marais, de Villiers, Moller, & Stein, 1999). All three studies had sample sizes more than 1,000 patients, used a lifetime timeline and were considered moderate or high-quality studies. However, Kramer et al. (2004) found that the prevalence of physical IPV was far greater than the other two studies (over 50% vs. 14.6% and 13.9%, respectively). The population may account for this variation. For example, M. Johnson and Elliott (1997) described a rural U.S. population, Kramer et al. (2004) used a U.S. English- and Spanish-speaking population, and Marais et al. (1999) used a South African population. It is plausible that differing populations and regions experience different rates of IPV. For example, urban populations experience higher rates of IPV than rural areas (Kramer et al., 2004; Lanier & Maume, 2009).

In addition, the studies included in this review used a variety of methods of data collection. MacMillan et al. (2006) found that the prevalence of IPV depends on the type of instrument administration (written, verbal, or computer-based), and there was an interaction between method of administration and screening tool used. Some studies suggest that computer-based screening can increase disclosure (Turner et al., 1998), and others suggest that face-to-face interviews increase disclosure over written surveys (McFarlane, Christoffel, Bateman, Miller, & Bullock, 1991). One of the included studies used computer-based screening and obtained an overall prevalence of 36.0% in the past year in emergency medicine (Houry, Kemball, Rhodes, & Kaslow, 2006). This is the highest included prevalence for the 1-year timeline in emergency medicine. Results vary for written surveys versus in-person interviews in this review.

We did not identify published studies on the prevalence of IPV across all subspecialties. There were no included studies in populations undergoing surgery, although surgeons likely encounter multiple patients who are victims of IPV. Orthopedic and trauma surgeons, for example, may frequently treat victims of physical IPV in their practice (Bhandari, Dosanjh, Tornetta, & Matthews, 2006), yet none of the included studies measured prevalence of IPV in orthopedic clinics. A large multicenter cross-sectional prevalence study is presently underway that will investigate the prevalence of IPV in patients presenting to orthopedic fracture clinics (PRAISE Investigators, 2010). None of the included studies reported the prevalence of IPV among psychiatric patients, which could be another high-risk population. It may be important to study other medical specialties, even those expected to identify lower rates of IPV, because victims of IPV do not readily disclose their history of abuse to health care providers (Spangaro, Zwi, Poulos, & Man, 2010).

In conclusion, prevalence rates have been reported in the literature for various medical specialties including family medicine, emergency medicine, and others. However, the studies show a great degree of heterogeneity and, therefore, are difficult to compare. It would be easier to compare prevalence rates across studies if the definition of IPV remained constant. Based on our pooled data, best estimates of IPV prevalence in emergency medicine and family medicine appear to be similar. Future studies could investigate the prevalence of IPV in other specialties and should use similar definitions of IPV.

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

Author Biographies

Sheila Sprague is the Research Program Manager at the Center for Evidence-based Orthopedics at McMaster University. She recently completed her PhD at the University of Amsterdam on the topic of intimate partner violence in orthopaedic trauma patients.

J. Carel Goslings is a Professor of Trauma Surgery and head of the Trauma Unit Department of Surgery in the Academic Medical Center in Amsterdam, the Netherlands. Prof. Goslings and his research group perform research in broad areas of trauma surgery including: treatment of pelvic, spinal and extremities injuries, post-traumatic stress disorders and intimate partner violence.

Celine Hogentoren is a co-assistant (intern) at the Academic Medical Centre in Amsterdam, the Netherlands. She is currently working towards completing her Doctorate in Medicine at the University of Amsterdam.

Simone de Milliano is a co-assistant (intern) at the Academic Medical Centre in Amsterdam, the Netherlands. She is currently working towards completing her Doctorate in Medicine at the University of Amsterdam.

Nicole Simunovic is a Research Coordinator in the Department of Clinical Epidemiology & Biostatistics at McMaster University. She has been involved with research on intimate partner violence for several years.

Kim Madden is a Research Coordinator in the Department of Clinical Epidemiology & Biostatistics at McMaster University. She is currently pursuing a Master’s Degree in Health Research Methodology at McMaster University focusing on intimate partner violence research.

Mohit Bhandari is a Professor of Surgery and Academic Head of the Division of Orthopedic Surgery at McMaster University. He has dedicated nearly a decade of his career to investigating intimate partner violence in orthopaedic trauma patients, including acting as principal investigator of the large multicenter PRAISE study that aims to assess the prevalence of intimate partner violence in orthopedic trauma patients globally.

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