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Questions What experiences do abused women have in the healthcare system? What are abused women's perceptions of the characteristics of the healthcare system that discourage or facilitate disclosure of abuse? What are abused women's perceptions of interventions that may improve detection and management of abuse in primary care?
3 community based mental health centres and a women's shelter in Baltimore, Maryland, USA.
21 women (62% African-American; 81% single, separated, or divorced) who were ≥18 years of age, spoke English, and were in group therapy for domestic violence. Annual family income ranged from <$15 000 (43%) to >$30 000 (28%). 5 women lived in a women's shelter for domestic violence.
Women participated in 1 of four 90 minute focus group sessions. The 3 main questions were about good or bad experiences when discussing violence with a healthcare professional, the ease with which women could discuss violence with a healthcare professional, and information that doctors should know when treating abused women. Each focus group had 3–8 participants and was facilitated by a female physician. Audiotapes of the group sessions were transcribed and checked for accuracy. The authors divided transcripts into fragments for each discrete thought and grouped fragments into themes.
5 main themes emerged. Medical problems that worsened with abuse were asthma, hypertension, headaches, eye pain, chest pain,stomach pains, back problems, vaginal bleeding, large changes in weight, insomnia, depression, and anxiety. Women's ability to access medical care was mainly affected by their partners who prevented them from receiving medical care. Women's attitudes about abuse that affected disclosure included feelings of shame, denial, and fear (of other people's reactions, of consequences to children, or of abuser's reaction to disclosure), and the lack of readiness to change the relationship with the abuser. One of the main clinician characteristics that hindered disclosure was the fear that the clinician would judge or blame women for their abuse. Women did not disclose abuse if they perceived clinicians to be uncaring, rushed, too busy, interested only in money, uncomfortable with the topic, or not listening. Some women were afraid that clinicians would share the information with other family members. Women were more likely to discuss the abuse if they perceived clinicians to be caring, easy to talk to, and protective and if clinicians offered follow up. Screening and treatment experiences showed that leaflets and posters about domestic violence found in clinician offices helped women to talk about their abuse. Most women said they would answer a questionnaire about abuse honestly if it were given in a private area. Some women received medication for depression, anxiety, or sleep disturbances. Many women feared addiction to prescribed medications, and some women feared that prescribed psychotropic medications might interfere with alertness. Women found referral to women's groups or other agencies beneficial, but they consistently described having negative experiences with psychologists or psychiatrists.
Abused women often experienced increased medical problems and barriers to health care. Clinician attitudes and behaviour either facilitated or acted as barriers to disclosure of abuse.
Clinicians repeatedly fail to ask adult women whether or not they have been abused by their partners.1 It has been suggested that fear of offending the patient by asking about abuse is one factor contributing to provider reluctance to open a Pandora's box.2 This qualitative study explored experiences of abused women with primary healthcare physicians in disclosing abuse and in being treated for stress related illnesses that were a consequence of victimisation. Of the 21 women who participated in focus group discussions, 81% were not married at the time and 62% were of African-American descent. No demographic data existed on whether the participants had children. Thus, the study results may not be applicable to women of other cultures, married women, or women with children. Despite the study's limitations, the results suggest that several clinician behaviours may facilitate a woman's decision to disclose abuse. Such behaviours include (1) structuring an environment that encourages disclosure by using leaflets and poster displays about domestic violence, (2) asking direct questions about violence, and (3) confidentially providing questionnaires about abuse. Given the frequency of abuser interference and the association between abuse and medical problems reported in this study, it would seem prudent to consider where to put the information (ie, women's restroom or waiting room) and what the exact content should be (eg, women's shelter phone numbers or medical problems that worsen with abuse).
This study, along with research by Rodriguez et al3 and Hayden et al,4 is an important step in informing clinicians that women want to be asked about abuse. After disclosure, clinicians need to know how to formulate a plan of action and know of resources available in their own community. Future research should validate these findings in more culturally diverse populations.
Source of funding: no external funding.
For correspondence: Dr J McCauley, Physician Advisor/Performance Improvement Department, Johns Hopkins Medical Service Corporation, 3100 Wyman Park Drive, 4th Floor, Baltimore, MD 21211, USA. Fax +1 410 338 3537.