Domestic violence screening among primary health care workers in Kuwait

Transcription

1 Alexandria Journal of Medicine (2013) 49, Alexandria University Faculty of Medicine Alexandria Journal of Medicine ORIGINAL ARTICLE Domestic violence screening among primary health care workers in Kuwait Modimajed Almutairi a, Abeer M. Alkandari b, Hebaahmad Alhouli c, Mohamed I. Kamel d,e, *, Medhat K. El-Shazly f,g a Shamyia Clinic, Primary Health Care, MOH, Kuwait b Qurain Center, Primary Health Care, MOH, Kuwait c Alzahraa Clinic, Primary Health Care, MOH, Kuwait d Community Medicine Department, Faculty of Medicine, Alexandria University, Egypt e Department of Occupational Medicine, Ministry of Health, Kuwait f Department of Medical Statistics, Medical Research Institute, Alexandria University, Egypt g Department of Health Information and Medical Records, Ministry of Health, Kuwait Received 18 July 2012; accepted 29 August 2012 Available online 21 September 2012 KEYWORDS Violence women; Screening; Primary health care Abstract Background: Screening for violence against women provides an important opportunity for early detection and proper management of affected women. Primary health care workers can play an important role to implement screening measures for women. Multiple factors such as knowledge, attitude as well as barriers and enabling factors available for medical staff can affect these programs. Objectives: The aim of this study was to reveal the extent of screening for domestic violence among physicians and nurses in the primary health care unit, identify knowledge, attitude, and barriers toward violence screening, and reveal factors affecting screening. Subjects and methods: To achieve these objectives, an observational cross-sectional study was carried out in PHC centers located in two randomly selected health regions in Kuwait. The study involved all available physicians (210) and nurses (464) in the selected centers. The overall response rate was 54.3%. A self-administrative questionnaire was used for data collection. Results: Less than two-thirds (62.5%) of the primary health care workers were aware about the topic while only about one-third (34.7%) regularly screened for violence among women. Of those regularly * Corresponding author. Present address: Department of Occupational Medicine, Ministry of Health, Kuwait. Tel.: addresses: drmoodi@hotmail.com (M. Almutairi), Omba der_q8@yahoo.com (A.M. Alkandari), De.h.al-houly@hotmail.com (H. Alhouli), kamelafm@yahoo.com (M.I. Kamel), (M.K. El-Shazly). Peer review under responsibility of Alexandria University Faculty of Medicine. Production and hosting by Elsevier ª 2012 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.

2 170 M. Almutairi et al. screening for violence, about two-thirds (66.1%) screened only less than 5% of women whom they examined, while 7.9% regularly screened more than 50% of their examinees. Physicians tended to screen for violence more than nurses as they constituted 51.2% of those screening compared with 26.4% of those not screening for violence, P < Those screening for violence had a significantly higher mean percent overall knowledge score (73.8 ± 9.5% compared with 70.9 ± 11.2%, P = 0.006) while they had a lower attitude score (65.5 ± 16.5 compared with 70.1 ± 18.6%, P = 0.015). Barriers related to the victim herself were the most common followed by those related to those related to women culture and administrative procedures. Conclusion: Primary health care workers admitted that they have low rates of screening for domestic violence against women. Physicians were more likely to screen for violence than nurses. Multiple barriers were revealed for screening including mainly those related to women whether their characteristics or culture in addition to administrative ones. ª 2012 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved. 1. Introduction Domestic violence against women is physical or sexual violence or threats of violence made by husband or another family member, often accompanied by controlling behaviors. 1 Domestic violence is a prevalent and serious health risk for women. 2 Despite frequent health care visits, 3,4 many women refrain from disclosing their experience of violence to clinicians because of feelings of shame. 5 7 Direct inquiry by physicians facilitates disclosure, 8 but physicians often fail to inquire about domestic violence risk owing to lack of time, more pressing acute medical problems, discomfort, fear of offending the patient, and lack of familiarity with resources The result is missed opportunities for intervening and preventing harm. In spite of the controversial impact of domestic violence screening for women; most of the major American medical organizations recommend routine violence screening of domestic violence against women as a part of standard patient care. 12 This might be attributed to the seriousness of medical sequel of violence. 13 In view of the seriousness of the violence problem and the availability of information about the association of domestic violence with health outcomes, primary health care workers have a responsibility to assess for this type of violence as a means of monitoring health status. Early identification of abuse has been a priority in efforts to improve the health care response to domestic violence against women. 14 Gathering these data serve first to alert health professionals and researchers about the scope of the problem and second to illuminate the social conditions that are often associated with these types of harmful behaviors. 15 In the meantime we can support and empower women to generate individual strategies to reduce harm to themselves and their children. 16 Little research in the primary care setting has investigated domestic violence against women in the State of Kuwait. Reviewing the available literature did not reveal any studies dealing with screening for domestic violence against women in Kuwait. Thus, the current study was formulated to reveal the extent of screening for domestic violence among physicians and nurses in the primary health care unit, identify knowledge, attitude, and barriers toward violence screening, and reveal factors affecting screening. 2. Subjects and methods An observational cross-sectional study design was adopted for this study. The study was carried out in the PHC centers located in two randomly selected health areas (Capital and Jahra) out of five in Kuwait. The total number of physicians and nurses working in the selected centers was 239 and 510, respectively. All available physicians (210) and nurses (464) during the field work of the study in the selected centers were the target population of this study. Out of these, only 366 (128 physicians and 238 nurses) agreed to share in the study with an overall response rate of 54.3% (61.0% and 51.3%, respectively) The study covered the period of August 2011 to February Data were collected over three months starting from September to December, Data of this study were collected through a specially designed questionnaire. This questionnaire consisted of several sections. The first section dealt with socio-demographic characteristics, including age, sex, nationality, marital status, educational qualification, and current job. Four questions dealt with screening for violence. The second section included the attitude scale and consisted of seven questions in addition to one question asking about the expected health impacts of screening. The third section entailed the knowledge domain and consisted of four sub-domains. The first sub-domain dealt with deprivation/neglect and consisted of ten questions, while the second sub-domain the psychological aspects and formed of four questions, the third sub-domain covered the physical aspect and consisted of six questions, while the last sub-domain dealt with the sexual aspects of violence definition and consisted of three questions. The fourth section included barriers for screening of women exposed to domestic violence and was classified into four parts, the first part dealt with women culture (six questions), the second covered factors related to the examiner (six questions), the third part (administrative barriers) included eight questions, while the fourth part dealt with barriers related to the victim herself (five questions). Participants were asked if they agree or not about these statements. For each statement score 1 was given for positive answer and score 0 for negative answer. The total percentage score for each domain was calculated as well as the overall score. A pilot study was carried out on 30 physicians and nurses (not included in the final study). This study was formulated with the following objectives: test the clarity, applicability of the study tools, accommodate the aim of the work to actual feasibility, and identify the difficulties that may be faced during the application. Also, the time needed for filling the questionnaire by the staff was estimated during this pilot study. The necessary modifications according to the results obtained

3 Domestic violence screening among primary health care workers in Kuwait 171 were done, so some statements were reworded. Also, the structure of the questionnaire sheet was reformatted to facilitate data collection. All the necessary approvals for carrying out the research were obtained. The Ethics Committee of the Kuwaiti Ministry of Health approved the research. A written format explaining the purpose of the research was prepared and signed by the physician before filling the questionnaire. In addition, the purpose and importance of the research were discussed with the director of the health center. 3. Statistical analysis Before analysis; data were imported to the Statistical Package for Social Sciences (SPSS) which was used for both data analysis and tabular presentation. Descriptive measures were utilized (count, percentage, arithmetic mean and standard deviation) as well as analytic measures (Chi-square for qualitative variables and Student s t test for normally distributed quantitative variables). Multiple logistic regression was used to identify factors that could be associated with screening or not screening for DV. 4. Results Table 1 shows socio-demographic characteristics of studied PHC staff. Medical staff screening for DV against women were slightly older than those not screening ( years compared with years old, P = 0.14) and spent nearly similar years at the current job ( years compared with years, P = 0.25). Also, the marital status and educational qualification of both groups did not differ significantly. Males were significantly more likely to screen for violence (36.2% compared with 18.8%, P < 0.001). Physicians also, tended to screen for violence more than nurses as they constituted 51.2% of those screening as compared with 26.4% of those not screening for violence, P < Table 2 reveals the screening pattern for DV against women. Less than two-thirds of participants (62.5%) were aware about the topic while only about one-third (34.7%) regularly screened for violence among women. Of those regularly screening for violence, about two-thirds (66.1%) screened only less than 5% of women whom they examined, while 7.9% regularly screened more than 50% of their examinees. The same table shows that the majority (95.2%) of screened women are in the fertile age from18 to 50 years. Table 3 shows the knowledge and the attitude of primary health care staff about violence. Those screening for violence had a significantly higher mean percent overall knowledge score (73.8 ± 9.5% compared with 70.9 ± 11.2%, P = 0.006). The medical staff practicing screening tended to have a slightly higher or similar mean percent score for deprivation/neglect (53.9 ± 17.1% compared with %, P = 0.097), physical (94.3 ± 9.5 compared with 94.5 ± 8.9%, P = 0.948), Table 1 Socio-demographic characteristics of primary health care staff screening and not screening for domestic violence against women. Character Screen (n = 127) Do not screen (n = 239) P value No. % No. % Age (years) < > Sex Male <0.001 * Female Nationality Kuwaiti Non Kuwaiti Marital status Single Married Job Physician <0.001 * Nurse Qualification Bachelor degree Higher qualification Years at work < P * Significant, P

4 172 M. Almutairi et al. Table 2 Participants experience regarding domestic violence screening in primary health care. Variables No. % Awareness about screening for violence against women Yes No Regular screening of women for violence Yes No Percentage of women examined during the last year <5% % >50% Age of women examined <18 years years >50 years and sexual (92.4 ± 9.4 compared with 90.9 ± 10.5%, P = 0.194) sub-domains. The only sub-domain showing significant difference was the psychological sub-domain (78.4 ± 20.3 compared with 69.4 ± 26.3%, P = 0.004). On the other hand, those not screening for violence had a significant higher attitude mean percent score than those screening for violence (70.1 ± 18.6 compared with 65.5 ± 16.5%, P = 0.015). Table 4 portrays that the most frequently met barriers by both primary health care staff screening or not for violence against women were those related to the victim herself (91.0 ± 2.9% and 86.9 ± 20.2%) followed by those related to the culture of women (83.9 ± 19.4% and 86.8 ± 19.9%). Barriers related to the examiner were the least frequently met (68.5 ± 25.7% and 69.6 ± 29.2%) followed by administrative barriers (76.3 ± 21.7% and 73.8 ± 26.9%). All these differences between those screening or not were not statistically significant. Studying the simultaneous effect of predictors of screening with controlling for the confounding effect by the multiple logistic model revealed that only the job of the primary health care staff (a physician or a nurse) proved to be a significant predictor, while all the other factors including the knowledge and the attitude score were not statistically significant predictors of screening for DV against women. The model revealed a constant coefficient of 1.106, a coefficient job (physician = 1 and nurse = 2) of 1.075, with and odds ratio of and a 95% confidence interval of and Discussion Primary care allows considerable scope in terms of women who are reached, and is unique in that it has the potential to facilitate early detection and intervention as well as support for abused women who are still at risk. 17 Abused women are over-represented in outpatient settings and in primary care. 18 Approximately a third of abused women disclose abuse to their general practitioners. 19 Yet the evidence on how to screen and effectively intervene once problems are identified is limited, and few clinicians routinely screen patients who do not have apparent injuries. 8,20 24 Thus, the current study was formulated to reveal the extent of screening for domestic violence among physicians and nurses in the PHC units, identify knowledge, attitude, and barriers toward violence screening, and reveal factors affecting screening. The results of this study showed that male participants tended to screen for DV against women significantly more than females. Also, those screening for violence were more likely to be physicians than nurses. Although it is unexpected to find more males screening for violence against women than females yet, this can be explained by the higher proportion of females among nurses than physicians and the results of the multiple logistic regression which excluded gender as a predictor of screening. It seems that the effect of gender was associated with the job and its confounding effect was excluded in the multivariate analysis of the results. Studying the pattern of screening for domestic violence against women among primary health care workers in Kuwait showed that although 62.5% were aware about screening yet, only 34.7% were actually screening for violence among women. What adds to the complexity of the problem is the finding that 66.1% of them were only regularly screening less that 5% of women attending to their PHC units. This means that a large proportion of PHC workers are missing an important opportunity to detect and deal with DV against women. 25 A number of studies targeted at physician practices suggest that only a small proportion of physicians and other health care workers commonly inquire about DV against women Rates of routine inquiry about woman abuse by health care providers are generally in the range of 5 10% in primary care settings The health care providers may feel inadequate in helping the abused victims with the lack of knowledge on the availability of various DV resources. 32 Enabling factors available at the health establishment for the management of DV will empower and encourage the health care providers to manage these cases. Multiple factors might be behind the low rate of screening of women for DV. The current study revealed that the knowledge of violence definition was significantly better among those screening than those not screening. The first group had an overall mean percent knowledge score of 73.8 ± 9.5 compared with 70.9 ± 11.2%, P = The main sub-domain of knowledge showing significant difference is that dealing with the psychological definition of violence. In contrast, the attitude of those not screening for violence was higher than that of those screening yet, after adjustment for other confounders, this relationship proved to be insignificant. Multiple uncertainties might affect the process of screening and thus the prevalence of DV against women. Three approaches have been used to assess violence against women. The behavioral approach, 33 the outright approach, and the impact approach 8,15,37 with different sensitivity, specificity, and predictivity. 8,15 The different forms and consequences of DV upon women can also play a significant role in identification of abused women. Apart from the evident physical injury, other forms such as verbal abuse, threats, neglect, as well as emotional and economic forms of violence are difficult to detect. In addition, some consequences are difficult to be differentiated from other etiologies such as maternal complications and psychological problems. 38 In health care settings, the best approach to identifying women exposed to violence remains unclear, with insufficient evidence regarding the effectiveness of screening in improving outcomes for women Due to lack of a universal consensus about screening of women for DV, a routine inquiry when signs and symptoms of violence are present has been suggested. However, it has to

5 Domestic violence screening among primary health care workers in Kuwait 173 Table 3 Knowledge and attitude percentage score of primary health care staff practicing and not practicing screening of domestic violence against women. Score Screen (n = 127) Do not screen (n = 239) P Knowledge scales Deprivation/neglect 53.9 ± ± 18.7 (0.097) Psychological 78.4 ± ± 26.3 (0.004) * Physical 94.3 ± ± 8.9 (0.948) Sexual 92.4 ± ± 10.5 (0.194) Total knowledge 73.8 ± ± 11.2 (0.006) * Attitude scale 65.5 ± ± 18.6 (0.015) * * Significant, P Table 4 Barrier percentage score for screening of women exposed to domestic violence stated by primary health care staff practicing and not practicing screening. Domains of barriers Screen (n = 127) Do not screen (n = 239) P Women culture 83.9 ± ±19.9 (0.066) The examiner 68.5 ± ±29.2 (0.426) Health administration 76.3 ± ±26.9 (0.874) The victim 91.0 ± ± 26.9 (0.171) Total barrier percent score 79.4 ± ± 20.2 (0.417) be noted that this will be a diagnostic rather than a screening test. 42,43 This diagnostic approach requires raising awareness of the medical staff about factors associated with recent or current abuse. 44 Not only the knowledge and the attitude of primary health care workers can affect detection of battered women but also the barriers they are facing. The results of the current study revealed multiple barriers. The most frequently met barriers were those related to the victim herself and the culture of women in general, followed by those related to the administration and the examiner himself. Barriers of screening for DV against women related to the medical staff included lack of time, the way of inquiring about violence as well as lack of training for both physicians and nurses during undergraduate studies. 33,45 Reluctance of PHC workers to inquire about women abuse can be also attributed to the lack of effective interventions and the complexities of providing whole family care. 46,47 Some studies showed that female patients favored physician inquiry and reported that they would reveal abuse histories if asked directly. 26,48 Another study showed that nurses felt that they are less prepared than physicians to screen for violence against women. 46 The current study showed that physicians were more likely to screen for DV against women than nurses even after controlling for the confounding effects of other variables. The key factors affecting readiness to identify and respond to DV included gaps in provider knowledge and lack of education regarding DV; the perception of a lack of patient compliance; lack of effective interventions; and perceived system support, especially time. Other factors include provider self-efficacy including feelings of powerlessness, and loss of control. Safety concerns and fear of offending, affective barriers, poor interviewing or communication skills, providers personal experience with abuse, and their age and years in practice may play a role. 8,19,48 52 This goes hand in hand with most of the results revealed by this study. Identification of and intervention in DV are critical to providing comprehensive patient care. All health care personnel must be knowledgeable not only in the medical but also in the legal implications of DV and its impact on health care and victim safety. 46 Several national medical organizations have developed practice guidelines for intimate partner abuse that encourage routine screening and interventions. 53 These guidelines need to be tailored to the Kuwaiti circumstances and integrated in the PHC delivery system. References 1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Violence by intimate partnersworld report on violence and health. Geneva: World Health Organization; p Cohen MM, Maclean H. Violence against Canadian women. BMC Womens Health 2004;4(Suppl. 1, S22): Kernic MA, Wolf ME, Holt VL. Rates and relative risk of hospital admission among women in violent intimate partner relationships. Am J Public Health 2000;90: Sansone RA, Wiederman MW, Sansone LA. Health care utilization and history of trauma among women in a primary care setting. Violence Vict 1997;12: Plichta SB, Falik M. Prevalence of violence and its implications for women s health. Womens Health Issues 2001;11: Bauer HM, Rodriguez MA, Quiroga SS, Flores-Ortiz YG. Barriers to health care for abused Latina and Asian immigrant women. J Health Care Poor Underserved 2000;11: Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence. expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006;166: Rodrıguez MA, Sheldon WR, Bauer HM, Pérez-Stable EJ. The factors associated with disclosure of intimate partner abuse to clinicians. J Fam Pract 2001;50:

6 174 M. Almutairi et al. 9. Garimella R, Plichta SB, Houseman C, Garzon L. Physician beliefs about victims of spouse abuse and about the physician role. J Womens Health Gend Based Med 2000;9: Waalen J, Goodwin MM, Spitz AM, Petersen R, Saltzman LE. Screening for intimate partner violence by health care providers. Barriers and interventions. Am J Prev Med 2000;19: Bradley F, Smith M, Long J, O Dowd T. Reported frequency of domestic violence. Cross sectional survey of women attending general practice. BMJ 2002;324: Nelson J, Johnston C. Screening for family and intimate partner violence. Ann Intern Med 2004;141(1): Flitcraft A, Hadley S, Hendricks-Matthews S, McLeer S, Warshaw C. American Medical Association. Diagnostic and treatment guidelines on domestic violence. Arch Fam Med 1992;1: Council on Scientific Affairs. American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267: Peralta RL, Fleming MF. Screening for intimate partner violence in a primary care setting: the validity of feeling safe at home and prevalence results. J Am Board Fam Pract 2003;16: Janssen P, Dascal-Weichhendler H, McGregor M. Assessment for intimate partner violence. Where do we stand? JABFM 2006;19: Hegarty KL, Gunn JM, O Doherty LJ, et al. Women s evaluation of abuse and violence care in general practice: a cluster randomized controlled trial (weave). Public Health 2010;10: Plichta SB. Interactions between victims of intimate partner violence against women and the health care system: policy and practice implications. Trauma Violence Abuse 2007;8(2): Hegarty KL, Taft AJ. Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice. Aust N Z J Public Health 2001;25(5): Borowsky IW, Ireland M. Parental screening for intimate partner violence by pediatricians and family physicians. Pediatrics 2002;110: Chamberlain L, Perham-Hester KA. Physicians screening practices for female partner abuse during prenatal visits. Matern Child Health J 2000;4: Chamberlain L, Perham-Hester KA. The impact of perceived barriers on primary care physicians screening practices for female partner abuse. Women Health 2002;35: Glass N, Dearwater S, Campbell J. Intimate partner violence screening and intervention: data from eleven Pennsylvania and California community hospital emergency departments. J Emerg Nurs 2001;27: Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatrics 2001;108: Yanikkerem E, Karadas G, Adıguzel B, Sevil U. Domestic violence during pregnancy in Turkey and responsibility of prenatal healthcare providers. Am J Perinatol 2006;23: Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. Inquiry about victimization experiences: a survey of patient preferences and physician practices. Arch Intern Med 1992;152: Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995;173: Derk S, Reese D. Rural health-care providers attitudes, practices, and training experience regarding intimate partner violence: West Virginia, March MMWR Morb Mortal Wkly Rep 1998;47: Thompson RS, Rivara FP, Thompson DC, et al. Identification and management of domestic violence. a randomized trial. Am J Prev Med 2000;19(4): Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282(5): Elliott L, Nerney M, Jones T, Friedmann PD. Barriers to screening for domestic violence. J Gen Intern Med 2002;17(2): Othman S, Adenan NAM. Domestic violence management in Malaysia: A survey on the primary health care providers. Asia Pac Fam Med 2008;7: Straus MA, Hamby SL, Boney-McCoy S, et al. The revised conflict tactics scale (CTS2): development and preliminary psychometric data. J Fam Issues 1996;17: Bonomi AE, Holt VL, Thompson RS, et al. Ascertainment of intimate partner violence in women seeking legal protection. Am J Prev Med 2005;58: Ernst AA, Weiss SJ, Cham E, et al. Comparison of three instruments for assessing ongoing intimate partner violence. Med Sci Monit 2002;8: Weiss SJ, Ernst A, Cham E, Nick TG. Development of a screen for ongoing intimate partner violence. Violence Vict 2003;18: Coker AL, Smith PH, McKeown RE, et al. Frequency and correlates of intimate partner violence by type: physical, sexual and psychological battering. AJPH 2000;90: Sugg NK, Thompson RS, Thompson DC, Maiuro R, Rivara FP. Domestic violence and primary care: attitudes, practices and beliefs. Arch Fam Med 1999;8: Nelson HD, Nygren P, McInerney Y, Klein J. Screening women and elderly adults for family and intimate partner violence. a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140: Ramsay J, Richardson J, Carter YH, Davidson L, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325: Wathen CN, MacMillan HL. Interventions for violence against women: Scientific review. JAMA 2003;289: U.S. Preventive Services Task Force. Screening for family and intimate partner violence recommendation statement. Ann Intern Med 2004;140: Wathen CN, MacMillan HL. Prevention of violence against women: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2003;169(6): Campbell JC, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health 2003;93(7): Sugg NK, Inui T. Primary care physician s response to domestic violence. opening Pandora s Box. JAMA 1992;267(23): Gutmanis I, Beynon C, Tutty L, Wathen CN, MacMillan HL. Factors influencing identification of and response to intimate partner violence: a survey of physicians and nurses. Public Health 2007;7: Taft A, Broom D, Legge D. General practitioner management of intimate partner abuse and the whole family: a qualitative study. BMJ 2004;328: Caralis PV, Musialowski R. Women s experience with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 1997;9: Minsky-Kelly D, Hamberger LK, Pape DA, Wolff M. We ve had training, now what? Qualitative analysis of barriers to domestic violence screening and referral in a health care setting. J Interpers Violence 2005;20(10): Stinson CK, Robinson R. Intimate partner violence: continuing education for registered nurses. J Contin Educ Nurs 2006;37(2): Protheroe L, Green J, Spiby H. An interview study of the impact of domestic violence training on midwives. Midwifery 2004;20(1): Cherniak D, Grant L, Mason R, Moore B, Pellizzari R, IPV Working Group of the Society of Obstetricians and Gynaecologists of Canada. Intimate partner violence consensus statement. J Obstet Gynaecol Can 2005;27(4): American Academy of Family Physicians. Family violence: an AAFP white paper. Am Fam Physician 1994;50( ):