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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 Occupa- tional Medicine, Ministry of Health, Kuwait. Tel.: +965 66337402. E-mail addresses: [email protected] (M. Almutairi), Omba [email protected] (A.M. Alkandari), [email protected] (H. Alhouli), [email protected] (M.I. Kamel), medshaz @yahoo.com (M.K. El-Shazly). Peer review under responsibility of Alexandria University Faculty of Medicine. Production and hosting by Elsevier Alexandria Journal of Medicine (2013) 49, 169–174 Alexandria University Faculty of Medicine Alexandria Journal of Medicine www.sciencedirect.com 2090-5068 ª 2012 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajme.2012.08.010

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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, Kuwaitb Qurain Center, Primary Health Care, MOH, Kuwaitc Alzahraa Clinic, Primary Health Care, MOH, Kuwaitd Community Medicine Department, Faculty of Medicine, Alexandria University, Egypte Department of Occupational Medicine, Ministry of Health, Kuwaitf Department of Medical Statistics, Medical Research Institute, Alexandria University, Egyptg 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 Occupa-

tional Medicine, Ministry of Health, Kuwait. Tel.: +965 66337402.

E-mail addresses: [email protected] (M. Almutairi), Omba

[email protected] (A.M. Alkandari), [email protected]

(H. Alhouli), [email protected] (M.I. Kamel), medshaz

@yahoo.com (M.K. El-Shazly).

Peer review under responsibility of Alexandria University Faculty of

Medicine.

Production and hosting by Elsevier

Alexandria Journal of Medicine (2013) 49, 169–174

Alexandria University Faculty of Medicine

Alexandria Journal of Medicine

www.sciencedirect.com

2090-5068 ª 2012 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.

http://dx.doi.org/10.1016/j.ajme.2012.08.010

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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 < 0.001. 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 bar-

riers were revealed for screening including mainly those related to women whether their characteris-

tics 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 vio-lence or threats of violence made by husband or another familymember, often accompanied by controlling behaviors.1

Domestic violence is a prevalent and serious health risk for wo-

men.2 Despite frequent health care visits,3,4 many women re-frain from disclosing their experience of violence to cliniciansbecause of feelings of shame.5–7 Direct inquiry by physicians

facilitates disclosure,8 but physicians often fail to inquire aboutdomestic violence risk owing to lack of time, more pressingacute medical problems, discomfort, fear of offending the pa-

tient, and lack of familiarity with resources.9–11 The result ismissed opportunities for intervening and preventing harm. Inspite of the controversial impact of domestic violence screening

for women; most of the major American medical organizationsrecommend routine violence screening of domestic violenceagainst women as a part of standard patient care.12 This mightbe attributed to the seriousness of medical sequel of violence.13

In view of the seriousness of the violence problem and theavailability of information about the association of domesticviolence with health outcomes, primary health care workers

have a responsibility to assess for this type of violence as ameans of monitoring health status. Early identification of abusehas been a priority in efforts to improve the health care response

to domestic violence against women.14 Gathering these dataserve first to alert health professionals and researchers aboutthe scope of the problem and second to illuminate the socialconditions that are often associated with these types of harmful

behaviors.15 In the meantime we can support and empower wo-men to generate individual strategies to reduce harm to them-selves and their children.16 Little research in the primary care

setting has investigated domestic violence against women inthe State of Kuwait. Reviewing the available literature did notreveal any studies dealing with screening for domestic violence

against women in Kuwait. Thus, the current study was formu-lated to reveal the extent of screening for domestic violenceamong physicians and nurses in the primary health care unit,

identify knowledge, attitude, and barriers toward violencescreening, and reveal factors affecting screening.

2. Subjects and methods

An observational cross-sectional study design was adopted forthis study. The study was carried out in the PHC centers

located in two randomly selected health areas (Capital andJahra) out of five in Kuwait. The total number of physiciansand 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 werethe target population of this study. Out of these, only 366 (128

physicians and 238 nurses) agreed to share in the study with anoverall response rate of 54.3% (61.0% and 51.3%, respec-tively) The study covered the period of August 2011 to Febru-

ary 2012. Data were collected over three months starting fromSeptember to December, 2011.

Data of this studywere collected through a specially designedquestionnaire. This questionnaire consisted of several sections.

The first section dealt with socio-demographic characteristics,including age, sex, nationality, marital status, educational qual-ification, and current job. Four questions dealt with screening

for violence. The second section included the attitude scaleand consisted of seven questions in addition to one question ask-ing about the expected health impacts of screening. The third

section entailed the knowledge domain and consisted of foursub-domains. The first sub-domain dealt with deprivation/ne-glect and consisted of ten questions, while the second sub-do-

main the psychological aspects and formed of four questions,the third sub-domain covered the physical aspect and consistedof six questions, while the last sub-domain dealt with the sexualaspects of violence definition and consisted of three questions.

The fourth section included barriers for screening of women ex-posed to domestic violence andwas classified into four parts, thefirst part dealt with women culture (six questions), the second

covered factors related to the examiner (six questions), the thirdpart (administrative barriers) included eight questions, while thefourth part dealt with barriers related to the victim herself (five

questions). Participants were asked if they agree or not aboutthese statements. For each statement score ‘‘1’’ was given for po-sitive answer and score ‘‘0’’ for negative answer. The total per-

centage score for each domain was calculated as well as theoverall 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 ofthe study tools, accommodate the aim of the work to actualfeasibility, and identify the difficulties that may be faced dur-

ing the application. Also, the time needed for filling the ques-tionnaire by the staff was estimated during this pilot study.The necessary modifications according to the results obtained

170 M. Almutairi et al.

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were done, so some statements were reworded. Also, the struc-

ture of the questionnaire sheet was reformatted to facilitatedata collection.

All the necessary approvals for carrying out the researchwere obtained. The Ethics Committee of the Kuwaiti Ministry

of Health approved the research. A written format explainingthe purpose of the research was prepared and signed by thephysician before filling the questionnaire. In addition, the pur-

pose and importance of the research were discussed with thedirector 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 anal-ysis and tabular presentation. Descriptive measures were uti-lized (count, percentage, arithmetic mean and standard

deviation) as well as analytic measures (Chi-square for qualita-tive variables and Student’s t test for normally distributedquantitative variables). Multiple logistic regression was usedto identify factors that could be associated with screening or

not screening for DV.

4. Results

Table 1 shows socio-demographic characteristics of studiedPHC staff. Medical staff screening for DV against women were

slightly older than those not screening (37.2 + 8.5 years com-

pared with 35.8 + 8.3 years old, P = 0.14) and spent nearlysimilar years at the current job (11.5 + 7.5 years comparedwith 10.5 + 7.8 years, P = 0.25). Also, the marital statusand educational qualification of both groups did not differ sig-

nificantly. Males were significantly more likely to screen forviolence (36.2% compared with 18.8%, P < 0.001). Physiciansalso, tended to screen for violence more than nurses as they

constituted 51.2% of those screening as compared with26.4% of those not screening for violence, P < 0.001.

Table 2 reveals the screening pattern for DV against wo-

men. Less than two-thirds of participants (62.5%) were awareabout the topic while only about one-third (34.7%) regularlyscreened for violence among women. Of those regularly screen-

ing for violence, about two-thirds (66.1%) screened only lessthan 5% of women whom they examined, while 7.9% regularlyscreened more than 50% of their examinees. The same tableshows 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). Themedical staff practicing screening tended to have a slightly high-

er or similar mean percent score for deprivation/neglect(53.9 ± 17.1% compared with 51.3 + 18.7%, 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)

<30 18 14.2 64 26.8 0.14

30– 40 31.5 56 23.4

35– 24 18.9 53 22.2

40– 23 18.1 27 11.3

>45 22 17.3 39 16.3

Sex

Male 46 36.2 45 18.8 <0.001*

Female 81 63.8 194 81.2

Nationality

Kuwaiti 24 18.9 34 14.2 0.244

Non Kuwaiti 103 81.1 205 85.8

Marital status

Single 20 15.7 30 12.6 0.397

Married 107 84.3 209 87.4

Job

Physician 65 51.2 63 26.4 <0.001*

Nurse 62 48.8 176 73.6

Qualification

Bachelor degree 49 38.6 85 35.6 0.568

Higher qualification 78 61.4 154 64.4

Years at work

<5 24 18.9 55 23.0 0.25

5– 37 29.1 74 31.0

10– 28 22.0 54 22.6

P15 17 13.4 21 8.8

* Significant, P 6 0.05.

Domestic violence screening among primary health care workers in Kuwait 171

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and sexual (92.4 ± 9.4 compared with 90.9 ± 10.5%,P = 0.194) sub-domains. The only sub-domain showing signif-icant 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 attitudemean 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 relatedto 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 administrativebarriers (76.3 ± 21.7% and 73.8 ± 26.9%). All these differ-ences 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 lo-

gistic model revealed that only the job of the primary healthcare staff (a physician or a nurse) proved to be a significantpredictor, while all the other factors including the knowledge

and the attitude score were not statistically significant predic-tors of screening for DV against women. The model revealeda constant coefficient of 1.106, a coefficient job (physician = 1and nurse = 2) of �1.075, with and odds ratio of 0.341 and a

95% confidence interval of 0.217 and 0.536.

5. Discussion

Primary care allows considerable scope in terms of women whoare reached, and is unique in that it has the potential to facili-

tate early detection and intervention as well as support forabused women who are still at risk.17 Abused women areover-represented in outpatient settings and in primary care.18

Approximately a third of abused women disclose abuse to theirgeneral practitioners.19 Yet the evidence on how to screen andeffectively intervene once problems are identified is limited, and

few clinicians routinely screen patients who do not have appar-ent injuries.8,20–24 Thus, the current study was formulated to re-veal 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 fac-tors affecting screening.

The results of this study showed that male participantstended to screen for DV against women significantly more

than females. Also, those screening for violence were morelikely to be physicians than nurses. Although it is unexpectedto find more males screening for violence against women than

females yet, this can be explained by the higher proportion offemales among nurses than physicians and the results of themultiple logistic regression which excluded gender as a predic-

tor of screening. It seems that the effect of gender was associ-ated with the job and its confounding effect was excluded inthe multivariate analysis of the results.

Studying the pattern of screening for domestic violenceagainst women among primary health care workers in Kuwaitshowed 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 that66.1% of them were only regularly screening less that 5% ofwomen attending to their PHC units. This means that a large

proportion of PHC workers are missing an important opportu-nity to detect and deal with DV against women.25 A number ofstudies targeted at physician practices suggest that only a small

proportion of physicians and other health care workers com-monly inquire about DV against women.26–28 Rates of routineinquiry about woman abuse by health care providers are gener-ally in the range of 5–10% in primary care settings.29–31 The

health care providers may feel inadequate in helping the abusedvictims with the lack of knowledge on the availability of variousDV resources.32 Enabling factors available at the health estab-

lishment for the management of DV will empower and encour-age 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 knowledgeof violence definition was significantly better among thosescreening than those not screening. The first group had an over-

all mean percent knowledge score of 73.8 ± 9.5 compared with70.9 ± 11.2%, P = 0.006. The main sub-domain of knowledgeshowing significant difference is that dealing with the psycho-logical definition of violence. In contrast, the attitude of those

not screening for violence was higher than that of those screen-ing yet, after adjustment for other confounders, this relation-ship proved to be insignificant. Multiple uncertainties might

affect the process of screening and thus the prevalence of DVagainst women. Three approaches have been used to assess vio-lence against women. The behavioral approach,33 the outright

approach,34–36 and the impact approach8,15,37 with differentsensitivity, specificity, and predictivity.8,15 The different formsand consequences of DV upon women can also play a signifi-

cant role in identification of abused women. Apart from the evi-dent physical injury, other forms such as verbal abuse, threats,neglect, as well as emotional and economic forms of violenceare difficult to detect. In addition, some consequences are diffi-

cult to be differentiated from other etiologies such as maternalcomplications and psychological problems.38 In health care set-tings, the best approach to identifying women exposed to vio-

lence remains unclear, with insufficient evidence regarding theeffectiveness of screening in improving outcomes for wo-men.39–42 Due to lack of a universal consensus about screening

of women for DV, a routine inquiry when signs and symptomsof violence are present has been suggested. However, it has to

Table 2 Participants’ experience regarding domestic violence

screening in primary health care.

Variables No. %

Awareness about screening for violence against women

Yes 229 62.5

No 137 37.5

Regular screening of women for violence

Yes 127 34.7

No 239 65.3

Percentage of women examined during the last year

<5% 84 66.1

5–50% 33 26.0

>50% 10 7.9

Age of women examined

<18 years 3 2.4

18–50 years 121 95.2

>50 years 3 2.4

172 M. Almutairi et al.

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be noted that this will be a diagnostic rather than a screeningtest.42,43 This diagnostic approach requires raising awarenessof the medical staff about factors associated with recent or cur-

rent abuse.44

Not only the knowledge and the attitude of primaryhealth care workers can affect detection of battered women

but also the barriers they are facing. The results of the cur-rent study revealed multiple barriers. The most frequentlymet barriers were those related to the victim herself and the

culture of women in general, followed by those related tothe administration and the examiner himself. Barriers ofscreening for DV against women related to the medical staff

included lack of time, the way of inquiring about violence aswell as lack of training for both physicians and nurses duringundergraduate studies.33,45 Reluctance of PHC workers to in-quire about women abuse can be also attributed to the lack

of effective interventions and the complexities of providingwhole family care.46,47

Some studies showed that female patients favored physi-

cian inquiry and reported that they would reveal abuse histo-ries if asked directly.26,48 Another study showed that nursesfelt that they are less prepared than physicians to screen for

violence against women.46 The current study showed thatphysicians were more likely to screen for DV against womenthan nurses even after controlling for the confounding effects

of other variables. The key factors affecting readiness to iden-tify and respond to DV included gaps in provider knowledgeand lack of education regarding DV; the perception of a lackof patient compliance; lack of effective interventions; and

perceived system support, especially time. Other factors in-clude provider self-efficacy including feelings of powerless-ness, and loss of control. Safety concerns and fear of

offending, affective barriers, poor interviewing or communi-cation skills, providers’ personal experience with abuse, andtheir 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 thisstudy.

Identification of and intervention in DV are critical to pro-

viding comprehensive patient care. All health care personnelmust be knowledgeable not only in the medical but also inthe legal implications of DV and its impact on health care

and victim safety.46 Several national medical organizationshave developed practice guidelines for intimate partner abusethat encourage routine screening and interventions.53 These

guidelines need to be tailored to the Kuwaiti circumstancesand integrated in the PHC delivery system.

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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

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Psychological 78.4 ± 20.3 69.4 ± 26.3 (0.004)*

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Total knowledge 73.8 ± 9.5 70.9 ± 11.2 (0.006)*

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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

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Health administration 76.3 ± 21.7 73.8 ±26.9 (0.874)

The victim 91.0 ±21.9 86.9 ± 26.9 (0.171)

Total barrier percent score 79.4 ±15.7 78.9 ± 20.2 (0.417)

Domestic violence screening among primary health care workers in Kuwait 173

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