Domestic Violence: Patterns and Indicators
Monash University Accident Research Centre - Report #63 - 1994
Authors: J. Sherrard, J. Ozanne-Smith, I. Brumen, V. Routley & F. Williams
Full report in .pdf format [7.6MB]
Domestic violence is a substantial intersectoral public health issue, which impacts on the economy, health services, and policing, court and welfare systems. This study aimed to determine the occurrence, patterns and indicators of domestic violence in Victoria using current injury data collection systems, and to explore the barriers to detection of domestic violence victims in hospital emergency departments. The definition of domestic violence used for this study is "partner inflicted injury".
Coroner's data showed that deaths in women due to assault were more likely to be the result of domestic violence compared with men, and that 90% of all domestic violence deaths occur in women. Although a potentially useful source of data, the hospital admissions injury data set does not allow discrimination between different categories of assault, with respect to perpetrator, and therefore cannot be used in its current form to identify domestic violence victims. Emergency department presentation data showed, as for deaths, a disproportionate representation of women as positive victims of domestic violence injury, although, as a proportion of all injury presentations for women, domestic violence injury is low (1.3%).
Medical records analysis revealed differences between domestic violence injury cases and controls including a higher rate of repeated presentations and admissions to hospital, alcohol abuse, injuries to the head and trunk, and referral and utilisation of services by domestic violence victims. Interviews with clinical staff showed a lack of protocols and training for detecting and managing domestic violence victims.
Based on descriptive categories of probable and suggestive cases of domestic violence in emergency department presentation data, a crude estimate of under detection of domestic violence indicated that up to 70% of female domestic violence victims may be missed by hospitals. Our findings also revealed that the proportion of female hospital admissions for self harm or suicide attempt was three times greater than for men, and in some cases was associated with a suggestion of domestic conflict.
Recommendations include improvement in data collection systems, education and training, information and services for domestic violence victims, and future research.
Domestic violence is a substantial intersectoral public health problem which impacts on the economy, health services and policing, court and welfare systems, as well as on the victims and perpetrators of domestic violence. The recent, strong and continuing media focus on domestic violence, child abuse, assault and the issue of gun legislation has increased public attention, concern and support for action.
Domestic violence appears to be relatively widespread and is reported in the U.S. to be considerably unrecognised by the medical profession. Current research suggests that the Australian experience may reflect that of the United States of America. Domestic violence is specifically identified as a public health issue in 'Goals and Targets for Australia's Health in the Year 2000 and Beyond' (Nutbeam et al., 1993) and a target has been set to reduce morbidity resulting from domestic violence, with women as the priority population.
Although there have been attempts to measure the extent of domestic violence by the judicial system, the police, the hospital admissions system and women's refuges, no method is available to systematically measure the incidence and prevalence of domestic violence in the wider community. The development of protocols for improving the identification, treatment and referral of domestic violence in the hospital setting, and the establishment of increased services, including those after-hours, are seen as priorities for reducing the incidence and prevalence of domestic violence in the community. This report documents a study of the patterns and indicators of domestic violence, with a particular focus on injuries.
The major findings of the literature review include; over-representation of women as victims of domestic violence, under detection of domestic violence, overuse of medical, health, psychiatric and social services by victims of domestic violence, repeated presentations, various barriers to the identification, management and recording of domestic violence, high rates of suicide by victims of domestic violence, the cyclical nature of abuse, the relationship between child and adult victimisation, history of family violence, and the high incidence of domestic violence injury during pregnancy. The lack of protocols and training concerning the identification, management and recording of domestic violence by professional personnel is also highlighted. Finally, clarification of definitions, improvements in baseline data, and identification of risk factors are required to adequately describe the problem, to identify appropriate points for intervention, and to evaluate the effectiveness of preventive measures.
Aims and Objectives
- To determine the occurrence and patterns and indicators of domestic violence in Victoria using current data collection systems.
- To explore the barriers to detection of domestic violence victims in emergency departments with a view to making recommendations for improvements to data collection and management systems and for improving detection levels and services.
- To determine additional alerting characteristics to domestic violence injury, and develop recommendations for their validation.
- To recommend improvements to data collection methodologies to more precisely define and monitor the prevalence of domestic violence
- To develop recommendations for data collection and systems which Will identify language spoken at home, aboriginality, country of birth, and any other demographic risk factors identified by the study.
Three approaches to determining the patterns and indicators, and to estimating the frequency of domestic violence (partner inflicted) have been employed for this study. The first is the extraction and analysis of domestic violence injury data from routine injury data currently contained in three data bases. The second is the detailed extraction and analysis of previous histories from medical records of cases identified as domestic violence injury, and from a comparison group, to determine additional patterns and indicators of domestic violence presentation from this source. The third is a survey of clinical staff in hospital emergency departments to determine their level of training in relation to domestic violence issues, and the barriers they perceive to the detection and management of domestic violence victims.
Deaths - Coroner's Facilitation System
Domestic violence injury deaths as a proportion of all injury death is low (0.7% in 1991). However, the proportions of assaultive deaths in women due to domestic violence for the financial years 1990 and 1991 were 71% and 42% respectively, whereas the proportions for men were only 3% and 2.4%. Not only are deaths due to assault in women more likely to be as a result of domestic violence compared with men, but of all domestic violence deaths, women are highly over represented (90% of all domestic violence victims). The use of guns and knives as weapons of death in domestic violence, in a high proportion of cases, provides some support for countermeasures aimed at gun and knife control.
Admissions data - Victorian Inpatient Minimum Database (VIMD)
Males are disproportionably represented in admissions to hospital for assault, with an overall male to female ratio of 5:1. However, because of the coding system, the proportion of cases resulting from partner inflicted injury cannot be discriminated from the database. It is clear that VAM in its current form can offer little useful information on hospital admissions due to domestic violence. Additional codes in the ICD database for type of perpetrator in assault cases would clarify and contribute to information on the nature and extent of domestic violence cases admitted to hospital.
Presentation data - Victorian Injury Surveillance System (USS)
The analysis was based on 53,320 cases of adult injury presenting to the emergency departments of five VISS participating hospitals. Following careful screening of the data for cases of domestic violence injury (using the categories of domestic violence injury of Stark and Flitcraft 1981), the final subset consisted of 288 positive cases of partner inflicted domestic violence (83% female), 402 probable cases, 313 suggestive cases, and 52,320 negative cases of domestic violence.
The above findings represent a very small proportion of all injury presenting to the emergency departments of VISS hospitals, even combining positives, probables and suggestive, and account for only 2.0% of all emergency department presentations. These results also indicate that of all injury presentations in women, up to 4.4% may be due to domestic violence.
Extrapolation, using VISS and VIMD data, gives a very crude estimate that approximately 1 in 200 injury admissions for women are the result of partner inflicted violence. The proportion of female hospital admissions for self harm or suicide attempt was three times greater than for men, and in some cases was associated with a suggestion of domestic violence. Further exploration of this association is warranted.
Analysis of medical records
Data was extracted from the Medical Records of 44 definite cases of domestic violence and 44 controls (initially selected from all VISS cases admitted to hospital). Data which could have provided considerable insight into the circumstances surrounding some cases of domestic violence were missing from medical histories.
Females comprised 75% of the victims of domestic violence requiring hospital admission. An overview of the total number of hospital presentations/admissions to the index hospital highlights the repeated use of services by the domestic violence cases. A larger number of domestic violence victims (57%) were recorded as having more than one prior admissions to the index hospital than the controls (36%). Similarly, more victims of domestic violence (57%) were noted as having previous presentations to the index hospital than were the control group (9%).
A number of differences were found between the two groups. Significant differences were found for involvement of police and ambulance services, a history of alcohol abuse and current alcohol abuse, injuries to the head and trunk, referral to a social worker, and previous non-domestic violence related presentations or admissions to hospital. This supports the view that the utilisation of medical services by victims of domestic violence is generally high.
Interestingly, 20% of the controls (women under 40 years selected from VISS presentations as negative cases of domestic violence) were subsequently found to have a history of suspected abuse when their medical records were examined in detail. The similarity with other studies merits further research using a larger sample of medical records to determine the significance of this result.
Clinical staff interviews
A total of 21 senior doctors and nurses from hospital Emergency Departments (E.D.) and senior hospital social workers were interviewed regarding their formal training, both basic and post-graduate, and attendance at in-service training sessions. Staff were also asked how many hours overall have been allocated specifically to domestic violence training, whether they considered more training necessary and whether they were aware of their hospital having a policy or protocol for the identification and management of domestic violence. In sum, the results show a lack of protocols and education for detecting and managing victims of domestic violence.
According to VISS data, the ratio of positive male to female cases of domestic violence is 1:5. This suggests that 1.3% of female and 0.14% of male presentations to emergency departments (0.54 % of all adult presentations) are clearly the result of partner inflicted injury (positive cases). Thus, injuries in females presenting to Emergency Departments are 10 times more likely than those in males to be due to domestic violence. If the estimate (4%) of new cases from the study by Stark and Flitcraft (1991) were correct, this result could suggest an under detection of more than 60% for domestic violence in females. An estimate of under detection of domestic violence using VISS data on probable and suggestive cases for females was 70%, although this figure is likely to be an over estimate due to difficulties in interpreting case narratives.
Similarly, a crude estimate of under detection can be extrapolated from the analysis of medical records cases. In all, a total of 55 potential controls were selected and 11 (20%) rejected after examination. Although the numbers are very small these figures give a very crude estimate of the potential level of under detection of domestic violence defined in the broader sense (beyond partner inflicted injury). It suggests that up to 1 in 5 admissions for injury in women under 40 years, (after presentation at emergency departments), may be associated with a history of domestic violence, or be self-inflicted injury following a domestic dispute. However this crude estimate should be interpreted with caution.
A number of recommendations are made in relation to data collection systems, education, information and services for domestic violence victims and future research.
1. Standardisation of definitions and terminology of domestic violence.
2. Introduction of a locally expanded ICD-9 E-code classification to identify partner inflicted violence.
3. Utilisation of the narrative in the National Minimum Dataset (Injury Surveillance) to identify partner inflicted violence.
4. Investigation of the feasibility of linkage of justice and police databases to give expanded measures of the prevalence of domestic violence
5. Collection of information to identify language spoken at home, aboriginality, country of birth and other demographic variables identified by the study as potential risk factors.
6. Data collection from general practice to determine the prevalence and characteristics of domestic violence presentation to this sector.
(b) Education and Training
7. Development and implementation of policy and strategies for education and training of health sector personnel for effective detection and response to domestic violence.
8. Collaboration between Medical, Nursing and other relevant professional bodies to develop hospital protocols for the detection, management and prevention of domestic violence.
9. Evaluation of the effects of training together with protocols in the Emergency Department on detection and recording of domestic violence cases.
(c) Information and Services
10. Establishment of access to domestic violence information for domestic violence victims and perpetrators.
11. Provision of information for hospital staff regarding outside services for domestic violence victims and perpetrators.
12. Determination of the need for increased provision and hours of services in hospitals and increased resources to manage psychosocial and other issues of domestic violence as a result of the increasing detection of victims and their children.
13. Investigation of improved service linkages between hospital emergency departments, general practice, community based domestic violence and sexual assault support services.
14. Evaluation of the effectiveness of early intervention services on domestic violence.
15. Estimation of the level of under reporting of domestic violence injuries to the health care system by means of community surveys.
16. Ongoing reviews of successful countermeasures and implementation strategies.
17. Exploration of the role of domestic violence in suicide and attempted suicide and self-harm.
18. Determination of the most effective service provision model for domestic violence victims in crisis.
19. Adoption and implementation of the recently developed National and State Strategies for the Prevention and Control of Interpersonal Injury and Suicide.
Sponsor: Department of Health and Community Services, Victoria