Validity of the ACTS intimate partner violence screen in antenatal care: a cross sectional study.

BACKGROUND: Intimate partner violence (IPV) is a major public health problem with harmful consequences. In Australia, there is no national standard screening tool and screening practice is variable across states. The objectives of this study were to assess in the antenatal healthcare setting: i) the validity of a new IPV brief screening tool and ii) women's preference for screening response format, screening frequency and comfort level. METHODS: One thousand sixty-seven antenatal patients in a major metropolitan Victorian hospital in Australia completed a paper-based, self-administered survey. The survey included four screening items about whether they were Afraid/Controlled/Threatened/Slapped or physically hurt (ACTS) by a partner or ex-partner in the last 12 months; and the Composite Abuse Scale (reference standard). The ACTS screen was presented firstly with a binary yes/no response format and then with a five-point ordinal frequency format from 'never' (0) to 'very frequently' (4). The main outcome measures were test statistics of the four-item ACTS screening tool (sensitivity, specificity, predictive values, and area under the curve) against the reference standard and women's screening preferences. RESULTS: Twelve-month IPV prevalence varied depending on the ACTS response format with 8% (83) positive on ACTS yes/no format, 12.8% (133) positive on ACTS ordinal frequency format and 10.5% (108) on the reference Composite Abuse Scale. Overall, the ACTS screening tool demonstrated clinical utility for the ordinal frequency format (AUC, 0.80; 95% CI = 0.76 to 0.85) and the binary yes/no format (AUC, 0.74, 95% CI = 0.69 to 0.79). The frequency scale (66%) had greater sensitivity than the yes/no scale (51%). The positive and negative predictive values were 56 and 96% for the frequency scale and 68 and 95% for the yes/no scale. Specificity was high regardless of screening question response options. Half (53%) of the women categorised as abused preferred the yes/no scale. Around half of the women (48%, 472) thought health care providers should ask pregnant women about IPV at every visit. CONCLUSIONS: The four-item ACTS tool (using the frequency scale and a cut-off of one on any item) is recommended for written self-administered screening of women to identify those experiencing IPV to enable first-line response and follow-up.

Vulnerability to intimate partner violence and poor mental health in the first 4-year postpartum among mothers reporting childhood abuse: an Australian pregnancy cohort study.

The purpose of this study was to investigate intergenerational patterns of abuse and trauma and the health consequences for women in the early childbearing years. A prospective pregnancy cohort of 1507 nulliparous women (≦24 weeks gestation) were recruited in Melbourne, Australia, 2003-2005. Follow-up was scheduled in late pregnancy, 3-, 6- and 12-month and 4-year postpartum. Childhood abuse was retrospectively reported at 4-year postpartum using the Child Maltreatment History Self Report. Intimate partner violence (IPV) was assessed at 1- and 4-year postpartum with the Composite Abuse Scale. Maternal depressive symptoms were assessed in all follow-ups using the Edinburgh Postnatal Depression Scale. Multivariable logistic regression was used to examine associations between childhood abuse, maternal mental health and IPV. Childhood abuse was reported by 41.1 % of women. In the 4 years after having their first child, 28.2 % of women reported IPV, 25.2 % depression and 31.6 % anxiety. Childhood abuse was associated with odds of depression or anxiety 1.5-2.6 times greater and 1.8-3.2 times greater for IPV. Childhood physical abuse remained significantly associated with depression and anxiety in pregnancy and postpartum after adjusting for IPV and stressful life events, while sexual abuse remained significantly associated only with anxiety. Women who begin childbearing with a history of childhood abuse are more vulnerable to IPV and poor mental health. All health care services and agencies in contact with children, young people and families should have adequate training to identify trauma associated with abuse and IPV and provide first line supportive care and referral.

Depressive symptoms and intimate partner violence in the 12 months after childbirth: a prospective pregnancy cohort study.

OBJECTIVE: To examine maternal depressive symptoms during and after pregnancy and explore their relationship with intimate partner violence in the 12 months after birth. DESIGN: Prospective pregnancy cohort study of nulliparous women. SETTING: Melbourne, Australia. POPULATION: In all, 1507 eligible women completed baseline data (mean gestation 15 weeks). Analyses are presented for 1305 women who completed all follow-up questionnaires. METHODS: Women were recruited from six public hospitals at between 6 and 24 weeks of gestation. Written questionnaires were completed at recruitment and at 3, 6 and 12 months postpartum. MAIN OUTCOME MEASURES: Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Intimate partner violence was assessed using the short version of the Composite Abuse Scale. RESULTS: Sixteen per cent of women reported depressive symptoms (EPDS ≥ 13) in the 12 months postpartum, with most women first reporting depressive symptoms in the second 6 months after birth. Around 40% of women reporting depressive symptoms at each follow up also reported intimate partner violence. Factors associated with postpartum depressive symptoms in multivariable models were: emotional abuse alone (adjusted odds ratio [OR] 2.72, 95% CI 1.72-4.13), physical abuse (adjusted OR 3.94, 95% CI 2.44-6.36), depression in pregnancy (adjusted OR 2.89, 95% CI 1.75-4.77) and unemployment in early pregnancy (adjusted OR 1.60, 95% CI 1.03-2.48). CONCLUSIONS: Screening for maternal depression at 3 months postpartum or earlier may miss over half the women with depression in the first 12 months after birth. Intimate partner violence is common among women reporting postnatal depressive symptoms and may be an important factor for health professionals to consider in their management.

Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy cohort study.

To assess intimate partner violence (IPV) in a longitudinal cohort study during and after pregnancy, and examine social and economic factors encouraging or inhibiting violence. Nulliparous women were recruited from 6 public hospitals in Melbourne, Australia. Self-administered questionnaires included standardised measures assessing fear of an intimate partner at enrolment, 6 and 12 months postpartum; and period prevalence of physical and emotional abuse in the first 12 months postpartum. 1,507 women completed baseline data (mean gestation 15 weeks). Response fractions at 3, 6 and 12 months postpartum were 95, 93 and 90%, respectively. 5.1 and 5.4% of women reported fear in pregnancy and the first year postpartum, respectively. 17% experienced physical and/or emotional abuse in the first year postpartum. Most women who reported fear of an intimate partner in the first year after the index birth reported fear before and/or during pregnancy. Women working in early pregnancy who qualified for paid maternity leave had significantly reduced odds of reporting combined physical and emotional IPV in the first 12 months postpartum compared with women not working (Adj. OR 0.21, 95% CI 0.08-0.55). Women working but not eligible for paid leave had reduced odds compared with women not working (Adj. OR 0.49, 95% CI 0.24-1.00). Models adjusted for maternal age, relationship status, income and education level. Few first time mothers reported fear for the first time after childbirth suggesting that IPV more commonly commences prior to the first birth. Paid maternity leave may have broader social benefits beyond immediate financial benefits to women and families.

General practitioners and St. John's Wort: a question of regulation or knowledge?

BACKGROUND: St. John's Wort (SJW), also known as Hypericum perforatum, is a herbal remedy available over-the-counter. There is evidence that it can treat mild to moderate depression but has potential side effects and important drug interactions. OBJECTIVE: To determine general practitioners' (GPs') knowledge and recommendation of SJW for mild to moderate depression within a climate of widespread community use of complementary therapies and debate about regulation. DESIGN AND SETTING: Postal survey of a random sample of 350 Australian GPs. RESULTS: Forty-eight percent responded. One-third (31%) reported recommending SJW to patients with mild to moderate depression. Of these, only one-third (32%) reported specific dosage instructions. Respondents' knowledge of side effects and interactions was much less than for selective serotonin reuptake inhibitor antidepressants. CONCLUSIONS: Australian GPs know less about safety of SJW than antidepressants and do not widely recommend it to patients. Despite this, many patients use SJW, probably in combination with other pharmaceuticals. Effective dissemination of further research into effectiveness and risk profiles of complementary therapies is needed to inform health professionals, regulatory bodies and consumers.

Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice.

OBJECTIVES: To determine the barriers to and rates of disclosure of partner abuse by women attending GPs. METHODS: In a qualitative study, abused Melbourne women were interviewed about their experiences with GPs. Following this, adult women attending a random sample of Brisbane general practices were surveyed. Multivariate analyses were conducted on the data, using levels of disclosure and GP inquiry adjusting for cluster effect to obtain prevalence rate ratios. RESULTS: Thirty-seven per cent of the survey participants (n=1836, response rate 78.5%) admitted to having ever experienced abuse in an adult intimate relationship. One-third (36.7%) of these abused women (n=674) had ever told a GP and 87.8% had never been asked by their GP about partner abuse. Women who disclosed were almost twice as likely than women who have not: to be middle aged, have experienced combined physical, emotional and sexual abuse and be afraid of their partner. They were more than twice as likely to have been asked about abuse. A GP's good communication skills facilitated disclosure. The main barriers to disclosure were that women saw the problem as their own i.e. internal barriers. The data from the qualitative study (n=20) are used to illustrate these findings. CONCLUSION: Educational interventions that improve GPs' communication skills might result in increased disclosure and early intervention in partner abuse. GPs need sensitive attitudes, greater skills, knowledge and support to manage the consequences of disclosure.

Are men and women equally violent to intimate partners?

Violence against women is a significant public health issue. One form of violence against women, intimate partner abuse or domestic violence, is prevalent in Australia. In this article, we summarise the main theoretical and methodological debates informing prevalence research in this area. We explain why studies finding equivalent victimisation and perpetration rates between the sexes are conceptually and methodologically flawed and why coercion and control are fundamental to the definition and measurement of partner abuse. We conclude that while male victims of partner abuse certainly exist, male victims of other forms of male violence are more prevalent. A focus on gendered risk of violence in public health policy should target male-to-male public violence and male-to-female intimate partner abuse.

Domestic violence in Australia: definition, prevalence and nature of presentation in clinical practice.

Domestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse. Women experience domestic violence at far greater rates than men do, and women and children often live in fear as a result of the abuse that is used by men to maintain control over their partners. Domestic violence is a major public health problem and is very common in women attending clinical practice. Women present most commonly with a range of chronic symptoms to unsuspecting general practitioners, emergency department doctors or medical specialists. Women who have experienced partner abuse want to be asked about it and are more likely to disclose if asked in an empathic, non-judgemental way. Doctors can make a difference.

How common is domestic violence against women? The definition of partner abuse in prevalence studies.

We systematically reviewed studies of the prevalence of domestic violence. Selected overseas community studies were compared with all Australian prevalence studies found to be published. Twelve-month prevalence estimates of partner abuse in Australia varied from 2.1 per cent to 28.0 per cent, depending mainly on the definition of domestic violence used in each study. Implications of the lack of a precise definition result in varying operationalised definitions of partner abuse, from all types of violence in relationships (including a single minor violent incident), through to only those violent incidents that are classified as a crime. Recommendations for any future prevalence studies in this field include the need to collect frequency data which reflected the fact that partner abuse against women is a complex behavioural phenomenon involving emotional, physical and sexual abuse against a partner, not just simply physical incidents.

Counselling in general practice. A structured approach to the management of stress.

Many patients currently taking psychoactive drugs or being referred to psychiatrists for the outpatient treatment of general psychological distress could be offered effective management in a general practice setting, with or without inclusion of pharmaceutical supports. This article offers practical guidelines for practitioners in counselling emotionally distressed patients in a general practice setting.