Development of a health care provider survey for domestic violence: psychometric properties.

BACKGROUND: Despite rapid proliferation of descriptive studies of health care providers (HCPs) and protocols for identification and management of domestic violence (DV), few reliable instruments exist for assessing HCPs' attitudes, beliefs, and behaviors regarding this practice. This study describes the development and psychometric properties of a measure of attitudes, beliefs, and self-reported behaviors related to the identification and management of DV. METHODS: We used a multiphase study design to develop items across eight content domains. We administered an initial pool of 104 items to a pilot sample of 129 primary care providers (physicians, physician assistants, nurse practitioners, and medical assistants) in a large, urban health maintenance organization. Descriptive statistics, principal components, and reliability analyses were performed on each of the eight content domains. The analyses guided the deletion of items and development of additional items, yielding a 56-item pool. The items were then administered and re-analyzed with an independent sample of 246 HCPs. RESULTS: Six separate and reliable domains were identified: Perceived Self-Efficacy, System Support, Blame Victim, Professional Role Resistance/Fear of Offending Patient, Victim/Provider Safety, and Frequency of DV Inquiry. We found item domain Cronbach alpha to be acceptable, ranging from 0.73 to 0.91. The final overall measure had 39 items and an alpha of 0.88. Data are reviewed that support the measure's sensitivity to change in response to a training intervention. CONCLUSION: The measure provides a reliable method for assessing provider characteristics and training needs. It may also serve to evaluate training and policy interventions in DV.

Identification and management of domestic violence: a randomized trial.

BACKGROUND: Diagnosis of domestic violence (DV) in primary care is low compared to its prevalence. Care for patients is deficient. Over a 1-year period, we tested the effectiveness of an intensive intervention to improve asking about DV, case finding, and management in primary care. The intervention included skill training for providers, environmental orchestration (posters in clinical areas, DV questions on health questionnaires), and measurement and feedback. METHODS: We conducted a group-randomized controlled trial in five primary care clinics of a large health maintenance organization (HMO). Outcomes were assessed at baseline and follow-up by survey, medical record review, and qualitative means. RESULTS: Improved provider self-efficacy, decreased fear of offense and safety concerns, and increased perceived asking about DV were documented at 9 months, and also at 21 months (except for perceived asking) after intervention initiation. Documented asking about DV was increased by 14.3% with a 3.9-fold relative increase at 9 months in intervention clinics compared to controls. Case finding increased 1.3-fold (95%, confidence interval 0.67-2.7). CONCLUSIONS: The intervention improved documented asking about DV in practice up to 9 months later. This was mainly because of the routine use of health questionnaires containing DV questions at physical examination visits and the placement of DV posters in clinical areas. A small increase in case finding also resulted. System changes appear to be a cost-effective method to increase DV asking and identification.

A training program to improve domestic violence identification and management in primary care: preliminary results.

Domestic violence as encountered in day-to-day practice is greatly underidentified. It is estimated that only 3% of cases are presently being identified, and practitioners are uncertain of what to do if a case is discovered. In this paper, a training program to improve identification and management of domestic violence (DV) in primary care and the providers' responses to the program are described. A multimodal training program was undertaken to demonstrate and practice the incorporation of didactic content into practice for the health care teams. Two medical centers from a large staff-model HMO were chosen at random from five volunteering for training. The entire adult health care medical center teams, including physicians, physician assistants, RNs, LPNs, medical assistants, and receptionists, were the recipients of the training. Assessment of provider valuation of the components of the training program was performed by administering a standardized 5-point Likert-scaled questionnaire 9 months after the training. This time interval was chosen because we were interested in lasting program effects. Core didactic content, such as the epidemiology of DV, identification and management of victims and batterers, and legal issues, was highly rated. Delivery of the content through role-playing, start-stop videos and presentations by former victims received lesser but solid support. Follow-up assessment 9 months post training demonstrates solid support for many components of the program: highest for specific information content areas, but strong for techniques and processes. The training program appears to be a promising method to improve provider skills in DV management.

Psychopharmacological treatment of aggressive behavior: implications for domestically violent men.

In an attempt to further evolve our understanding and response to domestic violence as a public health problem, a number of investigators have begun to prioritize the development of specialized diagnostic and intervention methods from a biomedical perspective. The potential use of selectively prescribed and carefully monitored medications to help end violent and abusive behavior would be an important step toward mainstreaming the treatment of domestically violent men into the realm of modern medicine and health care. While much work remains in understanding the specific linkages and mechanisms between psychobiology and aggressive and violent behavior, there is a growing body of basic and clinical research which has important potential for expanding our intervention efforts. This article reviews this research in relation to current efforts to understand and treat domestically violent men. A biopsychosocial model which incorporates selective and adjunctive psychopharmacological treatment within the context of cognitive-behavioral and social systems interventions is outlined and discussed.

Predictors of burden in spouse caregivers of individuals with Alzheimer's disease.

This study used the following model of distress: Distress = [Exposure to Stress + Vulnerability]/[Psychological and Social Resources]. The constructs in the model were operationalized as (a) distress in response to caregiver experiences (burden); (b) exposure to stress (care recipient functional impairment in activities of daily living [ADLs]); (c) vulnerability (caregiver health problems, anger, and anxiety); and (d) resources (coping, outlook on life, and social supports). Long-term burden (15-18 months after entry) was predicted by several baseline variables: burden, care recipient ADLs, vulnerability and resource variables, and specific interactions of burden, ADLs, vulnerability, and resource variables. The interactions showed that caregivers with high vulnerability and low resources had higher burden scores than caregivers with other combinations of these variables.

The screen for caregiver burden.

The Screen for Caregiver Burden (SCB) is a measure designed to identify distressing caregiver experiences rapidly. The 25-item SCB, created specifically for spouse caregivers of Alzheimer's care recipients, provides scores for objective burden (OB; number of potentially negative experiences) and subjective burden (SB; appraised distress in response to the experiences). Three separate studies (total N = 191) demonstrate the internal consistency, test-retest reliability, and validity (content, divergent, convergent, and criterion) of the scales. Finally, evidence suggests that changes in OB and SB over time are explained by changes in care-recipient functioning and caregiver distress.

Appraised changeability of a stressor as a modifier of the relationship between coping and depression: a test of the hypothesis of fit.

The goodness of fit among the appraised changeability of a stressor, coping, and depression in people with psychiatric, physical health, work, and family problems was examined (N = 746). It was expected that problem-focused coping (as opposed to emotion-focused coping) would be used more and be more adaptive in situations appraised as changeable as compared with situations appraised as not changeable. Although few relationships existed between appraisal and coping, tests of fit between coping and depressed mood (maladaption) were much stronger. In people with nonpsychiatric conditions, problem-focused coping and depressed mood were negatively related when a stressor was appraised as changeable but were unrelated when a stressor was appraised as not changeable. Emotion-focused coping was positively related to depression when a stressor was appraised as changeable. No general relations were observed in the people with psychiatric conditions.

Coping profiles associated with psychiatric, physical health, work, and family problems.

Compares the coping profiles of 11 samples (total N = 1,298) of individuals experiencing psychiatric, physical health, work, or family problems. Comparisons are made in individuals with and without anxiety and depression to control for the effects of distress. Coping was similar for samples in similar problem categories but different for samples in different categories. Psychiatric patients made more use of avoidance and less use of social supports than individuals in the other categories. Samples with physical health problems were among the most frequent users of social supports. Individuals with a family problem were among the most frequent users of problem-focused coping and the least frequent users of self-blame. Groups with work stress were the most frequent users of self-blame. These results suggest that coping profiles may be useful in describing and differentiating groups of stressed individuals.

Anger, hostility, and depression in assaultive vs. suicide-attempting males.

Hostility and depression were examined in male psychiatric patients who exhibited either assaultive (n = 40) or suicide-attempting behavior (n = 20). Both groups were compared to a sample of nonviolent males (n = 22) to provide a basis for interpreting the absolute as well as relative magnitude of these variables in relation to their violent behavior. Both suicide-attempting and assaultive patients were characterized by high levels of hostility and depression, as evidenced by significantly higher scores than those of the nonviolent group on almost all indices. Assaultive subjects evidenced relatively greater overt expression, frankly assaultive impulses, and verbalized anger and hostility. Suicide-attempting subjects tended to experience anger and hostility in a more intropunitive and covert manner and displayed higher levels of guilt and depression. Covariance analyses indicated that anger and depression contributed separately to the affective configuration of the assaultive and suicide-attempting groups.

Coping in chest pain patients with and without psychiatric disorders.

We first examined relations between psychiatric disorder and coronary heart disease (CHD) in 77 patients presenting with chest pain. The coping profiles of chest pain patients with and without psychiatric disorder and CHD were then compared. Psychiatric patients with no medical illness (n = 129) were also studied. On the basis of previous research we hypothesized specific coping differences across the groups. As expected, chest pain patients without psychiatric disorder scored significantly higher on a problem-focused coping scale than chest pain patients with psychiatric disorder, who in scored higher on this scale than psychiatric patients with no medical illness. The opposite pattern occurred for a measure of wishful thinking. Scores of chest pain patients with psychiatric disorder were higher on a measure of avoidance and lower on a measure of seeking of social supports than those without psychiatric disorder. Scores on a self-blame measure were not different across the groups. The results are discussed in the context of illness behavior and somatization.

Medical student distress. A longitudinal study.

This longitudinal study investigated the relative importance of correlates of psychological distress in first year medical students (N = 312) in September and May. Anxiety levels were one SD above the mean when compared with nonpatient levels in both September and May, and the percentage of students reporting depression doubled over the study period. Problem-focused coping decreased, emotion-focused coping increased, and satisfaction with social supports decreased over the year. In contrast, type A behavior and anger expression were more stable. Students distressed in September were at higher risk for distress in May. Students distressed in May were also characterized by higher scores for suppressed anger and type A behavior in May, even after controlling for distress in September.

New developments in research on aggression: an international report.

During the first week of July 1988, the International Society of Research on Aggression (ISRA) conducted its Eighth World Conference at the University College of Swansea in Wales, United Kingdom. The present paper reviews some of the highlights of the recent conference, with particular attention given to those topics that might be of interest to researchers and clinicians specializing in interpersonal violence. Topics include theoretical work, relevant animal studies, developmental and longitudinal studies of childhood aggression, child abuse, violence by adolescents, wife abuse and assault, biological correlates of aggression, and advances in measurement and assessment. The reported findings support an interdisciplinary approach to the study of interpersonal violence.

Patient reactions to a no smoking policy in a community mental health center.

The prevalence of cigarette smoking in a CMHC population was surveyed and patient attitudes and affective reactions regarding the implementation of a no smoking policy were assessed. The prevalence of smoking (80-84%) was in line with previous reports which have suggested that an extraordinarily high percentage of psychiatric patients engage in cigarette smoking. Significant differences were observed between smokers' and nonsmokers' reactions to the no smoking policy which resulted partially from negative reactions by smokers but also from positive reactions by nonsmokers. Although a slight decrease in client satisfaction was observed, the emotional reactions of smokers were generally not clinically substantive. A 16 month follow-up survey of clinicians further supported the idea that the negative reactions of smokers were not of major magnitude and were probably transitory. The authors conclude that the primary effects of a mental health center smoking policy may be the protection of the service environment and improvements in the well-being of nonsmoking patients and staff who would otherwise be at risk for the effects of second hand smoke.

Perceived stress in medical school: resistors, persistors, adaptors and maladaptors.

A longitudinal study of perceived medical student stress (PMSS) was conducted on 305 first year medical students. Data were collected at orientation in September and again in May, 2 weeks before exams. Four types of students were identified using a standardized and reliable measure of PMSS. These included students whose PMSS scores began and ended low (resistors), whose PMSS scores began and remained high (persistors), whose PMSS scores decreased from high to low (adaptors) and whose PMSS scores increased from low to high (maladaptors). The four groups differed predictably on indices of distress and were also distinguishable by a variety of psychosocial variables including type A personality, anger expression and coping. In contrast, life events played a minor role in distinguishing the groups. The results are discussed in relation to previous research on medical student stress.

A biopsychosocial model of medical student distress.

Medical student distress was examined in two consecutive first-year classes (N = 312) in September, before they interacted with the school regimen, and again in May before exams. Anxiety means were one SD above the normative mean for nonpatients at both times. The number of students reporting a significant level of depression doubled from September (N = 36) to May (N = 78). The correlation of distress in September and May was .40, indicating that for many students distress was enduring. A biopsychosocial model of initial distress explained more variance (36%) in the cross-validation sample than did any one variable alone. Distressed students had higher Type A scores. Also, anger held in was a risk factor for distress in students with a family history of cardiovascular disease (CVD). Students who hold anger in may experience prolonged stress which, coupled with a family history of CVD, could make them psychobiologically vulnerable to distress.

Raw versus relative scores in the assessment of coping strategies.

Raw scores (frequency of efforts) versus relative scores (percentage of efforts) were compared on the five scales of the revised Ways of Coping Checklist. It was hypothesized that, conditional on the source of and appraisal of a stressor, problem-focused coping should be inversely related and Wishful Thinking should be positively related to depression when relative scores were used but that raw problem-focused scores would be less clearly related to depression in such a way. It was further hypothesized that these relationships would hold for very diverse samples: psychiatric outpatients (n = 145), spouses of patients with Alzheimer's disease (n = 66), and medical students (n = 185). Given the maladaptive status of the psychiatric outpatients, it was hypothesized that they would report more emotion-focused strategies and less problem-focused coping than the nonclinical samples and that these differences would be better observed using relative rather than raw scores. The hypotheses were generally supported.

Coping as an index of illness behavior in panic disorder.

Illness behavior in panic disorder was examined by comparing the coping strategies of female primary care patients (34 with panic disorder, 30 with simple panic, and 78 without panic.) Relationships of coping and distress were also examined within each group. The groups differed significantly on the Ways of Coping Checklist, anxiety (SCL-90 and Zung scales), depression (SCL-90 and Beck scales), and number of phobias. The panic disorder group used proportionately less problem-focused and more wishful thinking than the other groups. Within the panic disorder group, anxiety and depression were correlated negatively with problem-focused coping and positively with wishful thinking, and number of phobias was correlated negatively with the seeking of social support and positively with wishful thinking. Most importantly, when an attempt was made to statistically separate panic patients with multiple phobias from those without multiple phobias, coping was a better marker than was distress. These results emphasize the importance of cognitions in illness behavior and anxiety disorder.