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
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.
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
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.
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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