Intimate Partner Violence


14 Intimate Partner Violence


Sheila Sprague PhD1,2, Taryn Scott MSW1, Erika Arseneau MSc2, Prism Schneider MD FRCSC3, Andrew Furey MD FRCSC4, Rudolf Poolman MD PhD5, Emil Schemitsch MD6, and Mohit Bhandari MD PhD7


1 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


2 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada


3 Division of Orthopaedic Trauma, Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada


4 Orthopaedics, Memorial University of Newfoundland, St. John’s, NF, Canada


5 Leiden University Medical Center, Amsterdam, The Netherlands


6 Division of Orthopaedic Surgery, Department of Surgery, Western University, London, ON, Canada


7 Department of Surgery, McMaster University, Hamilton, ON, Canada


Clinical scenario



  • A 32‐year‐old woman presents to your fracture clinic with a displaced clavicle fracture.
  • Your physical examination reveals multiple bruises across her chest, back, and arms which are in various stages of healing.
  • Radiographs reveal a previous clavicle fracture and a partially united ulna fracture.
  • The woman presents with her husband, who appears agitated and will not let her answer medical questions for herself.

Top three questions



  1. In adult women with orthopedic injuries who present to fracture clinics, what is the prevalence of intimate partner violence (IPV), and how does this compare to the general population?
  2. Do specific educational programs, compared to traditional education, for healthcare professionals improve universal IPV identification and referral to assistance programs?
  3. In adult women who present to fracture clinics, are universal IPV identification and assistance interventions, compared to standard practice, effective at improving health outcomes for women?

Question 1: In adult women with orthopedic injuries who present to fracture clinics, what is the prevalence of intimate partner violence (IPV), and how does this compare to the general population?


Rationale


To determine the relevance of IPV (also known as domestic violence) to orthopedic practice, it is important to understand how frequently it affects individuals with orthopedic injuries.


Clinical comment


While healthcare professionals (HPCs) have a duty of care to protect all vulnerable patients, the prevalence of IPV amongst orthopedic injury patients is an important factor in determining the amount of resources that fracture clinics should invest to implement IPV identification and assistance programs.


Available literature and quality of the evidence


PRAISE (PRevalence of Abuse and Intimate Partner Violence Surgical Evaluation), a large, multinational, cross‐sectional study, is the only study to have been conducted that assesses the prevalence of IPV within women attending fracture clinics.1 To determine prevalence, women (n = 2945) attending fracture clinics (n = 12) located across Canada, the United States of America, the Netherlands, Denmark, and India were asked to complete an anonymous questionnaire. Additionally, multiple studies have been conducted to assess prevalence in other healthcare settings,2 as well as the general population.3 The best available evidence is a systematic review by Sprague et al. which examined IPV prevalence rates across medical and surgical healthcare settings and provided pooled prevalence estimates.2 This review included 37 studies with a primary aim of determining IPV prevalence rates in adult women presenting to physicians regardless of medical specialty. Studies were conducted in family medicine (n = 15), emergency medicine (n = 12), obstetrics and gynecology (n = 3), internal medicine (n = 3), or multiple specialties (n = 4). Lastly, a large‐scale systematic review conducted by the World Health Organization (WHO) examined IPV prevalence in the general population.3 This review included all representative, population‐based studies that examined prevalence of IPV. The study included data from 185 studies from 86 countries. Because prevalence studies do not address therapeutic research questions, the level of evidence schema is not applicable and is therefore not provided here.4


Findings


IPV prevalence in orthopedic populations


The PRAISE study asked women to report experiences with IPV in their lifetime, within the last 12 months, and acutely.1 For the purpose of this study, IPV was defined as physical, emotional, sexual, psychological, or financial abuse between intimate partners. Results showed that one in three participants experienced IPV at some point in their lifetime (34.6%; 95% confidence interval [CI]: 32.8–36.5%) and one in six experienced IPV within the past year (16.0%; 95% CI: 14.7–17.4%) (Figure 14.1). Additionally, one out of every 50 participants (2.7%; 95% CI: 1.3–2.2%) were attending fracture clinics to receive treatment for an injury sustained as a direct result of IPV (acute prevalence).

Schematic illustration of the prevalence of IPV in orthopedic populations.

Figure 14.1 Prevalence of IPV in orthopedic populations.


IPV prevalence in other patient populations


The systematic review by Sprague et al. pooled the results of 10 studies conducted in emergency medicine which estimated a lifetime IPV prevalence rate of 38%.2 Similar results were found in family medicine (40%, n = 12) and slightly higher in other subspecialties including obstetrics and gynecology (59%, n = 4). Pooled 12‐month IPV prevalence rates were 20% in both family medicine (n = 8) and emergency medicine (n = 7). Additionally, between 2 and 4% of female patients presenting to emergency medicine settings were found to have injuries that were caused by IPV. There was heterogeneity in how studies defined IPV; however, this did not prevent pooling.


IPV prevalence in the general population


The systematic review by the WHO (2013) pooled the results of 155 population‐based studies from 81 countries.3 The estimated global lifetime prevalence for physical and sexual IPV among women who have been in relationships was 30% (95% CI: 27.8–32.2%). Regional pooled estimates of prevalence ranged from 16.3% (95% CI: 8.9–23.7%) in East Asia to 65.6% (95% CI: 53.6–77.7%) in Central Sub‐Saharan Africa. The pooled estimate for North America was 21.3% (95% CI: 16.2–26.4%) and ranged from 19.3% (95% CI: 15.9–22.7%) to 27.8% (95% CI: 22.7–33.0%) in Europe, depending on location.


Resolution of clinical scenario



  • The lifetime prevalence of IPV among orthopedic patients is similar to the global prevalence, but higher than the North American general population prevalence.
  • Orthopedic surgeons should be aware of the potential for IPV to be directly affecting the lives of their patients.
  • Orthopedic surgeons should consider IPV as a possible cause of injury, or coexisting life circumstance.
  • Concerning features in this clinical scenario include recurrent fractures, fractures, and bruises at various stages of healing, and the accompaniment of an agitated and controlling partner.
  • The absence of these signs does not indicate the absence of IPV.

Question 2: Do specific educational programs, compared to traditional education, for healthcare professionals improve universal IPV identification and referral to assistance programs?


Rationale


Though orthopedic surgeons and allied HCPs are uniquely positioned to identify and provide critical assistance to women experiencing IPV, they often report barriers to doing so. Previous research has found that education is one key barrier. It is therefore important to understand whether an educational program for HCPs is an appropriate method for improving IPV identification and assistance programs.


Clinical comment


Continuing education that helps HCPs safeguard vulnerable populations is an important part of orthopedic practice. Educational programs that supply HCPs with knowledge about IPV, strategies for improving care, and information on local resources may be helpful for improving existing IPV identification and assistance programs.


Available literature and quality of the evidence


A single pretest–posttest study, EDUCATE (Education on Domestic Violence: Understanding Clinicians’ and Traumatologists’ Experiences), is available that evaluated the impact of an educational program on 140 orthopedic fracture clinic staff (level III evidence).5,6

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Intimate Partner Violence

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