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Routine, Single-Item Screening to Identify Abusive Relationships in Women
METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N=13) and functional limitations (n=6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse.
RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P <.001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P <.001). They had twice as many bothersome symptoms (3.1 vs 1.7; P <.001) and functional problems (1.6 vs 0.8; P <.001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n=64) reported abusive relationships than in the high-risk group (n=36).
CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.
The prevalence of domestic abuse in 3 primary care studies ranged from 6% to 22%. In these studies domestic abuse was measured as physical abuse1-4 or a combination of both physical and verbal abuse.1,2,4 In these and many other studies, an abusive relationship was associated with psychological problems,3-14 drug and alcohol abuse,3,6,7,9-11 and many other different symptoms.3,5,7-13,15-19 Detection of abusive relationships in clinical settings is assumed to improve outcomes.3,20,21 Guidelines for detection and management are well described.22
Despite its prevalence and importance, a woman’s abusive relationship often goes unnoticed in primary care practice.1-3,23 We used the results of a comprehensive written health survey of 1526 women aged 19 to 69 from 31 practices across the United States to reemphasize why specific inquiry about an abusive relationship is important and how it might be accomplished in a busy office setting.
Methods
Settings and Patients
We used data from 31 sites participating in a 3-year quality improvement project.24 In 1999, at 2 times separated by 6 months, all sites asked 2 sequential samples of adults aged 19 to 69 years to complete an anonymous health survey. Each site determined when and how the sample would be obtained. A total of 2528 patients responded. The number of responses by practice ranged from 19 to 156, and the median was 64. Of these patients, 1584 were women.
Measures
The Screening Tool for an Abusive Relationship. To develop the single-item screening tool,9 primary care physicians and nurses examined several methods for detection of abuse identified in the published literature.25-27 They developed 2 word-and-picture charts based on previously tested methods.28,29 Two groups of women who had recently experienced domestic abuse (total N=13) reviewed these charts, and their suggestions were incorporated.
For our investigation, the word-and-picture Relationships Chart was used (Figure 1). To validate the Relationships Chart we administered it to 51 women volunteers in urban and rural domestic abuse support groups. The control group consisted of 48 randomly selected patients in 2 obstetric and gynecology clinics. These women were also asked to complete 41 items about spouse or partner abuse.25 The items were scored on a 5-point scale so the maximum score would be 205 and the minimum score 41.
Women seeking help from a support group because of their current or previous involvement in an abusive relationship scored much worse than women in the control group on both the single-item chart and the multi-item score (P <.001). Based on the chart, when women reported potential abuse “none or a little of the time,” their average score on the multi-item questionnaire was 62; when their response was “some of the time” their average score was 86; and when they reported “often or always” experiencing potential abuse during the previous 4 weeks their average score was 114.
Eighty-eight of the women completed the Relationship Chart a second time within 10 days after the initial administration. The average test-retest correlation was 0.60; on the 5-point scale 88.4% of the responses stayed the same or shifted by only 1 scale point.
Thus, the Relationship Chart had reasonable face and criterion validity and more than met minimum standards for reliability.30
The Patient Health Survey. The Relationships Chart was included as part of a patient health survey called “Improve Your Medical Care.” This survey was used as part of a quality improvement system that has been shown to improve care for different populations.31,32 However, in our study it was used only to sample patients’ needs and characteristics in the participant practices. The patient health survey contains questions about demographics and diagnoses (8 items), function (6 items), symptoms and bothers (22 items), habits and prevention (13 items), and utilization (4 items). A complete copy of this survey is available on request.
All practices received computer-scored reports for each respondent within 1 week of completion.
Analysis
To compare scores on the Relationships Chart with measures of functional status using the Dartmouth Primary Care Cooperative Information and Research Network (COOP) charts, we used a score of 4 or 5 on a 5-point Likert scale as the threshold for significant limitation in function.33 For bothersome symptoms we used a response of “often” or “always” in the previous 4 weeks. We used the chi-square test to assess the statistical significance of the comparisons.
We used prevalence ratios to compare the prevalence of abusive relationships for women with and without functional limits and symptoms.
Results
Clinical and Functional Impacts of an Abusive Relationship Ninety-six percent of the women completed the chart (1526/1584). Possible domestic abuse (as assessed by this chart) was reported by 13% (201) of the women visiting these 31 outpatient practices. The range of positive responses was 0% to 50%; the median was 11%.
The Table lists several factors highly associated with an abusive relationship. Women in an abusive relationship were more likely to be young and poor. They more often had multiple problems with function and many bothersome symptoms. They less often engaged in good personal health habits. More of these women smoked cigarettes: 24% vs 15%, P=.002; more of them drank more than 6 alcoholic beverages a week: 12% vs 7%, P=.001). They more often reported that they had been confined to bed in the previous 3 months than women who were not abused.
Despite a higher frequency of clinic use, women in an abusive relationship more often reported problems with access and slightly less often completed necessary preventive actions. However, they had the same number of chronic diagnoses and used the hospital and chronic medications at the same rate as other women (data not shown).
The most common functional limitations reported by all women were pain (24%), physical (21%), and feelings (18%). Figure 2 illustrates the probability of an abusive relationship for women with or without a particular functional limitation. Pain and feelings were most often associated with an abusive relationship. Almost a third of the women who are limited by feelings are at risk for domestic abuse. The prevalence ratio for feelings was 3.0.
The most common symptoms reported were eating/weight (26%), dizziness/fatigue (24%), joint pains (23%), back pains (22%), sleep problems (22%), and headaches (21%). Figure 3 illustrates the probability of an abusive relationship for women with or without a particular symptom. Among the 6 most prevalent symptoms, headache was most strongly associated with domestic abuse (24%). Among women who reported abusive relationships “most or all of the time” the chance of significant problems with feelings, dizziness/fatigue, headache, or sleep was greater than 50% (data not shown).
Identifying Women at Risk
Although a combination of demographic characteristics and clinical problems can be used to identify a group of women at high risk for abuse,3 such an approach makes little practical sense. For example, among women who have inadequate money and significant problems with feelings, 41% (36/89) were likely to have an abusive relationship. However, among the 1025 women with neither financial difficulties nor emotional problems, 64 were at risk for abuse (6%).
Discussion
We found that approximately 13% of women aged 19 to 69 years in 31 practices were identified as being in an abusive relationship by a single written measure. These women had significant psychosocial issues, poor health habits, and many somatic complaints.
Our descriptive study of screening for an abusive relationship in women has 4 important implications for clinical practice:
- It reaffirms the prevalence of abuse in office practice settings. In these 31 practices, the median rate of possible abuse was 11%.
- It provides a detailed illustration of the burden of clinical and social illness borne by women in abusive relationships. One other study3 has provided a similar level of detail. Where measures of symptoms were comparable, both studies found similar prevalence ratios for abuse.
- It reminds clinicians that direct inquiry about possible abuse is likely to be much more effective than using a combination of demographic and clinical factors.3,15 Clinical intuition used to select an at-risk woman from a group will be less effective than asking her directly about possible abuse.
- These results add to the growing body of literature that single-item word-and-picture charts that query patients about complex issues are very useful in clinical practice. Such charts have been shown to be valid and reliable for identifying important functional limitations in adults,28,29 depression,33 health and social problems in adolescents,34 and spirituality.35 Because they are single-item they are good for screening, can be easily adapted to other languages, and serve as the foundation for deeper inquiry about physician-patient interaction.33,36 For example, more than one third of the women in these practices felt that their clinician was unaware of important functional limitations or provided poor education about them.
This particular measure for an abusive relationship has face and criterion validity and reasonable reliability. It seems acceptable for use in practice, since 96% of the women who completed a health survey also completed this item. However, it is intentionally not as specific as direct questions about physical abuse such as: “Has your husband, boyfriend, partner/lover hit, kicked, threatened, or otherwise frightened you?”22 The clinicians and women who assisted in the design of the Relationships Chart felt that a screening question would appear less intimidating if it were less specific and did not require a yes or no response. We previously received the same advice from adolescents for inquiring about antisocial behavior and drug abuse.34 The pictures add to the appeal of the Dartmouth COOP Charts but do not seem to influence responses.37
The validation study (comparing response categories to another instrument) and the results illustrated in the Table (comparing functional and symptomatic impacts by response categories) indicate that a woman who says that she has experienced an abusive relationship at least some of the time in the past 4 weeks probably is experiencing abuse. For those women who screen positive, more direct inquiry is indicated about the nature of the abuse.
If clinicians do not actively screen but choose to wait for a woman in an abusive relationship to declare herself, the data suggest that she may enter a labyrinth of nonspecific complaints and increased utilization of services. If clinicians actively inquire about abuse, short-term demands for accurate documentation and effective referral will have to be met,20-22 and the longer-term benefit to the patient and clinician may be considerable.
Conclusions
Domestic abuse is a prevalent and important problem for women, and simple measures can detect domestic abuse in community practice. It is necessary to think of abuse when some functional and symptomatic issues are present, but that alone is not sufficient. Direct inquiry will be more effective. The symptoms and functional problems of these women may be erroneously evaluated unless the domestic abuse is detected.
Acknowledgments
We thank and acknowledge the physician practice sites that participated in our project: Baylor College of Medicine, Houston, Tex; Berlin Health System, Green Bay, Wis; Beth Israel Deaconess Medical Center, Boston, Mass; Cambridge Health Alliance, Cambridge, Mass; Dana Farber Cancer Institute, Boston, Mass; Federation of Swedish County Councils/Sweden Anderstop Health Center, Greater Lawrence Family Health Center, Lawrence, Mass; Harvard University Health Services, Cambridge, Mass; Independent Health: Buffalo Medical Group, Tonawanda Medical Associates, Buffalo, NY; Joslin Diabetes Center, Boston, Mass; Lathem Medical Group, Lathem, NY; Magic Valley Health Center, Twin Falls, Idaho; Mayo Health System: Luther Midelfort, Eau Clair, Wis, and Mayo Clinic Scottsdale, Ariz; Medical University of South Carolina, Charleston, SC; MeritCare, Fargo, ND; PeaceHealth, Eugene, Ore; PennState Geisinger Health System, Pa; Scripps Clinic, La Jolla, Calif; SSM Health System, St. Louis, Ohio; Dean Health System, Madison, Wis; St. Mary’s Health System, Jefferson City, Mo; Strong Health, University of Rochester, Rochester NY; and ThedaCare, Appleton, Wis.
1. Gin NE, Rucker L, Fryne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.
2. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
3. McCauley J, Kern DE, Kolodner K, et al. The “battering syndrome”: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123:737-46.
4. Johnson M, Elliott BA. Domestic violence among family practice patients in midsized and rural communities. J Fam Pract 1997;4:391-400.
5. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-31.
6. Bergman B, Brismar B. A 5-year follow-up study of 117 battered women. Am J Pub Health 1991;81:1486-89.
7. Briere J, Zaidi LY. Sexual abuse histories and sequalae in female psychiatric emergency room patients. Am J Psychiatry 1989;146:1602-06.
8. Pribor EF, Yutzy SH, Dean T, Wetzel RD. Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993;150:1507-11.
9. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75-80.
10. Walker EA, Katon WJ, Hansom J, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658-64.
11. Walker EA, Katon WJ, Roy-Byrne PP, Jemelka RP, Russo J. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatry 1993;150:1502-06.
12. Jaffe P, Wolfe DA, Wilson S, Zak L. Emotional and physical health problems of battered women. Can J Psychiatry 1986;31:625-29.
13. Briere J, Runtz M. Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 1988;12:51-59.
14. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women’s mental health. Lancet 1988;1:841-45.
15. Drossman DA, Talley NJ, Leserman J, Olden KW, Barreiro MA. Sexual and physical abuse and gastrointestinal illness. Ann Intern Med 1995;123:782-94.
16. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 1987;27:310-14.
17. Haber JD, Roos C. Effects of spouse abuse in the development and maintenance of chronic pain in women. Adv Pain Res 1985;9:339-95.
18. Reiter RC, Shakerin LR, Gambone DO, Milburn AK. Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 1991;165:104-09.
19. Schei B, Bakketeig LS. Gynaecological impact and sexual and physical abuse by spouse: a study of a random sample of Norwegian women. Br J Obstet Gynaecol 1989;96:1379-83.
20. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-92.
21. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800-02.
22. Alpert EJ. Violence in intimate relationships and the practicing internist: new “disease” or new agenda? Ann Intern Med 1995;123:774-81.
23. Sugg NK, Inui T. Primary care physicians’ responses to domestic violence. JAMA 1992;267:3157-60.
24. Hess AMR, Nelson EC, Johnson DJ, Wasson JH. Building an idealized measurement system to improve clinical office practice performance. Managed Care Q 1999;7:22-34.
25. Shepard MF, Campbell JA. The abusive behavior inventory: a measure of psychological and physical abuse. J Interpersonal Violence 1992;7:291-305.
26. Hudson WW, McIntosh SR. The assessment of spouse abuse: two quantifiable dimensions. J Marriage Fam 1981;873-88.
27. Fieldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
28. Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP functional health assessment charts: brief measures for clinical practice. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia, Pa: Lippincott-Raven Press; 1996;161-68.
29. Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patients: how can it be measured in physicians’ offices? Med Care 1990;28:1111-26.
30. Nunnally JC. Psychometric theory. New York, NY: McGraw-Hill; 1978.
31. Wasson JH, Jette AJ, Johnson DJ, Mohr JJ, Nelson EC. A replicable and customizable approach to improve ambulatory care and research. J Ambulatory Care Management 1997;20:17-27.
32. Wasson JH, Stukel TA, Weiss JE, Hays RD, Jette AM, Nelson EC. A randomized trial of using patient self-assessment data to improve community practices. Effective Clin Pract 1999;2:1-10.
33. Wasson JH, Keller A, Rubenstein LV, Hays RD, Nelson EC, Johnson D. and the Dartmouth Primary Care COOP. Benefits and obstacles of health status assessment in ambulatory settings: the clinician’s point of view. Med Care 1992;30(suppl):MS42-49.
34. Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau P. A short survey for assessing health and social problems of adolescents. J Fam Pract 1994;38:489-94.
35. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and health experiences. Fam Med 1998;30:122-26.
36. Magari ES, Hamel MB, Wasson JH. An easy way to measure quality of physician-patient interactions. J Ambulatory Care Management 1998;21:27-33.
37. Larson CO, Hays RD, Nelson EC. Do the pictures influence scores on the Dartmouth COOP charts? Qual Life Res 1992;1:247-49.
METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N=13) and functional limitations (n=6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse.
RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P <.001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P <.001). They had twice as many bothersome symptoms (3.1 vs 1.7; P <.001) and functional problems (1.6 vs 0.8; P <.001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n=64) reported abusive relationships than in the high-risk group (n=36).
CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.
The prevalence of domestic abuse in 3 primary care studies ranged from 6% to 22%. In these studies domestic abuse was measured as physical abuse1-4 or a combination of both physical and verbal abuse.1,2,4 In these and many other studies, an abusive relationship was associated with psychological problems,3-14 drug and alcohol abuse,3,6,7,9-11 and many other different symptoms.3,5,7-13,15-19 Detection of abusive relationships in clinical settings is assumed to improve outcomes.3,20,21 Guidelines for detection and management are well described.22
Despite its prevalence and importance, a woman’s abusive relationship often goes unnoticed in primary care practice.1-3,23 We used the results of a comprehensive written health survey of 1526 women aged 19 to 69 from 31 practices across the United States to reemphasize why specific inquiry about an abusive relationship is important and how it might be accomplished in a busy office setting.
Methods
Settings and Patients
We used data from 31 sites participating in a 3-year quality improvement project.24 In 1999, at 2 times separated by 6 months, all sites asked 2 sequential samples of adults aged 19 to 69 years to complete an anonymous health survey. Each site determined when and how the sample would be obtained. A total of 2528 patients responded. The number of responses by practice ranged from 19 to 156, and the median was 64. Of these patients, 1584 were women.
Measures
The Screening Tool for an Abusive Relationship. To develop the single-item screening tool,9 primary care physicians and nurses examined several methods for detection of abuse identified in the published literature.25-27 They developed 2 word-and-picture charts based on previously tested methods.28,29 Two groups of women who had recently experienced domestic abuse (total N=13) reviewed these charts, and their suggestions were incorporated.
For our investigation, the word-and-picture Relationships Chart was used (Figure 1). To validate the Relationships Chart we administered it to 51 women volunteers in urban and rural domestic abuse support groups. The control group consisted of 48 randomly selected patients in 2 obstetric and gynecology clinics. These women were also asked to complete 41 items about spouse or partner abuse.25 The items were scored on a 5-point scale so the maximum score would be 205 and the minimum score 41.
Women seeking help from a support group because of their current or previous involvement in an abusive relationship scored much worse than women in the control group on both the single-item chart and the multi-item score (P <.001). Based on the chart, when women reported potential abuse “none or a little of the time,” their average score on the multi-item questionnaire was 62; when their response was “some of the time” their average score was 86; and when they reported “often or always” experiencing potential abuse during the previous 4 weeks their average score was 114.
Eighty-eight of the women completed the Relationship Chart a second time within 10 days after the initial administration. The average test-retest correlation was 0.60; on the 5-point scale 88.4% of the responses stayed the same or shifted by only 1 scale point.
Thus, the Relationship Chart had reasonable face and criterion validity and more than met minimum standards for reliability.30
The Patient Health Survey. The Relationships Chart was included as part of a patient health survey called “Improve Your Medical Care.” This survey was used as part of a quality improvement system that has been shown to improve care for different populations.31,32 However, in our study it was used only to sample patients’ needs and characteristics in the participant practices. The patient health survey contains questions about demographics and diagnoses (8 items), function (6 items), symptoms and bothers (22 items), habits and prevention (13 items), and utilization (4 items). A complete copy of this survey is available on request.
All practices received computer-scored reports for each respondent within 1 week of completion.
Analysis
To compare scores on the Relationships Chart with measures of functional status using the Dartmouth Primary Care Cooperative Information and Research Network (COOP) charts, we used a score of 4 or 5 on a 5-point Likert scale as the threshold for significant limitation in function.33 For bothersome symptoms we used a response of “often” or “always” in the previous 4 weeks. We used the chi-square test to assess the statistical significance of the comparisons.
We used prevalence ratios to compare the prevalence of abusive relationships for women with and without functional limits and symptoms.
Results
Clinical and Functional Impacts of an Abusive Relationship Ninety-six percent of the women completed the chart (1526/1584). Possible domestic abuse (as assessed by this chart) was reported by 13% (201) of the women visiting these 31 outpatient practices. The range of positive responses was 0% to 50%; the median was 11%.
The Table lists several factors highly associated with an abusive relationship. Women in an abusive relationship were more likely to be young and poor. They more often had multiple problems with function and many bothersome symptoms. They less often engaged in good personal health habits. More of these women smoked cigarettes: 24% vs 15%, P=.002; more of them drank more than 6 alcoholic beverages a week: 12% vs 7%, P=.001). They more often reported that they had been confined to bed in the previous 3 months than women who were not abused.
Despite a higher frequency of clinic use, women in an abusive relationship more often reported problems with access and slightly less often completed necessary preventive actions. However, they had the same number of chronic diagnoses and used the hospital and chronic medications at the same rate as other women (data not shown).
The most common functional limitations reported by all women were pain (24%), physical (21%), and feelings (18%). Figure 2 illustrates the probability of an abusive relationship for women with or without a particular functional limitation. Pain and feelings were most often associated with an abusive relationship. Almost a third of the women who are limited by feelings are at risk for domestic abuse. The prevalence ratio for feelings was 3.0.
The most common symptoms reported were eating/weight (26%), dizziness/fatigue (24%), joint pains (23%), back pains (22%), sleep problems (22%), and headaches (21%). Figure 3 illustrates the probability of an abusive relationship for women with or without a particular symptom. Among the 6 most prevalent symptoms, headache was most strongly associated with domestic abuse (24%). Among women who reported abusive relationships “most or all of the time” the chance of significant problems with feelings, dizziness/fatigue, headache, or sleep was greater than 50% (data not shown).
Identifying Women at Risk
Although a combination of demographic characteristics and clinical problems can be used to identify a group of women at high risk for abuse,3 such an approach makes little practical sense. For example, among women who have inadequate money and significant problems with feelings, 41% (36/89) were likely to have an abusive relationship. However, among the 1025 women with neither financial difficulties nor emotional problems, 64 were at risk for abuse (6%).
Discussion
We found that approximately 13% of women aged 19 to 69 years in 31 practices were identified as being in an abusive relationship by a single written measure. These women had significant psychosocial issues, poor health habits, and many somatic complaints.
Our descriptive study of screening for an abusive relationship in women has 4 important implications for clinical practice:
- It reaffirms the prevalence of abuse in office practice settings. In these 31 practices, the median rate of possible abuse was 11%.
- It provides a detailed illustration of the burden of clinical and social illness borne by women in abusive relationships. One other study3 has provided a similar level of detail. Where measures of symptoms were comparable, both studies found similar prevalence ratios for abuse.
- It reminds clinicians that direct inquiry about possible abuse is likely to be much more effective than using a combination of demographic and clinical factors.3,15 Clinical intuition used to select an at-risk woman from a group will be less effective than asking her directly about possible abuse.
- These results add to the growing body of literature that single-item word-and-picture charts that query patients about complex issues are very useful in clinical practice. Such charts have been shown to be valid and reliable for identifying important functional limitations in adults,28,29 depression,33 health and social problems in adolescents,34 and spirituality.35 Because they are single-item they are good for screening, can be easily adapted to other languages, and serve as the foundation for deeper inquiry about physician-patient interaction.33,36 For example, more than one third of the women in these practices felt that their clinician was unaware of important functional limitations or provided poor education about them.
This particular measure for an abusive relationship has face and criterion validity and reasonable reliability. It seems acceptable for use in practice, since 96% of the women who completed a health survey also completed this item. However, it is intentionally not as specific as direct questions about physical abuse such as: “Has your husband, boyfriend, partner/lover hit, kicked, threatened, or otherwise frightened you?”22 The clinicians and women who assisted in the design of the Relationships Chart felt that a screening question would appear less intimidating if it were less specific and did not require a yes or no response. We previously received the same advice from adolescents for inquiring about antisocial behavior and drug abuse.34 The pictures add to the appeal of the Dartmouth COOP Charts but do not seem to influence responses.37
The validation study (comparing response categories to another instrument) and the results illustrated in the Table (comparing functional and symptomatic impacts by response categories) indicate that a woman who says that she has experienced an abusive relationship at least some of the time in the past 4 weeks probably is experiencing abuse. For those women who screen positive, more direct inquiry is indicated about the nature of the abuse.
If clinicians do not actively screen but choose to wait for a woman in an abusive relationship to declare herself, the data suggest that she may enter a labyrinth of nonspecific complaints and increased utilization of services. If clinicians actively inquire about abuse, short-term demands for accurate documentation and effective referral will have to be met,20-22 and the longer-term benefit to the patient and clinician may be considerable.
Conclusions
Domestic abuse is a prevalent and important problem for women, and simple measures can detect domestic abuse in community practice. It is necessary to think of abuse when some functional and symptomatic issues are present, but that alone is not sufficient. Direct inquiry will be more effective. The symptoms and functional problems of these women may be erroneously evaluated unless the domestic abuse is detected.
Acknowledgments
We thank and acknowledge the physician practice sites that participated in our project: Baylor College of Medicine, Houston, Tex; Berlin Health System, Green Bay, Wis; Beth Israel Deaconess Medical Center, Boston, Mass; Cambridge Health Alliance, Cambridge, Mass; Dana Farber Cancer Institute, Boston, Mass; Federation of Swedish County Councils/Sweden Anderstop Health Center, Greater Lawrence Family Health Center, Lawrence, Mass; Harvard University Health Services, Cambridge, Mass; Independent Health: Buffalo Medical Group, Tonawanda Medical Associates, Buffalo, NY; Joslin Diabetes Center, Boston, Mass; Lathem Medical Group, Lathem, NY; Magic Valley Health Center, Twin Falls, Idaho; Mayo Health System: Luther Midelfort, Eau Clair, Wis, and Mayo Clinic Scottsdale, Ariz; Medical University of South Carolina, Charleston, SC; MeritCare, Fargo, ND; PeaceHealth, Eugene, Ore; PennState Geisinger Health System, Pa; Scripps Clinic, La Jolla, Calif; SSM Health System, St. Louis, Ohio; Dean Health System, Madison, Wis; St. Mary’s Health System, Jefferson City, Mo; Strong Health, University of Rochester, Rochester NY; and ThedaCare, Appleton, Wis.
METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N=13) and functional limitations (n=6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse.
RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P <.001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P <.001). They had twice as many bothersome symptoms (3.1 vs 1.7; P <.001) and functional problems (1.6 vs 0.8; P <.001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n=64) reported abusive relationships than in the high-risk group (n=36).
CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.
The prevalence of domestic abuse in 3 primary care studies ranged from 6% to 22%. In these studies domestic abuse was measured as physical abuse1-4 or a combination of both physical and verbal abuse.1,2,4 In these and many other studies, an abusive relationship was associated with psychological problems,3-14 drug and alcohol abuse,3,6,7,9-11 and many other different symptoms.3,5,7-13,15-19 Detection of abusive relationships in clinical settings is assumed to improve outcomes.3,20,21 Guidelines for detection and management are well described.22
Despite its prevalence and importance, a woman’s abusive relationship often goes unnoticed in primary care practice.1-3,23 We used the results of a comprehensive written health survey of 1526 women aged 19 to 69 from 31 practices across the United States to reemphasize why specific inquiry about an abusive relationship is important and how it might be accomplished in a busy office setting.
Methods
Settings and Patients
We used data from 31 sites participating in a 3-year quality improvement project.24 In 1999, at 2 times separated by 6 months, all sites asked 2 sequential samples of adults aged 19 to 69 years to complete an anonymous health survey. Each site determined when and how the sample would be obtained. A total of 2528 patients responded. The number of responses by practice ranged from 19 to 156, and the median was 64. Of these patients, 1584 were women.
Measures
The Screening Tool for an Abusive Relationship. To develop the single-item screening tool,9 primary care physicians and nurses examined several methods for detection of abuse identified in the published literature.25-27 They developed 2 word-and-picture charts based on previously tested methods.28,29 Two groups of women who had recently experienced domestic abuse (total N=13) reviewed these charts, and their suggestions were incorporated.
For our investigation, the word-and-picture Relationships Chart was used (Figure 1). To validate the Relationships Chart we administered it to 51 women volunteers in urban and rural domestic abuse support groups. The control group consisted of 48 randomly selected patients in 2 obstetric and gynecology clinics. These women were also asked to complete 41 items about spouse or partner abuse.25 The items were scored on a 5-point scale so the maximum score would be 205 and the minimum score 41.
Women seeking help from a support group because of their current or previous involvement in an abusive relationship scored much worse than women in the control group on both the single-item chart and the multi-item score (P <.001). Based on the chart, when women reported potential abuse “none or a little of the time,” their average score on the multi-item questionnaire was 62; when their response was “some of the time” their average score was 86; and when they reported “often or always” experiencing potential abuse during the previous 4 weeks their average score was 114.
Eighty-eight of the women completed the Relationship Chart a second time within 10 days after the initial administration. The average test-retest correlation was 0.60; on the 5-point scale 88.4% of the responses stayed the same or shifted by only 1 scale point.
Thus, the Relationship Chart had reasonable face and criterion validity and more than met minimum standards for reliability.30
The Patient Health Survey. The Relationships Chart was included as part of a patient health survey called “Improve Your Medical Care.” This survey was used as part of a quality improvement system that has been shown to improve care for different populations.31,32 However, in our study it was used only to sample patients’ needs and characteristics in the participant practices. The patient health survey contains questions about demographics and diagnoses (8 items), function (6 items), symptoms and bothers (22 items), habits and prevention (13 items), and utilization (4 items). A complete copy of this survey is available on request.
All practices received computer-scored reports for each respondent within 1 week of completion.
Analysis
To compare scores on the Relationships Chart with measures of functional status using the Dartmouth Primary Care Cooperative Information and Research Network (COOP) charts, we used a score of 4 or 5 on a 5-point Likert scale as the threshold for significant limitation in function.33 For bothersome symptoms we used a response of “often” or “always” in the previous 4 weeks. We used the chi-square test to assess the statistical significance of the comparisons.
We used prevalence ratios to compare the prevalence of abusive relationships for women with and without functional limits and symptoms.
Results
Clinical and Functional Impacts of an Abusive Relationship Ninety-six percent of the women completed the chart (1526/1584). Possible domestic abuse (as assessed by this chart) was reported by 13% (201) of the women visiting these 31 outpatient practices. The range of positive responses was 0% to 50%; the median was 11%.
The Table lists several factors highly associated with an abusive relationship. Women in an abusive relationship were more likely to be young and poor. They more often had multiple problems with function and many bothersome symptoms. They less often engaged in good personal health habits. More of these women smoked cigarettes: 24% vs 15%, P=.002; more of them drank more than 6 alcoholic beverages a week: 12% vs 7%, P=.001). They more often reported that they had been confined to bed in the previous 3 months than women who were not abused.
Despite a higher frequency of clinic use, women in an abusive relationship more often reported problems with access and slightly less often completed necessary preventive actions. However, they had the same number of chronic diagnoses and used the hospital and chronic medications at the same rate as other women (data not shown).
The most common functional limitations reported by all women were pain (24%), physical (21%), and feelings (18%). Figure 2 illustrates the probability of an abusive relationship for women with or without a particular functional limitation. Pain and feelings were most often associated with an abusive relationship. Almost a third of the women who are limited by feelings are at risk for domestic abuse. The prevalence ratio for feelings was 3.0.
The most common symptoms reported were eating/weight (26%), dizziness/fatigue (24%), joint pains (23%), back pains (22%), sleep problems (22%), and headaches (21%). Figure 3 illustrates the probability of an abusive relationship for women with or without a particular symptom. Among the 6 most prevalent symptoms, headache was most strongly associated with domestic abuse (24%). Among women who reported abusive relationships “most or all of the time” the chance of significant problems with feelings, dizziness/fatigue, headache, or sleep was greater than 50% (data not shown).
Identifying Women at Risk
Although a combination of demographic characteristics and clinical problems can be used to identify a group of women at high risk for abuse,3 such an approach makes little practical sense. For example, among women who have inadequate money and significant problems with feelings, 41% (36/89) were likely to have an abusive relationship. However, among the 1025 women with neither financial difficulties nor emotional problems, 64 were at risk for abuse (6%).
Discussion
We found that approximately 13% of women aged 19 to 69 years in 31 practices were identified as being in an abusive relationship by a single written measure. These women had significant psychosocial issues, poor health habits, and many somatic complaints.
Our descriptive study of screening for an abusive relationship in women has 4 important implications for clinical practice:
- It reaffirms the prevalence of abuse in office practice settings. In these 31 practices, the median rate of possible abuse was 11%.
- It provides a detailed illustration of the burden of clinical and social illness borne by women in abusive relationships. One other study3 has provided a similar level of detail. Where measures of symptoms were comparable, both studies found similar prevalence ratios for abuse.
- It reminds clinicians that direct inquiry about possible abuse is likely to be much more effective than using a combination of demographic and clinical factors.3,15 Clinical intuition used to select an at-risk woman from a group will be less effective than asking her directly about possible abuse.
- These results add to the growing body of literature that single-item word-and-picture charts that query patients about complex issues are very useful in clinical practice. Such charts have been shown to be valid and reliable for identifying important functional limitations in adults,28,29 depression,33 health and social problems in adolescents,34 and spirituality.35 Because they are single-item they are good for screening, can be easily adapted to other languages, and serve as the foundation for deeper inquiry about physician-patient interaction.33,36 For example, more than one third of the women in these practices felt that their clinician was unaware of important functional limitations or provided poor education about them.
This particular measure for an abusive relationship has face and criterion validity and reasonable reliability. It seems acceptable for use in practice, since 96% of the women who completed a health survey also completed this item. However, it is intentionally not as specific as direct questions about physical abuse such as: “Has your husband, boyfriend, partner/lover hit, kicked, threatened, or otherwise frightened you?”22 The clinicians and women who assisted in the design of the Relationships Chart felt that a screening question would appear less intimidating if it were less specific and did not require a yes or no response. We previously received the same advice from adolescents for inquiring about antisocial behavior and drug abuse.34 The pictures add to the appeal of the Dartmouth COOP Charts but do not seem to influence responses.37
The validation study (comparing response categories to another instrument) and the results illustrated in the Table (comparing functional and symptomatic impacts by response categories) indicate that a woman who says that she has experienced an abusive relationship at least some of the time in the past 4 weeks probably is experiencing abuse. For those women who screen positive, more direct inquiry is indicated about the nature of the abuse.
If clinicians do not actively screen but choose to wait for a woman in an abusive relationship to declare herself, the data suggest that she may enter a labyrinth of nonspecific complaints and increased utilization of services. If clinicians actively inquire about abuse, short-term demands for accurate documentation and effective referral will have to be met,20-22 and the longer-term benefit to the patient and clinician may be considerable.
Conclusions
Domestic abuse is a prevalent and important problem for women, and simple measures can detect domestic abuse in community practice. It is necessary to think of abuse when some functional and symptomatic issues are present, but that alone is not sufficient. Direct inquiry will be more effective. The symptoms and functional problems of these women may be erroneously evaluated unless the domestic abuse is detected.
Acknowledgments
We thank and acknowledge the physician practice sites that participated in our project: Baylor College of Medicine, Houston, Tex; Berlin Health System, Green Bay, Wis; Beth Israel Deaconess Medical Center, Boston, Mass; Cambridge Health Alliance, Cambridge, Mass; Dana Farber Cancer Institute, Boston, Mass; Federation of Swedish County Councils/Sweden Anderstop Health Center, Greater Lawrence Family Health Center, Lawrence, Mass; Harvard University Health Services, Cambridge, Mass; Independent Health: Buffalo Medical Group, Tonawanda Medical Associates, Buffalo, NY; Joslin Diabetes Center, Boston, Mass; Lathem Medical Group, Lathem, NY; Magic Valley Health Center, Twin Falls, Idaho; Mayo Health System: Luther Midelfort, Eau Clair, Wis, and Mayo Clinic Scottsdale, Ariz; Medical University of South Carolina, Charleston, SC; MeritCare, Fargo, ND; PeaceHealth, Eugene, Ore; PennState Geisinger Health System, Pa; Scripps Clinic, La Jolla, Calif; SSM Health System, St. Louis, Ohio; Dean Health System, Madison, Wis; St. Mary’s Health System, Jefferson City, Mo; Strong Health, University of Rochester, Rochester NY; and ThedaCare, Appleton, Wis.
1. Gin NE, Rucker L, Fryne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.
2. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
3. McCauley J, Kern DE, Kolodner K, et al. The “battering syndrome”: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123:737-46.
4. Johnson M, Elliott BA. Domestic violence among family practice patients in midsized and rural communities. J Fam Pract 1997;4:391-400.
5. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-31.
6. Bergman B, Brismar B. A 5-year follow-up study of 117 battered women. Am J Pub Health 1991;81:1486-89.
7. Briere J, Zaidi LY. Sexual abuse histories and sequalae in female psychiatric emergency room patients. Am J Psychiatry 1989;146:1602-06.
8. Pribor EF, Yutzy SH, Dean T, Wetzel RD. Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993;150:1507-11.
9. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75-80.
10. Walker EA, Katon WJ, Hansom J, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658-64.
11. Walker EA, Katon WJ, Roy-Byrne PP, Jemelka RP, Russo J. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatry 1993;150:1502-06.
12. Jaffe P, Wolfe DA, Wilson S, Zak L. Emotional and physical health problems of battered women. Can J Psychiatry 1986;31:625-29.
13. Briere J, Runtz M. Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 1988;12:51-59.
14. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women’s mental health. Lancet 1988;1:841-45.
15. Drossman DA, Talley NJ, Leserman J, Olden KW, Barreiro MA. Sexual and physical abuse and gastrointestinal illness. Ann Intern Med 1995;123:782-94.
16. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 1987;27:310-14.
17. Haber JD, Roos C. Effects of spouse abuse in the development and maintenance of chronic pain in women. Adv Pain Res 1985;9:339-95.
18. Reiter RC, Shakerin LR, Gambone DO, Milburn AK. Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 1991;165:104-09.
19. Schei B, Bakketeig LS. Gynaecological impact and sexual and physical abuse by spouse: a study of a random sample of Norwegian women. Br J Obstet Gynaecol 1989;96:1379-83.
20. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-92.
21. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800-02.
22. Alpert EJ. Violence in intimate relationships and the practicing internist: new “disease” or new agenda? Ann Intern Med 1995;123:774-81.
23. Sugg NK, Inui T. Primary care physicians’ responses to domestic violence. JAMA 1992;267:3157-60.
24. Hess AMR, Nelson EC, Johnson DJ, Wasson JH. Building an idealized measurement system to improve clinical office practice performance. Managed Care Q 1999;7:22-34.
25. Shepard MF, Campbell JA. The abusive behavior inventory: a measure of psychological and physical abuse. J Interpersonal Violence 1992;7:291-305.
26. Hudson WW, McIntosh SR. The assessment of spouse abuse: two quantifiable dimensions. J Marriage Fam 1981;873-88.
27. Fieldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
28. Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP functional health assessment charts: brief measures for clinical practice. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia, Pa: Lippincott-Raven Press; 1996;161-68.
29. Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patients: how can it be measured in physicians’ offices? Med Care 1990;28:1111-26.
30. Nunnally JC. Psychometric theory. New York, NY: McGraw-Hill; 1978.
31. Wasson JH, Jette AJ, Johnson DJ, Mohr JJ, Nelson EC. A replicable and customizable approach to improve ambulatory care and research. J Ambulatory Care Management 1997;20:17-27.
32. Wasson JH, Stukel TA, Weiss JE, Hays RD, Jette AM, Nelson EC. A randomized trial of using patient self-assessment data to improve community practices. Effective Clin Pract 1999;2:1-10.
33. Wasson JH, Keller A, Rubenstein LV, Hays RD, Nelson EC, Johnson D. and the Dartmouth Primary Care COOP. Benefits and obstacles of health status assessment in ambulatory settings: the clinician’s point of view. Med Care 1992;30(suppl):MS42-49.
34. Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau P. A short survey for assessing health and social problems of adolescents. J Fam Pract 1994;38:489-94.
35. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and health experiences. Fam Med 1998;30:122-26.
36. Magari ES, Hamel MB, Wasson JH. An easy way to measure quality of physician-patient interactions. J Ambulatory Care Management 1998;21:27-33.
37. Larson CO, Hays RD, Nelson EC. Do the pictures influence scores on the Dartmouth COOP charts? Qual Life Res 1992;1:247-49.
1. Gin NE, Rucker L, Fryne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22.
2. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
3. McCauley J, Kern DE, Kolodner K, et al. The “battering syndrome”: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123:737-46.
4. Johnson M, Elliott BA. Domestic violence among family practice patients in midsized and rural communities. J Fam Pract 1997;4:391-400.
5. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-31.
6. Bergman B, Brismar B. A 5-year follow-up study of 117 battered women. Am J Pub Health 1991;81:1486-89.
7. Briere J, Zaidi LY. Sexual abuse histories and sequalae in female psychiatric emergency room patients. Am J Psychiatry 1989;146:1602-06.
8. Pribor EF, Yutzy SH, Dean T, Wetzel RD. Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993;150:1507-11.
9. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75-80.
10. Walker EA, Katon WJ, Hansom J, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658-64.
11. Walker EA, Katon WJ, Roy-Byrne PP, Jemelka RP, Russo J. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatry 1993;150:1502-06.
12. Jaffe P, Wolfe DA, Wilson S, Zak L. Emotional and physical health problems of battered women. Can J Psychiatry 1986;31:625-29.
13. Briere J, Runtz M. Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 1988;12:51-59.
14. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women’s mental health. Lancet 1988;1:841-45.
15. Drossman DA, Talley NJ, Leserman J, Olden KW, Barreiro MA. Sexual and physical abuse and gastrointestinal illness. Ann Intern Med 1995;123:782-94.
16. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 1987;27:310-14.
17. Haber JD, Roos C. Effects of spouse abuse in the development and maintenance of chronic pain in women. Adv Pain Res 1985;9:339-95.
18. Reiter RC, Shakerin LR, Gambone DO, Milburn AK. Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 1991;165:104-09.
19. Schei B, Bakketeig LS. Gynaecological impact and sexual and physical abuse by spouse: a study of a random sample of Norwegian women. Br J Obstet Gynaecol 1989;96:1379-83.
20. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-92.
21. Flitcraft A. From public health to personal health: violence against women across the life span. Ann Intern Med 1995;123:800-02.
22. Alpert EJ. Violence in intimate relationships and the practicing internist: new “disease” or new agenda? Ann Intern Med 1995;123:774-81.
23. Sugg NK, Inui T. Primary care physicians’ responses to domestic violence. JAMA 1992;267:3157-60.
24. Hess AMR, Nelson EC, Johnson DJ, Wasson JH. Building an idealized measurement system to improve clinical office practice performance. Managed Care Q 1999;7:22-34.
25. Shepard MF, Campbell JA. The abusive behavior inventory: a measure of psychological and physical abuse. J Interpersonal Violence 1992;7:291-305.
26. Hudson WW, McIntosh SR. The assessment of spouse abuse: two quantifiable dimensions. J Marriage Fam 1981;873-88.
27. Fieldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
28. Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP functional health assessment charts: brief measures for clinical practice. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia, Pa: Lippincott-Raven Press; 1996;161-68.
29. Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patients: how can it be measured in physicians’ offices? Med Care 1990;28:1111-26.
30. Nunnally JC. Psychometric theory. New York, NY: McGraw-Hill; 1978.
31. Wasson JH, Jette AJ, Johnson DJ, Mohr JJ, Nelson EC. A replicable and customizable approach to improve ambulatory care and research. J Ambulatory Care Management 1997;20:17-27.
32. Wasson JH, Stukel TA, Weiss JE, Hays RD, Jette AM, Nelson EC. A randomized trial of using patient self-assessment data to improve community practices. Effective Clin Pract 1999;2:1-10.
33. Wasson JH, Keller A, Rubenstein LV, Hays RD, Nelson EC, Johnson D. and the Dartmouth Primary Care COOP. Benefits and obstacles of health status assessment in ambulatory settings: the clinician’s point of view. Med Care 1992;30(suppl):MS42-49.
34. Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau P. A short survey for assessing health and social problems of adolescents. J Fam Pract 1994;38:489-94.
35. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and health experiences. Fam Med 1998;30:122-26.
36. Magari ES, Hamel MB, Wasson JH. An easy way to measure quality of physician-patient interactions. J Ambulatory Care Management 1998;21:27-33.
37. Larson CO, Hays RD, Nelson EC. Do the pictures influence scores on the Dartmouth COOP charts? Qual Life Res 1992;1:247-49.