Surveillance for homicide among intimate partners--United States, 1981-1998.

PROBLEM/CONDITION: A substantial percentage of all homicides in the United States are committed by intimate partners of the victims. Among females, approximately 1 in 3 homicides are intimate partner homicides (IPHs). Intimate partner homicides cannot be tracked by using death certificates because death certificates do not record the victim's relationship to the perpetrator. REPORTING PERIOD COVERED: This report summarizes information regarding IPHs that occurred in the United States during 1981-1998. DESCRIPTION OF THE SYSTEM: This report is based on Supplemental Homicide Reports (SHRs) collected by the Federal Bureau of Investigation (FBI) as part of their Uniform Crime Reporting System. SHRs are filed voluntarily by police departments for homicides occurring within their jurisdiction. SHRs include demographic variables regarding victims and perpetrators, their relationship, and weapon(s) used. Data from the SHR file were weighted by comparison with homicide data from death certificates to compensate for underreporting. IPHs were restricted to victims aged > or = 10 years. RESULTS: The risk for death from IPH among males was 0.62 times the risk among females. However, the rate among black males was 1.16 times the rate among black females. Among racial groups, rates among blacks were highest, and the rates among Asian or Pacific Islanders were lowest. Rates were highest among females aged 20-49 years and among males aged 30-59 years. During the study period, rates among white females decreased 23%, and rates among white males decreased 61.9%. Rates among black females decreased 47.6%, and rates among black males decreased 76.4%. Highest rates occurred in the southern and western states among both white and black females. A graded increase in IPH risk occurred with community population size. Approximately 50% of IPHs were committed by legal spouses and 33% by boyfriends or girlfriends for both male and female victims. IPH rates were less than expected during the months of January, October, and November. INTERPRETATION: Although total homicide rates have fluctuated during 1981-1998, IPH rates have decreased steadily during this period, and among certain subpopulations, the decrease has been substantial. Decreases are temporally associated with the introduction of social programs and legal measures to curb intimate partner violence, but a causal relationship has not been established. Likewise, no confirmed explanation exists for the greater decrease in rates among males compared with rates among females. The differences in IPH rates by race indicate that economic, social, and cultural factors are involved. The analysis by community population size and state demonstrates that regional sociocultural differences might be involved also. Access to firearms might be a key factor in both male and female IPHs. PUBLIC HEALTH ACTIONS: The descriptive epidemiology of IPH is changing rapidly and should continue to be monitored. Understanding the reasons forthe recent decreases in IPHs might help identify methods for primary and secondary prevention and further reduce IPH rates.

Screening for intimate partner violence by health care providers. Barriers and interventions.

INTRODUCTION: Routine screening for intimate partner violence (IPV) is endorsed by numerous health professional organizations. Screening rates in health care settings, however, remain low. In this article, we present a review of studies focusing on provider-specific barriers to screening for IPV and interventions designed to increase IPV screening in clinical settings. METHODS: A review of published studies containing original research with a primary focus on screening for IPV by health professionals was completed. RESULTS: Twelve studies identifying barriers to IPV screening as perceived by health care providers yielded similar lists; top provider-related barriers included lack of provider education regarding IPV, lack of time, and lack of effective interventions. Patient-related factors (e.g., patient nondisclosure, fear of offending the patient) were also frequently mentioned. Twelve additional studies evaluating interventions designed to increase IPV screening by providers revealed that interventions limited to education of providers had no significant effect on screening or identification rates. However, most interventions that incorporated strategies in addition to education (e.g., providing specific screening questions) were associated with significant increases in identification rates. CONCLUSION: Barriers to screening for IPV are documented to be similar among health care providers across diverse specialties and settings. Interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are likely to be more effective if they include strategies in addition to provider education.

Opportunities for intervention: discussing physical abuse during prenatal care visits.

BACKGROUND: The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that screening for physical abuse during prenatal care visits becomes routine. Although prenatal care visits offer a unique intervention opportunity, screening is not yet standard practice. DATA AND METHODS: We used data from the 1996 and 1997 Pregnancy Risk Assessment Monitoring System (PRAMS) to assess the prevalence of and the factors associated with health care providers' discussion of physical abuse with pregnant women in 14 states. PRAMS is a state-specific, population-based surveillance system that collects information from women on maternal behaviors before and during pregnancy, and at 2 to 6 months postpartum. RESULTS: Between 22% and 39% of the women surveyed reported that health care providers talked with them about physical abuse during prenatal care visits. Health care providers were more likely to discuss physical abuse with women who were black, Hispanic, young (aged <20 and 20 to 29), had a high school education or less, or paid for prenatal care with Medicaid. CONCLUSIONS: Our results indicate that most pregnant women do not report that their prenatal care providers discussed physical abuse with them. Logistic regression analyses identified consistent associations across the 14 states between discussion of abuse and demographic and pregnancy-related factors. A better understanding of the factors associated with whether a health care provider discusses physical abuse with a pregnant woman could increase intervention opportunities.

Violence and reproductive health: current knowledge and future research directions.

OBJECTIVES: Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available. METHODS: The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research. RESULTS: Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%-8% of pregnancies): (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes. CONCLUSIONS: Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996-1997. PRAMS Working Group. Pregnancy Risk Assessment Monitoring System.

OBJECTIVE: This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors. METHODS: In 1996-1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2-6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy. RESULTS: Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics, the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester. CONCLUSIONS: Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Future directions for violence against women and reproductive health: science, prevention, and action.

Despite the recognition that violence may be associated with serious consequences for women's reproductive health, the understanding of the relationship between the two remains limited, as does our understanding of the most effective role for reproductive health care providers and services. This paper briefly summarizes the history of the nexus of public health, health care, and violence against women in the United States. In addition, we present some considerations for future directions for research, health care practice, and policy that will advance the understanding of the complex relationship between violence and reproductive health.

Domestic violence and sexual abuse in women physicians: associated medical, psychiatric, and professional difficulties.

Physicians have been called on to identify victims of domestic violence (DV) and sexual abuse (SA). Few data exist, however, on the prevalence of DV and SA in physicians themselves or on the personal or professional sequelae of such experiences. We determined the reported lifetime prevalence of DV and SA among women physicians and the personal characteristics, health-related factors, and work-related factors associated with these forms of abuse. We used data from the Women Physicians' Health Study, a large (n = 4501 respondents), nationally distributed questionnaire study that included questions on DV and SA histories, personal characteristics, and psychiatric, medical, and work-related histories. We compared the characteristics of women physicians with and without histories of DV or SA. The logistic models indicate that women physicians reporting DV histories (3.7% of the population) were significantly (p < 0.05) less likely to be single and significantly more likely to report depression histories, suicide attempts, substance abuse, current or past cigarette smoking, severe daily stress at home, chronic fatigue syndrome, and DV experienced by their mothers. Women physicians reporting SA histories (4.7% of the population) were significantly more likely to be younger than 60 years, identify themselves as homosexual or bisexual, to have specialized in psychiatry, obstetrics and gynecology, or emergency medicine, and to report histories of depression, suicide attempts, eating disorders, and fair or poor perceived health status. Although the reported lifetime prevalence of DV and SA among women physicians is below other reported figures, such experiences are associated with medical and psychiatric difficulties that could negatively affect them personally and professionally.

Epidemiology of injuries among women after physical assaults: the role of self-protective behaviors.

Physical assaults against women result in more than 5,000 deaths and 1 million nonfatal injuries per year in the United States. Data from the National Crime Victimization Survey, 1992-1995, were used to test the association between injury risk and self-protective behaviors, while controlling for victim, offender, and crime-related characteristics. Unlike in prior studies, a self-protective behavior measure that accounted for the temporal sequencing of the occurrence of injuries and self-protective behaviors was used. The study also examined whether the effect of self-protective behaviors varied as a function of victim-offender relationship status. The sample included 3,206 incidents in which females were physically assaulted by a lone male offender within the previous 6 months. Multivariate results revealed that women who used self-protective measures were less likely to be injured than were women who did not use self-protective measures or who did so only after being injured. The effect of self-protective behaviors on risk of injury did not vary as a function of the victim-offender relationship. The inverse association found between self-protective behaviors and injury risk differs from those of previous studies. Owing to inconsistent findings across studies, caution should be used when making recommendations to women regarding whether or not they should use self-protective behaviors during a physical assault.

Intimate partner violence against women: do victims cost health plans more?

BACKGROUND: Previous studies of intimate partner violence have not compared the health care costs of female victims with those of a general female population. METHODS: Our study is an analysis of the computerized cost data for 126 identified victims of intimate partner violence in a large health plan in Minneapolis and St. Paul, Minnesota, in 1994. Data were compared with a random sample of 1007 general female enrollees (aged 18 to 64 years) who used health care services in the same year. RESULTS: We found that an annual difference of $1775 more was spent for victims of intimate partner violence than on a random sample of general female enrollees. Regression analyses found that victims of intimate partner violence were significantly younger and had more hospitalizations, general clinic use, mental health services use, and out-of-plan referrals. Use of emergency room services was the same across groups. CONCLUSIONS: Women who were victims of intimate partner violence cost this health plan approximately 92% more than a random sample of general female enrollees. Contrary to the findings of other studies, use of emergency room services was not a driving factor in the higher costs. Findings of significantly higher mental health service use are supported by other studies.

Massachusetts Weapon-Related Injury Surveillance System.

CONTEXT: Surveillance data on nonfatal weapon-related injuries--particularly those treated only in the emergency department (ED)--have been largely unavailable. OBJECTIVE: To develop a surveillance system for fatal and nonfatal gunshot wounds and sharp instrument assaults. DESIGN: The Massachusetts Department of Public Health (DPH) developed an ED-based reporting system for weapon-related injuries. Inpatient discharges and mortality data were linked to ED data, and police data sources were evaluated. SETTING: Statewide. PARTICIPANTS: All 84 acute care hospital emergency departments. Uniform Hospital Discharge Data Set (UHDDS), mortality, and police data were obtained from existing systems. MAIN OUTCOME MEASURES: System sensitivity, predictive value positive (PVP), representativeness, flexibility, usefulness, acceptability, and sustainability. RESULTS: The ED reporting system captured 82% of firearm-related injuries and 74% of reportable sharp instrument wounds from 1994 to 1996. Case reporting by demographic characteristics of the victim was representative and largely complete. Reporting by characteristics of the incident (e.g., type of gun) was less reliable. Police data were used to augment the system. From 1994 to 1996, ED-treated gunshot wounds dropped 41%, from 662 in 1994 to 393 in 1996. Unintentional and self-inflicted gunshot wounds showed no declines. For every firearm-related homicide, 4.7 nonfatal firearm assaults were treated; 85% of self-inflicted gunshot wounds were fatal. CONCLUSIONS: The system has proven timely (1996 ED data were available for release in March 1997), flexible (the reporting form has been revised several times), useful (DPH responds to 150 weapon injury data requests annually), acceptable (reporting is voluntary and no hospital declined participation), and sustainable (state funding is currently supporting the ED reporting system).

Recommended data elements for firearm-related injury surveillance.

During 1994, the Centers for Disease Control and Prevention (CDC) funded seven states to develop and evaluate surveillance systems for firearm-related injuries. In addition, New York City and California had related experience with firearm-related injury surveillance. At the time these nine jurisdictions began developing their surveillance systems, no standardized definitions or recommendations were available about the best methods or procedures of collecting data or suggested data elements of a firearm-related injury surveillance system. The nine jurisdictions and CDC developed a list of recommended data elements (RDEs) for fatal and nonfatal firearm-related injuries. We describe the process used to develop the RDEs, the 21 data elements suggested by the funded projects, the data sources that may be able to provide those data elements, and an indication of which sources may be most useful. We encourage all developing surveillance systems to strive to include these data elements, although some of the elements will be more easily attainable for fatal injury events than nonfatal ones, and no single data source will be able to provide all the desired information about both morbidity and mortality from firearm-related injuries. The RDEs capitalize on the preliminary experiences of the small group of jurisdictions, but they need to be pilot tested and revised as we collect more information about how well these elements capture the desired information and whether the information obtained is useful.

Violence during pregnancy: measurement issues.

OBJECTIVES: Standardized quantitative methods are needed to study occurrence and timing of violence in relation to pregnancy and to study the context in which pregnancy-related violence occurs. METHODS: Data from three published studies of prevalence of violence during pregnancy are used to illustrate ways to measure the association of violence in relation to pregnancy. RESULTS: Four patterns of violence in relation to pregnancy are identified, and related research issues are discussed. Also, 2 population-based surveys that address the suggestions presented here are discussed. CONCLUSIONS: Better measurement of the association between violence and pregnancy will facilitate development of data-based prevention and intervention programs.

Violence and adverse pregnancy outcomes: a review of the literature and directions for future research.

INTRODUCTION: Violence during pregnancy has been estimated to affect between 0.9% and 20.1% of pregnant women in the United States. This article presents a review of the research on the potential association between violence during pregnancy and adverse outcomes, explores mechanisms by which violence might influence pregnancy outcomes, and suggests directions for future research aimed at the development of successful interventions. METHODS: A review of the literature pertaining to violence during pregnancy and adverse pregnancy outcomes, trauma, and stress during pregnancy was completed. RESULTS: Overall, no pregnancy outcome was consistently found to be associated with violence during pregnancy. The trauma literature offers insight about the effects that injuries caused by physical violence might have on pregnancy outcomes. Information from the stress literature investigates potential mechanisms through which physical violence could indirectly affect pregnancy outcomes. The trauma and stress literature offers methodologic approaches that could be employed in future research on violence during pregnancy and pregnancy outcomes. CONCLUSIONS: This review lays the groundwork for the development of a future research agenda to investigate the association between violence during pregnancy and adverse outcomes. Future research should include quantitative and qualitative approaches, and investigation into the mechanisms and antecedents of how violence during pregnancy may lead to adverse outcomes. Only with such information can successful interventions to limit violence and its potential effects during pregnancy be implemented.

Behavioral science activities at the Centers for Disease Control and Prevention. A selected overview of exemplary programs.

Behavioral research and surveillance activities are conducted across the Centers for Disease Control and Prevention (CDC). This article highlights activities in 4 program areas: violence against women, tuberculosis elimination, HIV prevention, and occupational health. The unique constraints and opportunities of each organization and program focus have shaped the way research has developed in each of these areas. Behavioral scientists also face many common challenges at CDC. Despite the difficulties of integrating behavioral research into an institution that historically has focused on biomedical and epidemiological research, behavioral scientists have made important contributions to public health. Many opportunities remain for psychologists to translate theory and operationalize constructs for use in solving important public health problems.

Prevalence of violence against pregnant women.

OBJECTIVES: To summarize the methods and findings of studies examining the prevalence of violence against pregnant women and to synthesize these findings by comparing study characteristics for studies with similar and dissimilar results. DATA SOURCES: MEDLINE, POPLINE, Psychological Abstracts, and Sociological Abstracts databases were searched for all articles pertaining to violence during pregnancy for the period 1963 through August 1995. STUDY SELECTION: Thirteen studies were selected on the basis of specific criteria: a sample with initially unknown violence status; a clear statement of research question(s), with focus on measuring the prevalence of violence; descriptions of the sample, data source, and data collection methods; and data from the United States or another developed country. DATA EXTRACTION: Relevant data were extracted to compare studies by study description, methods, and results. DATA SYNTHESIS: Evidence from the studies we reviewed indicates that the prevalence of violence during pregnancy ranges from 0.9% to 20.1%. Measures of violence, populations sampled, and study methods varied considerably across studies, and these factors may affect prevalence estimates. Studies that asked about violence more than once during detailed in-person interviews or asked later in pregnancy (during the third trimester) reported higher prevalence rates (7.4%-20.1%). The lowest estimate was reported by women who attended a private clinic and responded to a self-administered questionnaire provided to them by a person who was not a health care provider. CONCLUSIONS: Violence may be a more common problem for pregnant women than some conditions for which they are routinely screened and evaluated. Future research that more accurately measures physical violence during pregnancy would contribute to more effective design and implementation of prevention and intervention strategies.

CDC's family and intimate violence prevention team: basing programs on science.

Women are frequent targets of both physical and sexual assault not only by strangers, but by partners and acquaintances as well. The public health approach to violence, including violence against women, focuses on prevention rather than treatment and is science based. Its steps include defining the problem, identifying causes, developing and testing interventions, and then implementing interventions and measuring their effectiveness. The Family and Intimate Violence Prevention Team in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention uses the public health approach to address the prevention of violence against women. We describe here some of the team's major activities and show how these activities will add to the scientific database on violence against women.

The relationship between pregnancy intendedness and physical violence in mothers of newborns. The PRAMS Working Group.

OBJECTIVE: To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. METHODS: Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. RESULTS: The state-specific prevalences (+/- standard error) of physical violence ranged from 3.8 +/- 0.5 to 6.9 +/- 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9-46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7-6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. CONCLUSION: Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

Self-reported childhood and adolescent sexual abuse among adult homosexual bisexual men.

From May 1989 through April 1990, 1,001 adult homosexual and bisexual men attending sexually transmitted disease clinics were interviewed regarding potentially abusive sexual contacts during childhood and adolescence. Thirty-seven percent of participants reported they had been encouraged or forced to have sexual contact before age 19 with an older or more powerful partner; 94% occurred with men. Median age of the participant at first contact was 10; median age difference between partners was 11 years. Fifty-one percent involved use of force; 33% involved anal sex. Black and Hispanic men were more likely than white men to report such sexual contact. Using developmentally-based criteria to define sexual abuse, 93% of participants reporting sexual contact with an older or more powerful partner were classified as sexually abused. Our data suggest the risk of sexual abuse may be high among some male youth and increased attention should be devoted to prevention as well as early identification and treatment.