The Epidemiology of Domestic Violence

Thomas Songer, PhDCristie Glasheen, MPHUniversity of Pittsburgh

Key Points

1. What is being measured?

2. What is NOT being measured?

3. How does this affect the results?

Definition of Violence

How would you define domestic violence?

…...To understand violence, you need to define violence

Defining Domestic ViolenceDefining Domestic Violence

• domestic violencedomestic violencenoun:noun: violence committed by one member  violence committed by one member of a family or household against anotherof a family or household against another

• The National Research Council defines The National Research Council defines violence as:violence as:

- behaviour by individuals that - behaviour by individuals that intentionally threaten, attempt, or inflict intentionally threaten, attempt, or inflict physical harm on others physical harm on others

Who is Affected by Domestic Violence?Who is Affected by Domestic Violence?

• ChildrenChildren

• Intimate Partners (IP)Intimate Partners (IP)

• EldersElders

Data SourcesData Sources

You are planning to do a study of domestic You are planning to do a study of domestic violence using pre-existing data.violence using pre-existing data.

Where would you look?Where would you look?

• Medical sourcesMedical sources• State sources State sources

• Government surveysGovernment surveys

Which surveillance system is likely to provide the best

estimates for domestic violence?

Surveillance in Domestic Violence• Hospital Admissions

• Trauma Center Admissions

• Emergency Department Admissions

• State-based Reporting Systems

• Government Surveys– National Criminal Victimization Survey– National Incidence Survey– Behavioral Risk Factor Survey– National Violence Against Women Survey

Medical SourcesMedical Sources

• Hospital RecordsHospital Records

• Trauma Center Trauma Center RecordsRecords

• Emergency Emergency DepartmentDepartment

Recommended: Rudman WJ. Coding and Documentation of Domestic Violence.December, 2000. Available at: http://endabuse.org/programs/healthcare/files/codingpaper.pdf

Definition of Health Care Events Related to Domestic Violence

• Based on N-codes and E-codes– 995.80 to 995.85 adult physical abuse

– 995.50 child abuse

– E coding to distinguish domestic violence is relatively poor

– E967.x

State Based ReportingState Based Reporting

• State-based ReportingState-based Reporting– Child Protective ServicesChild Protective Services

– Uniform Crime ReportsUniform Crime Reports

– National Incident-Based Reporting System National Incident-Based Reporting System (NIBRS)(NIBRS)

– Supplementary Homicide Report (SHR)Supplementary Homicide Report (SHR)

State-based Programs Related to Domestic Violence

• Based on reporting to state agencies– most frequently for child maltreatment

– definition of violence is not standard across the states

– reporting is subject to knowledge of the issues to medical, educational, and legal personnel

Government SurveysGovernment Surveys

• Government SurveysGovernment Surveys– National Crime Victimization Survey (NCVS)National Crime Victimization Survey (NCVS)

– National Violence Against Women Survey (NVAW)National Violence Against Women Survey (NVAW)

Surveys Related to Domestic Violence

• Self-report of violence based upon interviews– Aside from the NCVS, these surveys are

not regularly collected

– Definition of violence in surveys is not standard

– There may be extensive under-reporting of violence

What do we know aboutChild Maltreatment?

Epidemiology of Child AbuseEpidemiology of Child Abuse

• Maltreatment Maltreatment – ““behavior towards another person, which a) is outside behavior towards another person, which a) is outside

the norms of conduct, and b) entails a substantial risk the norms of conduct, and b) entails a substantial risk of causing physical or emotional harm” of causing physical or emotional harm”

» Physical AbusePhysical Abuse» Sexual AbuseSexual Abuse» Emotional & Psychological AbuseEmotional & Psychological Abuse» NeglectNeglect

Types of Maltreatment• Physical abuse: physical acts by a parent, guardian

or caretaker that caused physical injury to the child.• Neglect (including medical neglect): the failure by

the caretaker to provide needed, age-appropriate care (or provide for the health care) of the child.

• Sexual abuse: the involvement of a child in incest, or sexual assault by a relative or caretaker, includes fondling and exposure to indecent acts.

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

76 78 80 82 84 86 88 90 92 94

Substantiated Cases of Child Maltreatment,Pennsylvania, 1976-1994

The Pyramid of Child Maltreatment in Pennsylvania, 1994

53 deaths

33 head injuries

56 trauma center admissions

177 hospital admissions

2115 ED visits

7,038 substantiated cases

64,560 maltreatment events

What do we know about Violence Against Women?

Terminology of IPVTerminology of IPV

• Intimate Partner Violence (IPV) – relatively new term

• Also called: domestic violence, domestic abuse, spousal abuse, battery, violence against women

Who is an intimate?NCVS SHR NVAWS

Spouse Husband/wife Spouse

Ex-spouse Ex-husband/ex-wife Ex-spouse

Common-law husband or wife

Cohabitating partner

Boyfriend/girlfriend Boyfriend/girlfriend Boyfriend/girlfriend

Ex-boyfriend/ex-girlfriend

Same sex relationship Same sex relationship

Date

Study SampleSize Definition and Method Trauma

from AbuseOne year

PrevalenceLifetime

Prevalence

McCauley 1952Physical and sexual abuse reportedin physician practices 5.5% 33%

Gin 453Physical and sexual abuse and

threats by current partner reportedin internal medicine clinics

14% 28%

Goldberg 492Physical abuse reported in an urbanemergency department 22%

Dearwater 3455Physical or sexual abuse reported incommunity hospital emergency

departments2.2% 14.4% 36.9%

McLeer 412Physical abuse identified in traumapatients in urban emergency

department30%

Abbott 648Physical abuse or threats reported inurban, acute care emergencydepartments and clinics

2.7% 15.3% 54.2%

Muelleman 9057Physical trauma identified in tenemergency departments 3.1%

Estimates of the Frequency of Domestic Violence Against Women seen in Medical Settings

IPVIPV

Source: American Journal of Preventive MedicineVolume 34, Issue 2, February 2008, Pages 112-118

WHO Multi-country Study on Women’s Health and WHO Multi-country Study on Women’s Health and Domestic Violence against WomenDomestic Violence against Women

960,000 women victimized1992-96 NCVS

50% reported to police

51% had physical injuries

10% sought medical care

7% treated in emergency department

1418 murders

32% not treated for injury

The Pyramid of Violence Against Women, U. S.

Trends in the rates of violent victimizations by intimates*, United States, 1992 - 1996

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2

4

6

8

10

12

1992 1993 1994 1995 1996

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r 1,

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popu

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Females Males

Possible Risk FactorsPossible Risk Factors

• Gender

• Ethnicity

• Socio-Economic Status

• Age ?

• Alcohol ?

• Pregnancy ?

• Psychiatric problems ?

Intimate Partner Violence

What do we know about Elder Abuse?

Research MethodsResearch Methods

You have decided that existing data sources You have decided that existing data sources are not adequate to answer your research are not adequate to answer your research

question.question.

You want to design a new study.You want to design a new study.

What do you need to consider?What do you need to consider?

WhoWho

• Who are you going to measure?Who are you going to measure?

– Victims?Victims?

– Perpetrators?Perpetrators?

What is Your Outcome?What is Your Outcome?

• Physical Injury?Physical Injury?

• Psychological Injury?Psychological Injury?

Physical Injury

• Easiest to identify

• Severity of injury

• What are you missing?– Exposed with no injury

Psychological Injury

• What is the threshold?

• When is it a psychological “bruise” and when is it a “trauma”?

• What does this mean for prevention– Primary– Secondary– Tertiary

What is your exposure?

• Experienced or potential for abuse?

• Officially reported, unreported, or both

• Suspected or confirmed

• Attempts or completions

• Type of exposure– Physical and/or Neglect– Sexual– Emotional

How are You Going to Measure How are You Going to Measure It?It?

Domestic Violence is wrought with Domestic Violence is wrought with ethical considerations unique to this ethical considerations unique to this

field of researchfield of research

Key Lecture Points

• Surveillance for the frequency of domestic violence is not at the same level of development as for other unintentional injuries and for criminal violence

• Several limitations, including differing definitions, poor coding, and under-reporting influence our knowledge of the frequency of domestic violence

• Risk factor analysis in this area is just starting