What distinguishes unintentional injuries from injuries due to intimate partner violence: a study in Greekambulatory care settings E Petridou, A… [603576]

ORIGINAL ARTICLE
What distinguishes unintentional injuries from injuries
due to intimate partner violence: a study in Greekambulatory care settings
E Petridou, A Browne, E Lichter, X Dedoukou, D Alexe, N Dessypris
……………………………………………………………………………………………………………..
Injury Prevention 2002; 8:197–201
Objectives: Intimate partner violence (IPV) is an important sociocultural and public health problem.
This study aims to assess sociodemographic and injury characteristics of IPV victims among adults in a
traditional southern European population.Setting: Accident and emergency departments of three sentinel hospitals in Greece participating in the
Emergency Department Injury Surveillance System (EDISS).Methods: Data on sociodemographic variables, as well as event and injury characteristics were
retrieved from the EDISS database during the three year period 1996–98. Out of a total of 27 319injured women aged 19 years or more, 312 (1.1%) were reported as IPV related and were comparedwith 26 466 women with unintentional injuries. Among the 35 174 men with injuries 39 (0.1%) werereported as IPV related and were compared with 34 049 men with unintentional injuries. The datawere analyzed through simple cross tabulations and multiple logistic regression. Positive predictedvalues for selected injury characteristics were also calculated.Results: IPV is more common in rural than in urban areas of Greece. Women are 10 times more fre-
quently IPV victims but men are also IPV victims; younger women and older men are disproportionatelyaffected by IPV. The relative frequency of the phenomenon increases during the late evening and nighthours. Certain types of injuries, notably multiple facial injuries, and presentation of the injured personon his/her own at the emergency department or combinations of predictive characteristics are stronglyindicative of IPV.Conclusions: Injuries due to IPV are not uncommon in Greece, not withstanding the traditional struc-
ture of the society and the tendency of under-reporting. Certain injury characteristics have high positivepredictive values and could be used in screening protocols aiming at the correct identification of theunderlying external cause in injuries that may be caused by IPV.
Violence between intimate partners is an important but
underdiagnosed sociocultural, legal, and public healthproblem. Intimate partner violence (IPV)—defined here
as physical aggression between couples in marital or intimaterelationships—affects adults of all ages, nationalities, andsocioeconomic levels. IPV has a short and long term impact onthe physical, emotional, and social wellbeing of victims and per-petrators, even if the violence is hidden from the rest of theworld.
1
Detection and appropriate care for injuries due to IPV is criti-
cal for the long term physical and mental health of patients.Health professionals, especially those involved in primaryhealth care, have the opportunity to act as crucial links betweenpersons who experience IPV and medical and community basedresources. However, there is evidence that diagnosis of IPV inprimary health care settings is quite low compared with itsfrequency.
23Patients’ disclosure rates in medical settings are
not representative of the magnitude of the problem. The short-age of time to provide care, combined with health careproviders’ reluctance to investigate family issues in patients’lives, also contributes to the lack of accurate documentation ofintimate partner abuse.
4Skill training for health professionals,
supported by implementation of focused screening tools for the
identification of cases, may be a promising preventive strategy.
In recent years, new awareness of the health consequences of
partner violence has resulted in an increased emphasis byhealth care providers in some countries on identifying injuriesresulting from such violence. The authors of this articlerecognize the need for a similar effort in Greece and othercountries in the European Union. In Greece, although there issome evidence that violent family relationships exist, they arenot a topic of public discussion and protocols designed to iden-tify IPV in health care settings have not been developed. Thestudy reported here is an attempt to describe cases presentingwith injuries reported as due to partner violence in urban andrural health settings.
The goal of these analyses is to identify sociodemographic
and injury characteristics of individuals presenting to accidentand emergency departments in Greece as victims of physicalIPV . The study is based on data from the EmergencyDepartment Injury Surveillance System (EDISS).
5The immedi-
ate objectives are to calculate positive predictive values ofparticular manifestations and identify characteristics with highpredictive values as markers indicating likely partner abuse.
METHODS
Established in 1986 by the European Union, the EuropeanHome and Leisure Accident Surveillance System (EHLASS)collects data on injuries diagnosed in accident and emergencydepartments in hospitals. At present, 13 out of 15 memberstates of the European Union participate in EHLASS, withsome variations in data collection methods, whereas the othertwo countries use data from household surveys. In Greece theEDISS is run by the Greek Center for Research and Preventionof Injuries among the Y oung and collects data on all ages and
…………………………………………………….
Abbreviations: CI, confidence interval; EDISS, Emergency Department
Injury Surveillance System; EHLASS, European Home and Leisure
Accident Surveillance System; IPV, intimate partner violence; OR, oddsratioSee end of article for
authors’ affiliations
…………………..
Correspondence to:Dr Eleni Petridou, AssociateProfessor of Epidemiology,Department ofEpidemiology, AthensUniversity Medical School,75 Mikras Asias Str,Athens 11527, Greece;epetrid@med.uoa.gr
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all types of injuries. Four hospitals were chosen as EDISS data
collection sites. Two of them are located in the Greater Athensarea; one is a major trauma hospital and the other is achildren’s teaching hospital, which obviously did not contrib-ute data for the present analyses. Injury data representing therural areas of the country are collected from two district hos-pitals, one on the island of Corfu and the other in MagnesiaCounty on the mainland. All participating hospitals have resi-dency programs. The Trauma Hospital in Athens, being one ofthe two major trauma hospitals in the Greater Athens area, islikely to capture a representative sample of injury cases. Withrespect to the rural areas, a validation against the NationalStatistical Service of Greece hospital discharge trauma datadid not indicate any sharp deviation from representativeness.
Analyses for this study were based on injury data from
women and men over 19 years of age, collected during a three
year period from 1996–98. Specially trained health visitors, whoare equivalent to registered nurses in the United States,conducted in-person interviews with all individuals whopresented at accident and emergency departments of theTrauma Hospital in Athens and the two district hospitals, usinga standardized questionnaire. All 62 493 cases of intentionaland unintentional injuries, who contacted the emergencydepartments of the participating hospitals during the studyperiod, were interviewed in person by our trained health visitorsin the presence of the attending physician. Each interviewlasted for about seven minutes, but when IPV was suspected,the interviewee was encouraged to discuss freely her/hisproblem. The questions probed IPV by focusing on themechanism of injury and in particular, whether another personwas involved in the causation of injury. We did not useestablished IPV screening instruments because the objective ofthe study was to explore the potential of an existing injury sur-veillance system to identify and assess the dimensions of theIPV issue before undertaking more specialized studies. There-fore, we do not claim that our study meets the requirements ofa formal IPV screening program. Fewer than 1% of all eligiblepersons were not interviewed in the emergency departmentbecause of technical or administrative problems and none of theinjured persons refused to collaborate, because EDISS isintegrated in the routine functions of the emergency depart-ments of the participating hospitals. We have avoided the use ofproxy responders, except in rare circumstances (less than 2%),of mainly critically ill patients, who, in any case, are also inter-viewed in the wards. Information on sociodemographic features(gender, age, nationality), event characteristics (place, condi-tions, time), and nature of injury (type of injury, injured bodypart, number of injuries) were gathered. Three categories ofinjuries were subsequently created: (1) physical injuriesreported to have been inflicted by an intimate partner, irrespec-tive of current cohabitation with the perpetrator; (2) injuriesdue to all other types of interpersonal violence; and (3)unintentional injuries.
The statistical analyses were conducted using the SAS
program. Preliminary analyses involved simple cross tabula-tions. Subsequently, the data were modeled through multiplelogistic regression in order to control for mutual confounding
among variables routinely collected in this surveillance systemand to calculate adjusted odds ratios for a variety of characteris-tics. Type of injury and injured body part were alternativelyintroduced in the core model to avoid colinearity problemsbetween these two variables. The decision was made to compareintimate partner related injuries with unintentional injuries,because intentional injuries have their own specific manifesta-tion pattern. Thus, odds ratios reflect the likelihood that aninjury was due to intimate partner violence rather than anunintentional cause. Separate analyses by gender were con-ducted because the epidemiological pattern of intimate partnerinjuries among women is very different from that among men.Findings were considered significant at p<0.05. Finally, positivepredictive values for IPV were calculated for injuries of specificcharacteristics. Positive predictive values are calculated by
dividing the number of IPV injuries of certain characteristic(s)by the total number of injuries of the same characteristics (thetotal includes IPV injuries and unintentional injuries). Charac-teristics associated with high predictive values can be used asindicators of IPV , even when such information has not beenforthcoming from the injured person.
RESULTS
During the three year period of the study, 62 493 cases ofintentional and unintentional injuries were recorded. Ofthese, 312 among women (1.1% of injured women) and 39among men (0.1% of injured men) were reported as caused byIPV . During the same period 26 466 women and 34 049 menreported injuries attributed to unintentional causes, whereas541 women (2.0% of injured women) and 1086 men (3.1% ofinjured men) reported injuries due to violence inflicted byindividuals other than their intimate partners. Table 1(women) and table 2 (men) provide frequency distributions ofpersons with injuries caused by IPV and persons withunintentional injuries by sociodemographic variables, timeand place of the injury causing event, and injury characteris-tics. These tables provide a descriptive overview, but do notreveal the independent association of IPV with injuries of spe-cific characteristics, because of mutual confounding amongthe studied variables. Mutually adjusted findings for womenand men are presented in tables 3 and 4, respectively.
Findings related to women (table 1)
Nearly half of the women reporting an injury due to IPV wereaged 30–39 and over one fifth were less than 30 years of age.The large majority of injuries to women identified as resultingfrom IPV occurred at home (87%). Over half occurred betweenthe hours of 2 pm and 10 pm (54%) and nearly three quarterswere inflicted on a weekday (72%). Most of partner violenceinjuries identified in women were to the head and face (62%)and most presented at the hospital with multiple injuries(60%). The majority of women’s injuries due to IPV were con-tusions or open wounds (72%), whereas nearly one fifth (18%)of injuries were concussions; there were 4% fractures andanother 5% were dislocations.
Findings related to men (table 2)
Nearly one third of men who reported injuries by intimatepartners were in their 30s (31%), 36% were aged 40–60, andonly 10% were under the age of 30. As among women, thelarge majority of men’s IPV injuries also occurred at home(90%). Over half of male IPV injuries occurred between thehours of 2 pm and 10 pm (59%) and over half were located inthe head and face (62%). Injuries sustained by men consistedmostly of contusions (87%) and no man suffered a fracture ordislocation because of IPV .
Comparisons between IPV and unintentional injuries
Table 3 (women) and table 4 (men) provide multiple logisticregression derived adjusted odds ratios (ORs) and 95% confi-dence intervals (CIs).
Findings related to women (table 3)
Injuries reported by women aged 30–39 were more than twiceas likely to be due to IPV than to unintentional injury, whencompared with the reference category of women aged 40–49(OR 2.32; 95% CI 1.64 to 3.27). The likelihood that an injury wasdue to intimate partner violence declined sharply after the ageof 50. IPV was more than four times as likely to be reported asthe cause of injury by women in rural areas as by women inurban areas (OR 4.35; 95% CI 3.00 to 6.32). However, Greekwomen were not more likely than women of other nationalitiesliving in Greece to report IPV related injuries.
In reports by women, day of the week and season of the year
were not significantly related to injuries resulting from IPV ,although the likelihood of injury due to IPV was higher during198 Petridou, Browne, Lichter, et al
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the night hours than during the day hours. Women who came
to the emergency medical departments alone were more thanfour times as likely as women transferred to emergencydepartments by ambulance or brought by another person toreport that their injuries were due to IPV (OR 4.75; 95% CI3.59 to 6.28). Women with multiple injuries were 15 timesmore likely to report IPV as the cause of their injury as werewomen who presented at the emergency departments with asingle injury (OR 15.15; 95% CI 11.61 to 19.77). Injuriescaused by IPV were, as indicated, concentrated in the brain,skull, and facial region. The odds that injuries in these regions(compared with the reference category, upper and lowerlimbs) were due to IPV rather than unintentional causeexceeded the value of 13.
Findings related to men (table 4)
In contrast to women, age was not significantly related to IPV
injuries among men, and injuries due to IPV among men weregenerally less serious than unintentional injuries. As withwomen, men were almost five times more likely to suffer IPVinjuries in rural as in urban areas (OR 4.99; 95% CI 1.70 to14.67), but ethnicity was not significantly related to intimatepartner injuries. Among men who identified themselves asvictims of IPV , there was a trend toward injuries occurringduring weekends, rather than weekdays (p=0.06). As withwomen, injuries reported as resulting from IPV were concen-trated during the night hours. Like women, IPV relatedinjuries were more than four times more likely to be reportedby men who came to the emergency department alone ratherthan by ambulance or with another person (OR 3.92; 95% CI1.96 to 7.85) and more than 11 times more likely among menwith multiple injuries (OR 11.75; 95% CI 5.88 to 23.48).
Certain values of individual variables can be used to gener-
ate acceptable predictive values. For instance, among women,contusion and swelling of the lips had a predictive value in thisTable 1 Distribution of the 26778 women aged
over 19, with injuries recorded in EDISS during a threeyear period (1996–98) by demographic, event andinjury descriptive variables, and by the cause of injury
VariableNo (%) of
injuries dueto IPVNo (%) ofinjuries declaredas unintentional
Age (years)
<30 73 (23.4) 4965 (18.8)
30–39 136 (43.6) 3703 (14.0)40–49 60 (19.2) 3579 (13.5)50–59 28 (9.0) 3825 (14.4)60+ 15 (4.8) 10394 (39.3)
Nationality
Greek 287 (92.0) 25032 (94.6)Migrants 25 (8.0) 1434 (5.4)
Region
Urban 37 (11.9) 10809 (40.8)Rural 275 (88.1) 15657 (59.2)
Place
Home 272 (87.2) 13407 (50.7)Other 40 (12.8) 13059 (49.3)
Time
24.00–05.59 21 (6.7) 788 (3.0)06.00–13.59 89 (28.5) 12787 (48.3)14.00–21.59 167 (53.5) 11327 (42.8)22.00–23.59 35 (11.3) 1564 (5.9)
Day
Weekday 226 (72.4) 19370 (73.2)Weekend 86 (27.6) 7096 (26.8)
Season
Winter 62 (19.9) 5827 (22.0)Spring 68 (21.8) 6561 (24.8)Summer 104 (33.3) 7289 (27.5)Autumn 78 (25.0) 6789 (25.7)
Transfer of injured person
On her own 124 (39.7) 2353 (8.9)Ambulance/other person 188 (60.3) 24113 (91.1)
Time from injury to medical evaluation
Same day 228 (73.1) 20769 (78.5)More than one day 84 (26.9) 5697 (21.5)
Number of injuries
One 124 (39.7) 21757 (82.2)Multiple 188 (60.3) 4709 (17.8)
Type of injury
Contusion/open wound 223 (71.5) 12904 (48.8)Fracture 12 (3.9) 7047 (26.6)Concussion 55 (17.6) 1408 (5.3)Luxation/dislocation/other 16 (5.1) 4814 (18.2)No injury diagnosed 6 (1.9) 290 (1.1)
Body part inured
Brain 56 (17.9) 1441 (5.4)Skull 43 (13.8) 1007 (3.8)Face/rest of the head 94 (30.1) 1271 (4.8)Trunk 51 (16.4) 3836 (14.5)Upper limbs 52 (16.7) 8182 (30.9)Lower limbs 16 (5.1) 10729 (40.6)Table 2 Distribution of the 34088 men aged over
19, with injuries recorded in EDISS during a three year
period (1996–98) by demographic, event and injurydescriptive variables, and by the cause of injury
VariableNo (%) of
injuries dueto IPVNo (%) ofinjuries declaredas unintentional
Age (years)
<30 4 (10.3) 11295 (33.2)
30–39 12 (30.8) 7261 (21.3)40–49 7 (17.9) 5387 (15.8)50–59 7 (17.9) 3969 (11.7)60+ 9 (23.1) 6137 (18.0)
Nationality
Greek 37 (94.9) 31344 (92.1)Migrants 2 (5.1) 2705 (7.9)
Region
Urban 4 (10.3) 11311 (33.2)Rural 35 (89.7) 22738 (66.8)
Place
Home 35 (89.7) 8129 (23.9)Other 4 (10.3) 25920 (76.1)
Time
24.00–05.59 3 (7.7) 1267 (3.7)06.00–13.59 10 (25.6) 15059 (44.2)14.00–21.59 23 (59.0) 15440 (45.4)22.00–23.59 3 (7.7) 2283 (6.7)
Day
Weekday 22 (56.4) 24664 (72.4)Weekend 17 (43.6) 9385 (27.6)
Season
Winter 6 (15.4) 7297 (21.4)Spring 6 (15.4) 8133 (24.0)Summer 14 (35.9) 9533 (28.0)Autumn 13 (33.3) 9036 (26.6)
Transfer of injured person
On his own 19 (48.7) 8399 (24.7)Ambulance/other person 20 (51.3) 25650 (75.3)
Time from injury to medical evaluation
Same day 33 (84.6) 27694 (81.3)More than one day 6 (15.4) 6355 (18.7)
Number of injuries
One 19 (48.7) 26742 (78.5)Multiple 20 (51.3) 7307 (21.5)
Type of injury
Contusion/open wound 34 (87.2) 11299 (59.6)Fracture 0 (0.0) 6536 (16.6)Concussion 3 (7.6) 1855 (5.4)Luxation/dislocation/other 1 (2.6) 5969 (17.5)No injury diagnosed 1 (2.6) 290 (0.9)
Body part injured
Brain 3 (7.7) 1889 (5.5)Skull 7 (17.9) 1658 (4.9)Face/rest of the head 14 (35.9) 3362 (9.9)Trunk 8 (20.5) 4635 (13.6)Upper limbs 6 (15.4) 11512 (33.8)Lower limbs 1 (2.6) 10993 (32.3)Distinguishing unintentional injuries from injuries due to intimate partner violence 199
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study of about 43%, meaning that a women with an unknown
cause of contusion and swelling of the lips has a 43%probability to have sustained that injury because of intimatepartner assault. Moreover, with a combination of predictivecharacteristics—for example, an unaccompanied woman30–39 years old, from a rural area, presenting at night, withmultiple injuries including the face—the injury is more likelythan not (predictive value far in excess of 50%) to have beencaused as a result of IPV .
DISCUSSION
IPV is a universal phenomenon and—however under-reported—it has been documented in all populations thathave been properly investigated.
6–8This investigation shows
that IPV also exists in Greece and is more common in ruralareas. Women are far more frequently IPV victims but men arenot immune to this phenomenon. IPV can occur whenever thepartners coexist, but the relative frequency of the phenom-enon increases during the late evening and night hours, pos-sibly because alcohol intoxication plays an interactive part,
9
although the latter hypothesis could not be assessed in thissurveillance system. Y ounger women and older men aredisproportionally affected by IPV . Certain types of injuries,notably multiple facial injuries, and certain modes of presen-tation at the emergency department, notably presentation ofthe injured person on his/her own, are strongly indicative ofIPV . This is a finding of some importance, because IPV victimstend to grossly under-report their injuries, especially intraditional societies.
Overall, the frequency of IPV identified in this study is low,
compared with that in other countries. For example, between2% and 12% of women’s acute injuries seen in emergencydepartments in the United States are due to IPV ,
231 0although
this wide range may, at least in part, illustrate the difficulty ininterpreting IPV definitions across studies. To a certain extent,Table 3 Multiple logistic regression derived odd
ratios (ORs) and 95% confidence intervals (95% CIs)for a woman to sustain an injury due to IPV rather thanto declare an unintentional injury by a series ofdemographic, event and injury variables, controllingfor place of occurrence of the injury
Variable ORs 95% CIs p Value
Age (years)
<30 1.11 0.76 to 1.61 0.60
30–39 2.32 1.64 to 3.27 0.0001
40–49 Baseline
50–59 0.43 0.27 to 0.69 0.0005
60+ 0.07 0.04 to 0.13 0.0001
Nationality
Greek Baseline
Migrants 1.40 0.80 to 2.47 0.24
Region
Urban Baseline
Rural 4.35 3.00 to 6.32 0.0001
Time
24.00–05.59 2.76 1.55 to 4.92 0.0006
06.00–13.59 Baseline
14.00–21.59 1.35 1.02 to 1.81 0.04
22.00–23.59 2.26 1.41 to 3.63 0.0007
Day
Weekday 1.08 0.82 to 1.43 0.57
Weekend Baseline
Season
Winter 0.93 0.64 to 1.37 0.72
Spring Baseline
Summer 1.23 0.87 to 1.73 0.25
Autumn 1.02 0.71 to 1.46 0.92
Transfer of injured person
On her own 4.75 3.59 to 6.28 0.0001
Ambulance/other person Baseline
Time from injury to medical evaluation
Same day Baseline
More than one day 1.22 0.89 to 1.68 0.21
Number of injuries
One Baseline
Multiple 15.15 11.61 to 19.77 0.0001
Additional, alternatively introduced variables
Type of injury
Contusion/open wound Baseline
Fracture 0.21 0.12 to 0.39 0.0001Concussion 2.55 1.75 to 3.71 0.0001Luxation/dislocation 0.08 0.04 to 0.18 0.0001No injury diagnosed 0.61 0.24 to 1.56 0.30
Injured body part
Brain 13.21 8.57 to 20.38 0.0001Skull 12.67 8.05 to 19.96 0.0001Face/rest of the head 13.67 9.31 to 20.07 0.0001Trunk 3.49 2.33 to 5.21 0.0001Upper and lower limbs BaselineTable 4 Multiple logistic regression derived odd
ratios (ORs) and 95% confidence intervals (95% CIs)
for a man to sustain an injury due to IPV rather thanother causes of injuries except from violence, by aseries of demographic, accident and injury variables,controlling for place of occurrence of the injury
Variable ORs 95% CIs p Value
Age (years)
<30 0.44 0.13 to 1.52 0.19
30–39 1.44 0.56 to 3.72 0.45
40–49 Baseline
50–59 1.28 0.44 to 3.70 0.65
60+ 0.77 0.27 to 2.16 0.62
Nationality
Greek Baseline
Migrants 1.59 0.35 to 7.15 0.54
Region
Urban Baseline
Rural 4.99 1.70 to 14.67 0.003
Time
24.00–05.59 3.87 1.01 to 14.89 0.05
06.00–13.59 Baseline
14.00–21.59 1.79 0.83 to 3.85 0.14
22.00–23.59 3.39 0.85 to 13.49 0.08
Day
Weekday 0.54 0.28 to 1.03 0.06
Weekend Baseline
Season
Winter 1.29 0.41 to 4.06 0.66
Spring Baseline
Summer 2.31 0.87 to 6.13 0.09
Autumn 2.45 0.91 to 6.58 0.07
Transfer of injured person
On his own 3.92 1.96 to 7.85 0.0001
Ambulance/other person Baseline
Time from injury to medical evaluation
Same day Baseline
More than one day 0.54 0.21 to 1.41 0.21
Number of injuries
One Baseline
Multiple 11.75 5.88 to 23.48 0.0001
Additional, alternatively introduced variables
Type of injury
Contusion/open wound Baseline
Fracture/concussion 0.23 0.07 to 0.76 0.02Luxation/dislocation 0.10 0.01 to 0.75 0.02No injury diagnosed 2.85 0.37 to 21.96 0.31
Injured body part
Brain 5.46 1.29 to 23.09 0.02Skull 14.37 4.71 to 43.83 0.0001Face/rest of the head 11.31 4.36 to 29.36 0.0001Trunk 5.35 1.89 to 15.15 0.002Upper and lower limbs Baseline200 Petridou, Browne, Lichter, et al
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the lower proportion of IPV found in the Greek study may be
due to the lack of focused screening protocols for IPV . Anotherprobability is reluctance among patients to report IPV in aculture that views violence within families as occurring onlyinfrequently in that society.
Underdiagnosis, however, is a serious problem across all
national settings. Recent studies in North America suggestthat fewer than half of those who present with injuries due topartner violence are identified as victims of intimatepartners.
3In other studies, however, only 7% to 25% of injuries
inflicted by a partner are identified as such.2An unknown
fraction of IPV injuries may have been missed in the Greekmedical settings as well.
There are many barriers to identification of IPV in health
care settings. Health care providers often fail to connect apatient’s injuries with IPV , and are hesitant to discuss familyissues with their patients because of a lack of training andeducation on risk factors and prevalence of the phenomenon.Similarly, physicians may not feel comfortable intervening if apatient discloses family violence, or may fear offending thepatient by asking about interpersonal family relationships.
11 12
Research outside Greece indicates that time constraints alsolimit a physician’s likelihood of asking about violence withinfamilies.
13Lack of resources to refer patients for trauma
specific help or lack of knowledge of resources and establishedlinks for referral, further limit medical staff’s willingness tosolicit disclosures or become involved.
41 4
Findings in the current study share other similarities with
results of inquiries in other populations. For example, the size ofthe reported problem with women as victims in this study is 10times higher than that among men. Other studies in health caresettings also suggest that women sustain considerably higherrates of IPV related injury than men.
15 16The low rates of injuries
related to physical abuse among men make the cause of these
injuries less amenable to screening detection.
The present investigation is large, covers all adult ages and
both genders, and includes both rural and urban areas. Use, as acomparison group, of a large series of unintentional injuries isnot a drawback because the differential etiological diagnosis ofIPV injuries is generally oriented towards unintentional injuries(intentional injuries from persons other than intimate partnersare in general freely attributed). Inclusion in the study of allinjuries presented in emergency departments also allows theunbiased calculation of predictive values, which depend on theactual frequency of the phenomenon under investigation (in acase-control study with, say, equal number of IPV injuries andcomparison, injuries predictive values cannot be calculated).
The main disadvantage is that attribution of injuries to IPV
relies on reporting of events, which are believed to befrequently under-reported and may not even be documentedin the medical record. Indeed, a recent Greek study has shownconsiderable under-reporting of suspected cases of child abusein the medical files.
17A consequence of under-reporting is that
actual frequencies of IPV injuries are probably higher thanthose found, although the odds ratio estimates should be littleaffected by this under-reporting. Another shortcoming of thisstudy, which is, however, generic to this type of investigation,is that the findings may not be generalized in a straightfor-ward way to populations living and functioning under verydifferent conditions.
Identification of a health problem, estimation of its dimen-
sions, and characterization of major risk factors are prerequi-sites for the launching of an effective preventive strategy.Although, probably underestimated, IPV injuries represent animportant problem for Greeks as well as other populations andthis investigation represents a first attempt to delineate theproblem in this country or indeed, any other Mediterraneancountry.
More important, however, this study has helped identify
injury characteristics, which have the properties required forthe development of an effective screening tool towards theidentification of IPV in emergency department settings. Actu-
ally, finding that only 1.1% of women in this study identifiedthemselves as victims of IPV , lower than the lowest figure forwomen in studies in other countries, indicates the need for amore focused screening protocol to test whether the rate ofIPV presentation in Greek accident and emergency settings isactually lower than rates in medical settings in other nations,or whether a more focused instrument would yield higheridentification. Increasing public awareness of the occurrenceof family violence in Greek society and discussions of assaultsbetween partners in public discourse are also necessary tofacilitate individual disclosures. Lastly, specialized trainingand development of basic awareness of the problem of familyviolence is critical to motivate the development of identifica-tion protocols and resources in all countries. Without anadequate resource network, health care professionals willremain reluctant to solicit disclosures from patients, andpatients who do disclose will be frustrated or furtherendangered by the lack of services, once abuse is identified.
ACKNOWLEDGEMENTS
This research was partially supported by a grant from the European
Commission [DG SANCO (2001 CVG3-315) SI325058] and from theHarvard Injury Control Research Center (partially funded by the USCenters for Disease Control and Prevention).
…………………
Authors’ affiliations
E Petridou, Department of Hygiene and Epidemiology, Athens University
Medical School, Athens, Greece and Department of Epidemiology,
Harvard School of Public Health, Boston, USAA Browne, E Lichter, Harvard Injury Control Research Center, Harvard
University School of Public Health, Boston, USAN Dessypris, X Dedoukou, D Alexe, Department of Hygiene and
Epidemiology, Athens University Medical School, Athens, Greece
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study in Greek ambulatory care settingsinjuries due to intimate partner violence: a What distinguishes unintentional injuries from
E Petridou, A Browne, E Lichter, X Dedoukou, D Alexe and N Dessypris
doi: 10.1136/ip.8.3.1972002 8: 197-201 Inj Prev 
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