Introduction to Violence Epidemiology

Introduction to Violence Epidemiology

The Epidemiology of Domestic Violence Thomas Songer, PhD Cristie Glasheen, MPH University 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

...To understand violence, you need to define violence How would you define domestic violence? Defining Domestic Violence domestic violence noun: violence committed by one member of a family or household against another The National Research Council defines violence as:

- behaviour by individuals that intentionally threaten, attempt, or inflict physical harm on others Who is Affected by Domestic Violence? Children Intimate Partners (IP) Elders Data Sources You are planning to do a study of domestic violence using pre-existing data.

Where would you look? Medical sources State sources Government 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 Sources Hospital Records Trauma Center Records Emergency Department Recommended: Rudman WJ. Coding and Documentation of Domestic

Violence. December, 2000. Available at: 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 Reporting State-based Reporting Child Protective Services Uniform Crime Reports National Incident-Based Reporting System (NIBRS) 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 Surveys Government Surveys National Crime Victimization Survey (NCVS) 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 about Child Maltreatment?

Epidemiology of Child Abuse Maltreatment behavior towards another person, which a) is outside the norms of conduct, and b) entails a substantial risk of causing physical or emotional harm Physical Abuse Sexual Abuse Emotional & Psychological Abuse Neglect 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. Substantiated Cases of Child Maltreatment, Pennsylvania, 1976-1994 9000

8000 7000 6000 5000 4000 3000 2000 1000 0 76 78

80 82 84 86 88 90

92 94 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 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/exgirlfriend Same sex relationship Same sex relationship Date

stimates of the Frequency of Domestic Violen Against Women seen in Medical Settings Study McCauley Gin Goldberg Dearwater McLeer Abbott Muelleman Sample

Trauma One year Lifetime Definition and Method Size from AbusePrevalencePrevalence Physical and sexual abuse reported 1952 5.5% 33% in physician practices Physical and sexual abuse and 453 threats by current partner reported

14% 28% in internal medicine clinics Physical abuse reported in an urban 492 22% emergency department Physical or sexual abuse reported in 3455 14.4% 36.9% community hospital emergency 2.2%

departments Physical abuse identified in trauma 412patients in urban emergency 30% department Physical abuse or threats reported in 648 2.7% 15.3% 54.2% urban, acute care emergency departments and clinics

Physical trauma identified in ten 9057 3.1% emergency departments IPV Source: American Journal of Preventive Medicine Volume 34, Issue 2, February 2008, Pages 112-118 WHO Multi-country Study on Womens Health and Domestic Violence against Women

The Pyramid of Violence Against Women, U. S. 1418 murders 7% treated in emergency department 10% sought medical care 32% not treated for injury 51% had physical injuries 50% reported to police 1992-96 NCVS 960,000 women victimized

Trends in the rates of violent victimizations by intimates*, United States, 1992 - 1996 Females 12 Males Rate per 1,000 population 10

8 6 4 2 0 1992 1993 1994 1995

1996 Possible Risk Factors Intimate Partner Violence

Gender Ethnicity Socio-Economic Status Age ? Alcohol ? Pregnancy ? Psychiatric problems ? What do we know about Elder Abuse?

Research Methods You have decided that existing data sources are not adequate to answer your research question. You want to design a new study. What do you need to consider? Who Who are you going to measure? Victims? Perpetrators?

What is Your Outcome? Physical 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 It? Domestic Violence is wrought with ethical considerations unique to this field 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

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