Violencia contra la mujer: conocimiento y actitud del personal médico del Instituto Mexicano del Seguro Social, Morelos, México

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Abstract

OBJETIVO: Evaluar la actitud afectiva, cognoscitiva y conductual del personal médico del Instituto Mexicano del Seguro Social del estado de Morelos, México, hacia la identificación y canalización de mujeres maltratadas que acuden a consulta médica, así como identificar las barreras institucionales y de la práctica médica que dificultan el manejo dentro de los servicios de salud de las mujeres maltratadas. MATERIAL Y MÉTODOS: De septiembre a diciembre de 1999 se realizó un estudio transversal mediante un cuestionario de autoaplicación que se proporcionó a 269 médicos y médicas generales, especialistas y estudiantes de pre y posgrado que laboran en 30 unidades de salud, de primer y segundo nivel de atención, del Instituto Mexicano del Seguro Social del estado de Morelos. El instrumento se diseñó para evaluar el nivel de conocimiento sobre violencia doméstica y la actitud del personal médico hacia la atención, en la consulta, de mujeres maltratadas. Se construyó un índice de conocimiento, además de un análisis multivariado de los datos. RESULTADOS: El 90% de los entrevistados nunca ha recibido capacitación en violencia contra la mujer. La actitud afectiva y cognoscitiva del personal médico que recibió capacitación sobre el tema fue más favorable hacia la identificación y atención de mujeres maltratadas que llegan a consulta médica, en comparación con los que no la recibieron. Sobre el nivel de conocimiento acerca del tema, 21% de los entrevistados mostró un nivel bajo, 63% medio y 16% alto. En el personal médico, con nivel de conocimiento medio y alto, se observó 2.1 y 6 veces -respectivamente- una actitud afectiva más favorable respecto a la identificación y canalización de casos de mujeres maltratadas en comparación con el personal con nivel de conocimiento bajo. Las médicas mostraron 2.3 veces mejor actitud para identificar y canalizar mujeres maltratadas. El personal médico con interés por capacitarse en el tema mostró 7.6 veces mejor actitud que el personal no interesado. CONCLUSIONES: El personal médico evaluado mostró habilidades insuficientes para identificar y manejar adecuadamente los casos de mujeres maltratadas que atienden en su consulta. Este estudio evidencia la necesidad de capacitar y sensibilizar al personal médico sobre la materia; se recomienda empezar con los médicos generales y familiares, quienes demostraron estar más dispuestos a capacitarse, en comparación con los de especialidades clínicas e incorporar esta capacitación en los planes de estudio de medicina, enfermería, trabajo social, psicología y áreas afines a la salud pública.

Translated abstract

OBJECTIVE: To asses the affective, cognitive, and behavioral attitudes of healthcare providers at the Mexican Institute of Social Security (MISS) in Morelos, Mexico; to identify the institutional and medical practice barriers that hinder screening and reference of battered women. MATERIAL AND METHODS: A cross-sectional study was conducted between September and December 1999. A self-administered questionnaire was applied to 269 general practitioners, specialists, and pre- and postdoctoral students working in 30 primary and secondary level of healthcare units in Morelos State. The data collection instrument was designed to assess healthcare providers' knowledge of and attitudes towards domestic violence during medical office visits. A knowledge index was constructed and analyzed using multivariate regression methods. RESULTS: Ninety percent of healthcare providers had never received training on violence against women. Healthcare providers' affective and cognitive attitudes after receiving training on the subject matter were more favorable compared to those with no training. Favorable attitudes were directly related to the number of training sessions. Most participants (63%) showed a moderate degree of knowledge on the subject, whereas 21% were slightly knowledgeable and 16% were highly knowledgeable. Medical personnel with a moderate or high level of knowledge were 2.1 and 6 times more likely, respectively, to have favorable attitudes than those with a low degree of knowledge. Female physicians showed more favorable attitudes towards identifying and referring battered women. Medical personnel interested in further training on the subject of violence against women were 7.6 times more likely to show favorable attitudes than personnel not interested on the subject. CONCLUSIONS: Healthcare providers were not sufficiently able to assess and manage battered women. General and family practitioners were more interested in being trained, as compared with specialist physicians. Training on violence against women should be included in graduate medical, nursing, social service, psychology, and other public health areas.

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Primary care physicians' response to domestic violence. Opening Pandora's box.

T Inui, N K Sugg (1992)

To explore primary care physicians' experiences with domestic violence victims to determine the barriers to problem recognition and intervention in the primary care setting. Ethnography, a qualitative research method involving the use of open-ended, semistructured interviews. An urban health maintenance organization serving a predominantly white, middle-income population. Thirty-eight physicians, predominantly family practitioners (89%), were interviewed. Analysis of the interviews revealed that physicians found exploring domestic violence in the clinical setting analogous to "opening Pandora's box." Their issues include lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. This study revealed several barriers that physicians perceived as preventing them from comfortably intervening with domestic violence victims. These issues need to be addressed in training programs. Further studies should be done to assess generalizability of these findings to other groups of physicians.

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Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians.

L Lorenzo, Kirsten McLoughlin, K Grumbach … (1999)

Although practice guidelines encouraging the screening of patients for intimate partner abuse have been available for several years, it is unclear how well and in which circumstances physicians adhere to them. To describe the practices and perceptions of primary care physicians regarding intimate partner abuse screening and interventions. Cross-sectional survey of a stratified probability sample of 900 physicians practicing family medicine, general internal medicine, and obstetrics/gynecology in California. After meeting exclusion criteria, 582 were eligible for participation in the study. Reported abuse screening practices in a variety of clinic settings, based on a 24-item questionnaire, with responses compared by physician sex, practice setting, and intimate partner abuse training. Surveys were completed by 400 (69%) of the 582 eligible physicians, including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists. Data were weighted to estimate the practices of primary care physicians in California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%) of these primary care physicians routinely screen injured patients for intimate partner abuse. However, estimated routine screening was less common for new patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%), and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent intimate partner abuse training had significant effects on reported new patient screening practices. Obstetrician/gynecologists (17%) and physicians practicing in public clinic settings (37%) were more likely to screen new patients. Internists (6%) and physicians practicing in health maintenance organizations (1%) were least likely to screen new patients. Commonly reported routine interventions included relaying concern for safety (91%), referral to shelters (79%) and counseling (88%), and documentation in the medical chart (89%). Commonly cited barriers to identification and referral included the patients' fear of retaliation (82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up (52%), and cultural differences (56%). These findings suggest that primary care physicians are missing opportunities to screen patients for intimate partner abuse in a variety of clinical situations. Further studies are needed to identify effective intervention strategies and improve adherence to intimate partner abuse practice guidelines.