Intimate partner violence among health professionals: distribution by autonomous communities in Spain

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2017;51:e03256 1 Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain. 2 Universidad de Castilla la Mancha, Ciudad Real, Spain. 3 Universidad de Córdoba, Córdoba, Spain. 4 Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain. ABSTRACT Objective: To determine the prevalence of intimate partner violence among health care professionals who work in the Spanish National Health System, according to the autonomous communities of Spain. Method: This was a descriptive cross-sectional multicenter study conducted with male and female health professionals (doctors, nurses, and nursing aides) in the different autonomous communities that are part of the Spanish National Health System. The following instruments were employed: among women, an intimate partner violence screening questionnaire; and among men, a questionnaire that screened for violence in the family environment. Results: A total of 1,039 health professionals participated in the study. Of these, 26% had suffered some type of abuse. Among the men, this prevalence was 2.7%, while among the women, it was 33.8%. There were differences in the prevalence of intimate partner violence among different autonomous communities, with the highest percentages in the Canary Islands. In terms of profession, 19.5% of the doctors had been exposed to intimate partner violence, while this percentage was 31% and 48.6% for nurses and nursing professionals, respectively. Conclusion: The results indicate the presence of intimate partner violence among healthcare personnel in most of the autonomous communities of Spain. The data demonstrate the need to implement action plans, both to support victims and to mitigate the problem.


INTRODUCTION
Intimate Partner Violence (IPV) is the most common type of violence against women present in society, also affecting men to a lesser extent (1) .The World Health Organization has recognized IPV to be a public health and human rights issue (2) .This phenomenon is present among all social groups and has been recently documented within the nursing category (3)(4)(5)(6) .Healthcare services are a natural point of entry for possible victims (7)(8) , and health professionals tend to represent their first point of contact with the system.Thus, it is especially relevant to study the prevalence of this issue among health personnel.
Recent studies have been conducted in Spain to analyze the prevalence of IPV in the general population, but only one study involving health professionals focused on nurses, who represent a particularly sensitive group.In that study, 33% of the investigated Andalusian nurses had been victims of abuse (5) .
The prevalence of IPV found among nurses in Andalusia was higher than in other studies conducted with the general Spanish population, which determined that 24.8% (9) of women who had resorted to primary health services (2006-2007)  had suffered IPV at least once in their lives, and 15.1% had suffered IPV in the previous year, with greater prevalence in Ceuta and Melilla, followed by the community of Madrid and the Balearic Islands, and the lowest prevalence in Cantabria, Aragón and La Rioja (9) .This prevalence distribution of IPV seems to coincide with the distribution of gender-based violence in Spain (10) , given that the communities with the greatest number of reports per million women over the age of 15 were Melilla, Ceuta, and Balearic and Canary Islands.
Considering that IPV is a public health problem that affects the entire population, the research question was: To what extent does this issue personally affect health professionals who are responsible for providing health care to possible victims?Furthermore, the hypothesis have been proposed that experiencing situations of violence can result in failure to recognize the problem, explaining the low perception of IPV by health professionals (8,(13)(14) .Since health professionals play an important role in diagnosis of IPV (1,8,(14)(15) , the present study is of special relevance.Furthermore, cultural factors can be of interest as protective or predictive factors of IPV (9) .
Only one study has been conducted in Spain focused exclusively on nursing staff, and it demonstrated the severity of the problem: 33% of the studied female nurses had experienced IPV (3,5) .The high prevalence found in that study corroborates the international literature, such as in the United States (4) and Jordan (6) , although there is a paucity of studies on the phenomenon among health professionals.Considering the above, it is important to determine the prevalence of IPV among health professionals, since health services usually assist IPV victims.Furthermore, these studies (4,6) have also emphasized that the experience of health professionals with IPV can help them to identify IPV and care for such patients.
Thus, the objective of the present study was to establish the prevalence of IPV in the different autonomous communities of Spain, among both male and female health professionals working for the Spanish National Health System.

METHOD
This was a descriptive cross-sectional multicenter study.Participants were both male and female health professionals (physicians, nurses, and nursing aides) who worked for the Spanish National Health System, in both primary and specialized care services.
The sample size was calculated with Grammo software (version 7.11 March 2011) through population estimates using the baseline expected prevalence of 33%, the rate found in the sample of Andalusian female nurses (5) ; with 3% precision and 95% confidence level.This resulted in a minimum of 943 health professionals.Simple randomized sampling was used.
A total of 1,071 cases were recorded.However 32 were excluded, since to be included in the sample, the autonomous community had to present at least 20 cases for its data to be included in the analysis.Thus, the final sample consisted of 1,039 cases for which data was collected between October 2014 and April 2015.
The following instruments were used: A questionnaire developed by Delgado et al. (2006) (16) and validated for women (reliability of 0.8688 and 0.7072).This questionnaire consists of 10 Likert-type close-ended questions that screen for physical, psychological, and sexual abuse.The scale of measurement was that used by the authors of the questionnaire, with modifications whenever recoding errors were identified (17) .
The men were given a questionnaire developed by Sherin et al. (1998) (18) to screen for abuse, adapted to the Spanishspeaking population of the United States by Chen et al. (2005) (19) , (100% sensitivity and 86% specificity).It consists of four Likert-type questions focused on detecting physical and verbal/psychological abuse.Item scores ranged between 1 and 5, and total scores higher than 10 were considered indicative of abuse.
The first part of the data collection instrument consisted of the questionnaires mentioned above for women (17) and men (19) , while the second part consisted of a sociodemographic questionnaire that included a question about whether the participant had suffered or was suffering abuse, whether they had talked about it with anyone and with whom, and whether they had received support or treatment.The final part of the instrument provided an email address participants could use to contact the main researcher for a more in-depth interview.
The independent variables were: age, length of relationship in years, number of children and/or dependents, province, autonomous community, gender, profession, marital status, living situation, place of work, region of work, family income, social class of partner, presence of children and/or dependents over the age of 18, in silence, in treatment, care provider.
Intimate partner violence was the dependent variable.Among the women, types of abuse were also analyzed, including latent dimensions of abuse (indirect interpretation of severity of abuse based on information obtained on different items of the questionnaire, classified as: no abuse, less severe abuse, and very severe abuse).
For data collection, the researchers contacted the health management of each autonomous community, requesting that they send the link for the online questionnaire to healthcare professionals under their supervision.An email was sent from the public service care management of the Spanish provinces to health professionals with an invitation to participate in the study.The link contained an online self-administered close-ended questionnaire which was completed anonymously through a web browser.The link contained a unique code that prevented multiple submissions.
Statistical data analysis was conducted using PASW Statistic 18 software.All hypothesis contrasting was bilateral.
Values with a confidence level of 95% (p<0.05) were considered statistically significant.
The protocol was approved by the Research Ethics Committee of the province of Córdoba, Spain, reference no.2462, protocol 226.Research procedures were in accordance with the fundamental principles of the Declaration of Helsinki and the UNESCO Universal Declaration on Bioethics and Human Rights.
The study sample consisted of 1,039 health professionals, whose sociodemographic characteristics are presented in Table 1.Of the 1,039 professionals interviewed, 25.9% had suffered some form of abuse.Among the men, this prevalence was 2.7%.Among the women, this percentage was 33.8%, with the most common type being psychological abuse (24%), followed by psychological and sexual (4.4%), psychological and physical (2.2%), psychological, physical, and sexual (1.9%), sexual (1%), and physical (0.3%).Regarding the severity of abuse among women, 27.1% of the cases were less severe, while 6.7% were exposed to very severe abuse.In terms of profession, 19.5% of the doctors, 31% of the nurses, and 48.6% of the nursing aides had been victims of IPV.Furthermore, most of the participants who had suffered IPV worked in primary care services (Table 2).It is worth noting that 25.3% of the participants who had suffered IPV had talked to someone about the incident.The most commonly sought out individuals were people of trust (26.5%),followed by psychologists (23.5%), health professionals (19.1%), others (19.1%), and both (health professional and person of trust) (11.8%).17.5% of the sample who had suffered IPV agreed to participate in an in-depth interview with anonymity ensured.Furthermore, 10.8% of the professionals who had suffered IPV were receiving some type of support or treatment.
Regarding the different autonomous communities, IPV was more prevalent in the Canary Islands (43.8%).The lowest rates were found in the Basque Country (19%) (Table 3).
In addition to the differences among IPV rates, there were also significant differences (p=0.009) between marital status and autonomous community of participants, with the Community of Madrid presenting the highest percentage of married individuals.Significant differences were also found (p<0.01) between place of work and autonomous community, with the highest percentage of primary health professionals working in the Community of Madrid.Significant differences (p=0.03) were also found between gender and autonomous community, with Asturias presenting the highest proportion of women (Table 4).
Finally, significant differences (p<0.01) were also found between profession and autonomous community, with Andalusia presenting the highest number of nursing aides.

DISCUSSION
The prevalence of IPV among health professionals of both genders ranged between 19% to 43.8%.Furthermore, the prevalence of IPV found in the present study among health professionals working for the Spanish National Health System (25.9% of the total sample, 33.8% of women and 2.7% of men) was greater than that of the general population (9,(11)(12) .The last results of a study conducted by the Spanish Ministry of Health indicated that 24.4% had suffered some sort of abuse by their last partner (20) .
The prevalence of IPV among health professionals in the different autonomous communities of Spain found in the present study was higher than the prevalence reported in other studies conducted in Spain with the general population.The communities with the highest prevalence were the Canary Islands, Castile and León, and Catalonia, while in the general population, the communities with the highest prevalence were Ceuta and Melilla, the Balearic Islands, and the Community of Madrid (9) .The prevalence in this study did not coincide with the prevalence of reported genderbased violence according to the Ministry of Health, specifically the State Observatory on Violence against Women (10) .Thus, there seems to be a mismatch between the prevalence of violence and reported cases, in accordance with other studies conducted in Spain (21) .
The prevalence obtained was similar to that of other studies conducted with health professionals in other countries: a study in Jordan found that 59% of the nurses had suffered psychological IPV (6) ; a study in the United States found that 25% of the nurses had suffered IPV (4) .
The origin of the differences regarding prevalence of IPV in the different autonomous communities could be due to sociocultural differences or unequal development of gender equality and violence programs, among other causes (9,22) .
The percentage of IPV found among the women was similar to a previously mentioned study conducted with health professionals (5) .Of the different types of violence, psychological violence was the most common, similar to other studies conducted with the general population (5,9,(23)(24) .
No previous studies were found on IPV among Spanish men.Thus, the results are especially relevant because they demonstrate the existence of women who practice IPV against men, albeit to a lesser extent than that practiced by men towards women.This must be investigated, because society must be based on equality (25) .The prevalence of IPV among men was considerably lower than that found in other countries, such as Brazil, where one study found that 50% of the participants had suffered IPV (26) .However, in the Brazilian study, the sample consisted of all types of men, while the present study only investigated health professionals.
Greater prevalence of IPV among health professionals than the general population is especially significant.These professionals work in services that are usually points of entry for victims of gender-based violence in general and intimate partner violence.Some studies have shown that female victims of violence first seek out psychological and psychiatric help, followed by health services, since they are the most valued of all the resources available to victims (20) .Thus, health services must be able to identify and respond to issues related to gender-based violence.However, studies have shown that health professionals frequently face various barriers in diagnosing the problem: high care demands, lack of training, lack of awareness of this health problem, etc. (1,27) .
Professional health education regarding IPV must be improved in order to first raise awareness among professionals about the issue as a public health problem that affects all groups.Second, they must be trained to approach possible victims and contribute to eliminating barriers that hinder the detection of IPV and establishing action and coordination protocols among different social health services (27)(28)(29)(30) .A combination of professional training, knowledge about action protocols, and awareness among health professionals has been shown to increase IPV detection, mitigating health problems in abuse victims and reducing health costs (15,31) .
The limitations of the present study include the low number of participants in some communities, preventing generalization of the results, which must be considered with caution.Furthermore, it is possible that professionals who had suffered IPV were more motivated to participate in the study.Also, the rate of nonresponse could not be measured.And finally, the questionnaire required a mobile device or computer connected to the Internet, which may have influenced the higher participation of professionals in urban areas.

CONCLUSION
The findings of the present study indicate the presence of IPV among health professionals in most of the autonomous communities of Spain.The prevalence of IPV varied among communities, with the lowest rates in the Basque Country and Andalusia, and the highest in the Canary Islands and Castile and León.The prevalence of IPV in the studied health professionals was higher than that found in the general population.The data for some communities were excluded because of low response rates, requiring caution when interpreting the results.On the other hand, few studies have been conducted on the issue among health professionals, and those that exist were conducted with nurses.Thus, the results of the present research on the issue indicate a gap in the knowledge of IPV among health professionals.

Recommendations foR clinical pRactice
The data demonstrate the need to implement action and intervention plans, both to support victims and to mitigate the problem.Considering that health professionals also suffer from IPV, specific action plans must be implemented to provide them with specialized support.This could include improving professional education about IPV, enabling them to perceive when signs of abuse are present, including among themselves, so that early interventions could reduce case numbers and/or their consequences.
Considering the paucity of studies addressing the problem of IPV among health professionals, further studies are needed along this line of research in different countries with international samples.Health professionals who suffer IPV may have trouble identifying the problem among their patients.Health institutions must commit to resolving this severe problem, through measures such as education and victim support programs.

or dependents above the age of 18
Note: (n=1,039)

Table 2 -
Intimate partner violence by profession and place of work -Córdoba, Spain, 2015.