Experiences of being screened for intimate partner violence during pregnancy: a qualitative study of women in Japan

Experiences of being screened for intimate partner violence during pregnancy: a qualitative study... Background: Intimate partner violence (IPV) is physical, sexual or psychological violence by a current or former intimate partner. IPV threatens women’s health, and during pregnancy women are more vulnerable to violence. Therefore, IPV screening has been recommended during antenatal care; however, health care providers have expressed concern about the negative impact on women and therefore have been reluctant in conducting IPV screening. Consequently our objective was to investigate pregnant women’s experiences of reading and completing an IPV screening questionnaire. Methods: Semi-structured interviews were conducted with postpartum women who had received IPV screening during pregnancy to investigate their experiences using the IVP Violence Against Women Screen (VAWS). Qualitative data were analyzed based on content analysis. Results: A total of 43 women participated in this study. There were eight (18.6%) women positive for IPV screening during pregnancy. Content analysis for all participants revealed three themes: necessity, acceptability and optimality. ‘Necessity’ referred to benefits for women from IPV screening, and was supported by three categories: ‘redefining the relationship’, ‘promoting IPV awareness’ and ‘opportunity to initiate support’. ‘Acceptability’ of IPV screening was also supported by three categories: ‘comfortable’, ‘quickly completed’ and ‘difficulty’. ‘Optimality’ meant IPV screening during pregnancy was appropriate timing for women who had been screened as either positive or negative. Conclusions: The majority of women, including women experiencing IPV, had positive responses to IPV screening during pregnancy. Future diffusion of IPV screening requires safe environments for IPV screening and improved awareness of health care providers towards IPV. Keywords: Intimate partner violence, Pregnancy, Screening experience, Qualitative study Background male partners. IPV is also a serious social problem in Intimate partner violence (IPV) is defined as behavior by Japan. The Gender Equality Bureau Cabinet Office [3]in an intimate partner that causes physical, sexual or psy- Japan conducted a national survey and found 15% of chological harm, including acts of physical aggression, women experienced physical violence, 12% of women sexual coercion, psychological abuse and controlling be- were assaulted psychologically by male partners and 7% haviors [1]. The World Health Organization stated that of women experienced coercive sexual intercourse. In violence against women is a major global public health addition, the rate of IPV victims has not changed for problem and human rights concern. The study by the over ten years since the government survey started in WHO [2] in ten different countries reported that 1999. It is urgent that solutions be developed to elimin- 13%-61% of women had been abused by their intimate ate violence against women in all countries. Moreover, IPV towards pregnant women is a serious concern that the world faces. A systematic review indi- * Correspondence: yaeko-kataoka@slcn.ac.jp cated that prevalence of IPV during pregnancy ranged St. Luke’s International University, Tokyo, Japan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 2 of 9 from 0.9% to 20.1% [4]. Research on Japanese pregnant time limitations [23, 24], lack of confidence in screening women that applied the Index of Spouse Abuse (ISA) [5] [24, 25], difficulty to establish rapport [24], unease or found that 5% of women experienced IPV during preg- fear about angering patients or causing emotional dis- nancy, and another survey showed that 1% of pregnant comfort [26]. In a questionnaire survey of women in women had experienced physical intimate partner vio- Japan who had experienced IPV screening, most women lence [2]. IPV threatens several aspects of health among replied that it was not unpleasant [27, 28], but these pregnant women. These include not only physical injur- were only a few questionnaire items answerable in yes/ ies [6] but also psychological impairment such as post- no format, to elicit the extent of satisfaction and with no partum depression [7], posttraumatic stress disorder [8, psychometric controls applied. No other information 9], bonding disorders [10] and suicidality [11]. Violence was garnered about their experience. during pregnancy can result in pregnancy complications Accordingly, this study aimed to conduct semi-structured such as hypertension, vaginal and cervical bleeding, pla- interviews with postpartum women who received IPV cental problems, severe nausea, and kidney infection screening during pregnancy to investigate women’sexperi- [12]. In addition IPV during pregnancy affects the fetus ences of reading and completing the IPV screening and neonates, such as low birth weight, preterm delivery questionnaire. and neonatal death [13–15]. It may cause life-threatening results or the death of the mother and child [13, 15, 16]. In Japan, the Act on the Prevention of Spousal Vio- Methods lence and the Protection of Victims was promulgated in Design April 2001 in recognition of the high IPV prevalence The first part of this study was a descriptive IPV survey and its adverse social and health outcomes in Japan [17]. with a purposive sample of women. The second part of This was the first law to indicate explicitly that spousal the study was qualitative using content analysis of violence was a criminal act and the perpetrator must be semi-structured interviews of the same sample. punished by the criminal code. It also prescribed that prefectures establish and authorize at least one or more spousal violence counseling and support centers to take Study setting and participants a central role in the support system for IPV victims in This study was conducted in a general hospital that pro- Japan. As a result of the Act, the number of institutions vided antenatal to postpartum care in a city of the Na- such as shelters, women’s counseling centers and IPV gano region. The city has approximately 28,000 people counseling centers increased. By 2001, more than 180 and is located near the Japanese Alps on the large island spousal violence counseling and support centers had of Honshu. Participants eligible for this study were preg- been established in Japan. Counseling by these centers nant women whose due day was from the beginning of in 2007 numbered 62,078, about double the number in October through the end of November 2011 and plan- 2002 [18]. This indicates that given the opportunity, ning on giving birth at the general hospital, and who women in Japan seek help and receive support about were: (1) Japanese speaking, (2) had no severe complica- IPV and that support has been expanding. tions and (3) able to participate in the informed consent A systematic review concluded that there was evidence process. that IPV screening increased identification of women ex- After approval by the Institutional Review Board of St. periencing IPV, however, there was insufficient evidence Luke’s College of Nursing (Approval No.: 11-039) the of an effect for other outcomes such as recurrence of study commenced. Eligible women were invited to par- IPV or health measures [19]. Recently some evidence ticipate. Between September and December 2011, we from antenatal care settings suggested that advocacy and consecutively recruited pregnant women face-to-face at empowerment interventions that followed IPV screening their pregnancy checkup who matched inclusion criteria. provided results in improved mental health outcomes of We excluded one woman who was unable to read Japa- women [20, 21]. Based on this, WHO guidelines recom- nese. IPV screening was conducted at the prenatal mended IPV screening for women during their antenatal checkup at 35 weeks and onwards of pregnancy. Because care [1]. In Japan, the Act on the Prevention of Spousal at 35 weeks checkup women have an opportunity to Violence and the Protection of Victims also stipulated consult with a midwife, we conducted IPV screening the role of medical professionals for early detection and with self-administrated questionnaire at a privacy-secured consultation. However, a survey of four prefectures in room without her partner and other family members after metropolitan areas found that IPV screening is still not midwife’s consultation. Participation was voluntary and widespread, with only 5% of institutions conducting IPV participants were assured of their right to stop participat- screening [22]. The common barriers to conducting IPV ing at any time without harm. They were also assured that screening at health care settings have been reported as their data would be kept confidential and anonymous. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 3 of 9 Instruments of the participant’s partner or other family members. Basic- The screening instrument used was the VAWS [29]. ally Interview was carried out once. VAWS is a 3-point Likert Scale comprised of seven items dealing with physical, psychological and sexual Follow-up of participants violence. Participants could respond: never = 0; some- Before starting this study, the researchers developed the times = 1; or often = 2. A score of 2 points or more indi- support protocol for IPV victims at the hospital partici- cated IVP. Structural concept validity using factor pating in this study and also informed the local Spousal analysis, and concurrent validity of the General Health Violence Counseling and Support Centers about the Questionnaire and the Rosenberg Self Esteem Scale were study. After IPV screening and the interviews, all partici- established. Cronbach’s α was 0.70 for reliability. Kataoka pants in this study were provided information orally and [29] reported that when the Japanese version of the in written form about social resources available in the Index of Spouse Abuse (Japanese ISA) was applied as region surrounding the cooperating hospital. Also, for the optimized standard, sensitivity was 86.7% and speci- women who screened positive and needed support, a ficity was 80.2%. trained midwife was appointed to liaise with this study In addition to the VAWS, demographic information and to provide consultation, safety planning and referral about the participants was also collected such as age, to the IPV support center in the community. marital status, family configuration, educational back- During this study, if a participant experienced some ground, employment status, annual income, parity, and form of physical or mental problem or was judged to be information about the woman’s partner. at risk of IPV requiring specialist intervention, the re- Researchers or a trained midwife distributed the searchers coordinated with university academics self-administered VAWS questionnaire. Participants researching and advising about IPV, with advisors from completed it at a location guaranteeing privacy. After Spousal Violence Counseling and Support Centers, and the questionnaire was completed, researchers or a mid- with the liaison midwife from the general hospital co- wife from the hospital collected it. operating with this study, so that appropriate assistance could be provided with the safety of the women as first Data collection priority. Support was provided in accordance with the Maternity hospital stays are typically 5 – 7 days in Japan. Perinatal Domestic Violence Support Guidelines [30]. If Therefore allowing for physical recovery after childbirth, clear evidence of violence was discovered, after consent the interview to evaluate IPV screening during preg- was obtained from the study participant, the midwife rd nancy was conducted on the 3 - 4th day after vaginal from the general hospital cooperating with this study re- th delivery, or the 5 - 6th day after cesarean delivery dur- ported the matter to the Spousal Violence Counseling ing their hospital stay. and Support Center or the police. In order to obtain data of study participants’ experiences when reading and completing the VAWS, the researchers Data analysis created an interview guide (see Additional file 1), to elicit Frequencies and percentage were used for quantitative participants’ opinions and thoughts concerning IPV screen- data. Qualitative data were analyzed using content analysis ing, acceptability of the VAWS questionnaire items, such as [31]. The recorded contents from the IC recorder were words that participants found difficult to understand and ex- transcribed literally. The transcriptions were read repeat- pressions that participants found distasteful, and responses edly, and divided up for words and phrases that captured to screening methods and timing. Using the interview guide, the meaning of women’s experiences of IPV screening at the researchers conducted semi-structured interviews with the pregnancy checkup, and then labeled with codes that participants for about 30 minutes. The interview contents denoted the meaning. The codes were interpreted and were recorded on an IC recorder with the consent of the compared based on differences and similarities. Codes study participants. In order to confirm the interview con- were sorted into sub-categories, representing a more ab- tents and provide anonymity, ID numbers instead of individ- stract level, and then subsumed into categories regarding ual names were used to identify questionnaires. One of the their similarities. Finally, frequencies and percentages were researchers (MI), a female nurse who was also a graduate calculated by categories. The second author (MI) coded student, visited the cooperating hospital and conducted the each interview, and then discussed the coding with the interviews. Before commencement of this study, researcher first author (YK) until agreement was reached. (MI) did pre-interviews whether she could interview accord- ing to the interview guide and listen to participant’s feeling Results and thought with non-judgmental manner. All interviews Demographic characteristics of participants conducted after childbirth were at a location protecting the Of the 48 women meeting the inclusion criteria during privacy of the survey participant and without the presence the study period and invited to participate in this study, Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 4 of 9 agreement was received from 43 women (89.5%). The Table 1 Demographic characteristics of participants and their partner (N = 43) five not participating had been transferred to another hospital. After this information was provided and written n (%) informed consent was obtained data was collected. The Participants valid response rate for the Violence Against Women Age (year) Screen (VAWS) was 100%. All 43 women were then <20 1 (2.3) interviewed during their postpartum stay in the hospital. 20–29 14 (32.6) Table 1 displays the demographic characteristics of 30< 28 (65.1) participants. The majority (65.1%), of participants were Marital status in their thirties. Slightly over half were multiparas and the majority had vaginal births. All were married and Married 43 (100) most resided with their husbands. Family composition Divorce history was nuclear family for 31 women (72.1%). Slightly over Wife 3 (7.0) one-third of the participants were considered ‘house- Husband 1 (2.3) wives’ and the remainder worked full or part time. Most Living with partner had graduated from high school and some had higher Cohabitated 40 (93.0) education. The couple’s annual income was between ‘$21,000-and $40,000 for half of the participants and be- Separated 3 (7.0) tween $41,000 and $61,000 or more’ for almost the other Family structure half. No one was receiving welfare payments. The partic- Nuclear families 31 (72.1) ipants’ spouses were generally in their thirties (67.4%) Extended families 12 (27.9) and most were employed (90.6%). One man (2.3%) was Educational background suspended from duty, and 3 men (7.0%) were Junior high school graduate 4 (9.3) unemployed. High school graduate 10 (23.3) Results of IPV screening in pregnancy Junior college graduate 17 (39.5) Table 2 indicates the frequency of responses for each University graduate / Graduate school 12 (27.9) question of VAWS during pregnancy. A total 37.2% of Employment status participants responded “sometimes” for the question “Is House duty 15 (34.9) it difficult to settle by talking arguments between you Full-time 16 (37.2) and your partner?”, and 14% of participants responded “sometimes” for “feel frightened by their partner” and Part-time 10 (23.3) “Has your partner screamed and /or yelled at you?” Others 2 (4.7) “Sometimes” was answered by 4.7% for the question of Annual income (dollar) “hit the wall or thrown object”. One woman responded <200,000 2 (4.7) “sometimes” for sexual violence, and also one woman 200,000–400,000 22 (51.2) responded “sometimes” for physical violence. There were 400,000–600,000 9 (20.9) 8 women (18.6%) who screened positive for IPV during pregnancy; in other words their VAWS score exceeded 600,000≦ 9 (20.9) the cut-off of 2 points or greater and one was referred to Missing 1 (2.3) the counseling center. Parity Primipara 19 (44.2) Women’s experiences of IPV screening Multipara 24 (55.8) As a result of in-depth interviews, women’s experiences Partner of participants regarding IPV screening during pregnancy using the VAWS questionnaire were categorized into three Age (year) themes: necessity, acceptability and optimality. The first 20–29 9 (20.9) theme ‘necessity’ included benefits for women through 30–39 29 (67.4) IPV screening. Three categories supported ‘necessity’: re- 40< 5 (11.6) defining the relationship, promoting IPV awareness, and Employment status opportunity to initiate support. The second theme was Full-time 38 (88.4) focused on women’s ‘acceptability’ of IPV screening, es- pecially the VAWS questionnaire, and contained three Part-time 0 (0) categories: comfortable, quickly completed and difficulty. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 5 of 9 Table 1 Demographic characteristics of participants and ‘Once again, I start to take a look at our relationship, their partner (N = 43) (Continued) and think how to create a good relationship between n (%) me and my husband.’ Suspension from work 1 (2.3) ‘I thought about it (the relationship between us two), Unemployment 3 (7.0) remembering the way of talking with my husband, Others 1 (2.3) times when we have had an argument by doing IPV screening, The third theme, ‘optimality’ referred to IPV screening during pregnancy that had appropriate timing for both women screening positive or negative. These three themes are discussed next in more detail. (2) ‘Promoting IPV awareness’ There were seven women (16.3%) in the category ‘pro- Necessity moting IPV awareness’ due to IPV screening. These Participants talked about the necessity of IPV screening women said as a result of IPV screening, they under- for all women during pregnancy. There were three cat- stood that IPV was a serious social problem and that egories under this theme: ‘redefining the relationship’, there was a large number of women troubled by violence ‘promoting IPV awareness’ and ‘opportunity to initiate and felt sympathy with them, They said ‘I became aware support’ which all indicated benefits of IPV screening for again about IPV’; ‘Women are burdened by troubles not only potential victims but also all pregnant women. such as DV’. (1) ‘Redefining the relationship’ ‘From my opinion as a pregnant woman, women must never be subjected to it (violence). I have not experienced such violence, but if there are such There were 13 (30.2%) participants who discussed ‘re- women, they really are to be pitied. Question items defining the relationship’. For example they expressed (of VAWS) make me aware of it (violence) ’. opinions such as, ‘It caused me to think about my rela- tionship with my partner’. Participants were able to re- view their relationship with their partner and realized thereweremanypositiveattributes.There were also (3) ‘Opportunity to initiate support’ women who said that they felt the importance of sup- port from their partner during pregnancy and child Three women (7%) said that IPV screening ‘provides an rearing. Of particular note was that this category in- opportunity to receive support for women subjected to cluded women who had screened positive on the IPV’. In this category, the women indicated that IPV screen- VAWS during pregnancy. A few women (4.7%) said ing made disclosure easier and provided an opportunity to that IPV screening ‘provided an opportunity to discuss talk, and was linked to being able to get support. The par- their relationship with their partner’.Theyhad told ticipants said that particularly for women who had no one their partner about the IPV screening, and used it as an to consult with, this sort of opportunity was necessary. opening to discuss their relationship. Table 2 Frequency of each question of VAWS during pregnancy Often Sometimes None n% n% n% 1. Is it difficult to settle by talking arguments between you and your partner? 0 (0) 16 (37.2) 27 (62.8) 2. Do you feel frightened by what he does or said? 0 (0) 6 (14.0) 37 (86.0) 3. Has your partner screamed and/or yelled at you? 0 (0) 6 (14.0) 37 (86.0) 4. Has your partner ever hit the wall or thrown objects? 0 (0) 2 (4.7) 41 (95.3) 5. Has your partner ever forced you to have sex? 0 (0) 1 (2.3) 42 (97.7) 6. Has your partner ever pulled your arm, pushed, slapped you? 0 (0) 1 (2.3) 42 (97.7) 7. Has your partner ever hit or kicked you? 0 (0) 0 (0) 43 (100) Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 6 of 9 ‘If there are mothers worried by violence, it would be (3) ‘Difficulty’ good if they can be provided support after giving birth. For women with no one to consult, it is an There were only 2 women (4.7%) who replied that opportunity to talk about it’ ‘There was a question difficult to answer’. One of the reasons was that the contents of screening questions query about topics that are private especially regarding Acceptability sexual violence. This woman screened negative in the Acceptability of using the VAWS questionnaire emerged VAWS test before pregnancy and during pregnancy. from women’s experiences. There were three categories One woman responded that she did not feel discomfort supporting acceptability: ‘comfortable’, ‘quickly com- about the questions, but thought that if her partner saw pleted’ and ‘difficulty’. her answers he would feel uncomfortable, so they were difficult to answer. That woman screened positive in the (1) ‘Comfortable’ VAWS test before pregnancy and during pregnancy. Most of the women, 42 women (97.7%), described some ‘There was a question difficult to answer a bit. That is aspect of ‘comfortable’. In this category, a common ex- about sexual violence. Because it is private matter. I pression was ‘it was not unpleasant’ or ‘I wasn’t particu- can answer it, but I feel like difficult to answer’ larly concerned’. This means women in general accepted being questioned about IPV and about the expressions ‘I didn’t feel uncomfortable. But I feel the question is used for the questionnaire items. Most women did not feel private. I answered yes to the question “Does your uncomfortable about IPV screening, and among the 8 partner hit the wall or scream when he is angry”.If women who were positive for IPV screening during preg- my husband looked at this answer, he would feel nancy, 7 women replied ‘It was not unpleasant’. uncomfortable. I am afraid so.’ ‘Midwife promised that privacy was protected, so it wasn’t unpleasant’. Optimality The majority of the women (95.3%) thought that con- ‘I haven’t experienced this problem, so I wasn’t ducting IPV screening at the prenatal check-up was opti- concerned and uncomfortable. But I don’t know. mal. Those 41 women gave positive responses such as ‘I Women who experienced violence would be think it’s good’,and ‘I would not mind it’. On the other concerned, I am not sure. I don’t feel uncomfortable hand, 2 women gave negative responses such as, ‘It is for the questions (of IPV screening).’ not necessary’, and ‘I don’t think it is much good’.The reason for this was IPV is not an illness, so it is not ne- cessary to deal with it at a hospital. (2) ‘Quickly completed’ ‘I think it’s good. It is helpful for women who have There were 30 women (69.8%) who thought the VAWS experienced violence’ screening tool was easy to read and answer. Participants commented: ‘There were no questions difficult to under- ‘I don’t think it is much good. Because IPV is different stand’, ‘I think it was easy to answer’. The VAWS is a from an illness, so it is not necessary to deal with it at 7-item screening tool and each item is short and simple; a hospital. There are other places to help women like therefore women understood and found there were no shelters’. items that were difficult to understand. Additionally, 40 women (93.0%) thought the IPV screening could be In addition, when participants were asked whether completed quickly, so it was ‘just right’ or ‘appropriate’. they would consult with health care providers about IPV, However, three women thought it was ‘a lot’. only 8 women (18.6%) replied ‘Yes’. Reasons given for replying ‘Yes’ were ‘They seem close at hand’, ‘I want to consult a third party’, and ‘I can accept it if it is the opin- ‘There were no questions where I didn’t understand ion of a specialist’. Four women (9.3%) replied ‘I can’t the intention of the question’ say’. Reasons for replying ‘Ican’t say’ were ‘I don’t know’, ‘It depends on the details’, and ‘It depends on the situ- ‘The same types of questions are repeated. If asking ation’. The majority, 31 women (72.1%), replied ‘No’. these questions at a pregnancy checkup, fewer Reasons for replying ‘No’ were: ‘It is difficult to talk’, ‘I questions are better’ would talk with friends or family first’, ‘I would consult Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 7 of 9 an IPV specialist’, ‘It would be a problem if my partner Benefits and possible problems for IPV screening was informed of the fact that I consulted’, and ‘I don’t Benefits of IPV screening connect nurses with consultation about violence’. IPV affects not only a woman’s health, safety and inde- pendence, but also affects the future of the child(ren). In Discussion addition, Petersen and colleagues [37] indicated that Participants were about the same age, marital status and concern about children’s safety was a strong motivator parity as most pregnant women in Japan [32]. The level for women to seek help or access services. Therefore, it of education and annual income of participants reflected is advantageous to conduct IPV screening at the location the smaller cities and towns across Japan [33]. of perinatal care. Accordingly, in Japan where almost all women have health checkups by health care providers Experiences of women who were screened for IPV during during pregnancy, conducting IPV screening at the loca- pregnancy tion of perinatal care fulfills an important role in linking At the post-birth interviews for this study, concerning with interventions and continuing local support prior to IPV screening using the self-completed VAWS ques- the development into a serious problem. Conducting tionnaire at a pregnancy checkup, 97% of participants IPV screening provides an opportunity for women to replied that ‘They were not uncomfortable’. In earlier disclose about intimate partner violence and an oppor- research, with similar populations, participants who tunity for health professionals to follow-up, and it can replied that ‘They were not uncomfortable’ exceeded be linked to continuing support. 80% in Kataoka’sstudy [27], and the rate was 97% in In addition, we found that IPV screening not only in- the study by Inami et al. [28], similar to the results creased awareness concerning IPV, but also it triggered of our study. These results indicate that IPV screen- some women to think about their relationship with their ing using VAWS questions can be answered without partner. This may be considered a large benefit for the physical or mental burden on pregnant women, and women. IPV screening provides a good opportunity for without them feeling uncomfortable. Our study find- the women to review their relationship with their part- ings should eliminate concerns of health care pro- ner. Furthermore, among women victims, if the woman viders such as fear of offending the woman or the has not identified herself as being subjected to violence, woman’s reaction [26], and assist to promote the the IPV screening may provide the opportunity for that screening in prenatal settings in Japan. Moreover the recognition and awareness. In this study, a positive com- VAWS is a self-administered questionnaire, so it can ment was received from a woman who was screening help women to feel secure. The RCT conducted in positive for IPV. Women who have been victims of IPV Japan [34] indicated that self-completed screening do not always perceive themselves as victims, thereby identified more abused women than face-to-face inter- remaining isolated and alone. Awareness and naming of views. MacMillan et al. [35]alsoreportedthatwomen IPV for women can be considered the link towards re- preferred self-completed approaches instead of covery. Changing their self-perception may take time, face-to-face questioning. The VAWS questions and however it is important from a long-term viewpoint, as the self-completed questionnaire were the basic rea- they can share with other women who are IPV victims. sons why almost all participants felt comfortable in By labeling the woman’s experience as IPV, the woman the study. can finally join a support network [38]. However a few women in our study were uneasy an- swering the questions. When the woman’s partner domi- Possible problems for IPV screening nates her, the woman is deprived of feelings of personal There were several distinct problems found in this IPV control and feelings of safety, so may feel uneasy. The screening. Systematic review of possible barriers of abused health care provider will develop a relationship where woman revealed one of the problems was fear of retali- the woman feels safe. As indicated in the Feder, Hutson, ation by the partner [26]. The partner may accompany the Ramsay & Taket study, it is essential for all health care woman to the perinatal care location, and it may not be professionals to have a nonjudgmental, compassionate easy to guarantee privacy in a busy clinical situation [24]. and sensitive attitude, and to maintain confidentiality In this study, some women worried if her partner knows [36]. Additionally, we found that there was a minority of the IPV screening result. One critical issue is to maintain negative opinions about the VAWS question items, even privacy as much as possible and provide an environment though the question contents can be considered to where a woman can speak freely in peace. Next, the re- present low invasiveness for women. It is also necessary sults of this study clarified that women do not associate to consider revising VAWS, and refine simple question IPV with hospitals, as a health care issue and they are not items so that they can be used amongst a busy medical aware that nurses as health care providers can provide environment. consultation about IPV. One factor for this lack of Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 8 of 9 women’s awareness may be embedded in the health care Funding Support was provided by a Ministry of Education, Culture, Sports, Science environment itself due to health care providers’ low and Technology Study Support Grant (22390435). The funding body had no awareness about IPV. About 16 years have passed since influence on the study design and collection, analysis, and interpretation of enactment of the IPV Prevention Act. Guidelines for data and on writing the manuscript. nurses were created [30] within several years after that. Availability of data and materials However, nurses who knew the contents of the DV Pre- The data and materials are not available and are not openly shared due to vention Act represented less than 20% of nurses [39], and consent conditions with participants. health care providers who have implemented countermea- Authors’ contributions sures policy are still few [22]. One factor why DV screen- YK was involved in the design of the study, data analysis and manuscript ing has not spread was said to be that the screening writing. MI participated in the design of the study, data collection and data analysis. Both authors read and approved the final manuscript. method itself was not understood [22]. Other researchers pointed out that outcome evidence for conducting DV Ethics approval and consent to participate screening is insufficient and is a factor explaining why This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of St. Luke’s College screening is not widespread [40, 41]. of Nursing (Approval No.: 11-039). All participants gave written informed consent. Consent forms were signed by the study participants. Refusal to give consent did not influence management of the patient involved. Study limitations and future issues It is possible that the small sample size and characteris- Competing interests tics of participants and also location of this study was The authors declare that they have no competing interests. limiting. Accordingly, it is necessary to continue this study with diverse participants from a variety of back- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in grounds across a wider range of regions. Continued published maps and institutional affiliations. work on the questionnaire to eliminate unnecessary re- dundancy and confusing questions is also required. Author details 1 2 St. Luke’s International University, Tokyo, Japan. St. Luke’s International Hospital, Tokyo, Japan. Conclusion Evaluations by women who experienced IPV screening Received: 27 October 2016 Accepted: 16 May 2018 indicated that the majority did not find it uncomfortable. Although there were a few negative opinions about IPV References screening, such as concern if their husband found out, 1. World Health Organization. Violence against women. 2013. http://www.who. int/mediacentre/factsheets/fs239/en/. Accessed 15 Sept 2016. interestingly among the positive opinions were com- 2. 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Women Birth. 2016; 29(6):503–10. https://doi.org/10.1016/j.wombi.2016.04.010. 26. Sprague S, Madden K, Simunovic N, Godin K, Pham NK, Bhandari M, et al. Barriers to screening for intimate partner violence. Women Health. 2012; 52(6):587–605. 27. Kataoka Y. Effectiveness of two screening methods in a prenatal setting for identifying women experiencing domestic violence. Tokyo: St Luke’s College of Nursing; 2004. Doctoral dissertation. 28. Inami E, Kataoka Y, Eto H, Horiuchi S. Intimate partner violence against Japanese and non-Japanese women in Japan: A cross-sectional study in the perinatal setting. Jpn J Nurs Sci. 2010;7(1):84–95. 29. Kataoka Y. Development of the violence against women screen. J Jpn Acad Nurs Sci. 2005;25(3):51–60. [in Japanese] 30. Women-centered Care Working Group, St. Luke’s College of Nursing. Evidence-based guidelines for support of domestic violence victims in perinatal settings. Tokyo: Kanehara & Co., Ltd; 2004. in Japanese 31. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12. 32. Mothers’ & Children’s Health & Welfare Association. Maternal and child health statistics of Japan. Tokyo: Mothers’ & Children’sHealth Organization; 2016. 33. Ministry of Health, Labour and Welfare. Comprehensive Survey of Living Conditions (2016). http://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k- tyosa16/dl/03.pdf 34. Kataoka Y, Yaju Y, Eto H, Horiuchi S. Self-administered questionnaire versus interview as a screening method for intimate partner violence in the http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Women's Health Springer Journals

Experiences of being screened for intimate partner violence during pregnancy: a qualitative study of women in Japan

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Medicine & Public Health; Gynecology; Maternal and Child Health; Reproductive Medicine
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Abstract

Background: Intimate partner violence (IPV) is physical, sexual or psychological violence by a current or former intimate partner. IPV threatens women’s health, and during pregnancy women are more vulnerable to violence. Therefore, IPV screening has been recommended during antenatal care; however, health care providers have expressed concern about the negative impact on women and therefore have been reluctant in conducting IPV screening. Consequently our objective was to investigate pregnant women’s experiences of reading and completing an IPV screening questionnaire. Methods: Semi-structured interviews were conducted with postpartum women who had received IPV screening during pregnancy to investigate their experiences using the IVP Violence Against Women Screen (VAWS). Qualitative data were analyzed based on content analysis. Results: A total of 43 women participated in this study. There were eight (18.6%) women positive for IPV screening during pregnancy. Content analysis for all participants revealed three themes: necessity, acceptability and optimality. ‘Necessity’ referred to benefits for women from IPV screening, and was supported by three categories: ‘redefining the relationship’, ‘promoting IPV awareness’ and ‘opportunity to initiate support’. ‘Acceptability’ of IPV screening was also supported by three categories: ‘comfortable’, ‘quickly completed’ and ‘difficulty’. ‘Optimality’ meant IPV screening during pregnancy was appropriate timing for women who had been screened as either positive or negative. Conclusions: The majority of women, including women experiencing IPV, had positive responses to IPV screening during pregnancy. Future diffusion of IPV screening requires safe environments for IPV screening and improved awareness of health care providers towards IPV. Keywords: Intimate partner violence, Pregnancy, Screening experience, Qualitative study Background male partners. IPV is also a serious social problem in Intimate partner violence (IPV) is defined as behavior by Japan. The Gender Equality Bureau Cabinet Office [3]in an intimate partner that causes physical, sexual or psy- Japan conducted a national survey and found 15% of chological harm, including acts of physical aggression, women experienced physical violence, 12% of women sexual coercion, psychological abuse and controlling be- were assaulted psychologically by male partners and 7% haviors [1]. The World Health Organization stated that of women experienced coercive sexual intercourse. In violence against women is a major global public health addition, the rate of IPV victims has not changed for problem and human rights concern. The study by the over ten years since the government survey started in WHO [2] in ten different countries reported that 1999. It is urgent that solutions be developed to elimin- 13%-61% of women had been abused by their intimate ate violence against women in all countries. Moreover, IPV towards pregnant women is a serious concern that the world faces. A systematic review indi- * Correspondence: yaeko-kataoka@slcn.ac.jp cated that prevalence of IPV during pregnancy ranged St. Luke’s International University, Tokyo, Japan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 2 of 9 from 0.9% to 20.1% [4]. Research on Japanese pregnant time limitations [23, 24], lack of confidence in screening women that applied the Index of Spouse Abuse (ISA) [5] [24, 25], difficulty to establish rapport [24], unease or found that 5% of women experienced IPV during preg- fear about angering patients or causing emotional dis- nancy, and another survey showed that 1% of pregnant comfort [26]. In a questionnaire survey of women in women had experienced physical intimate partner vio- Japan who had experienced IPV screening, most women lence [2]. IPV threatens several aspects of health among replied that it was not unpleasant [27, 28], but these pregnant women. These include not only physical injur- were only a few questionnaire items answerable in yes/ ies [6] but also psychological impairment such as post- no format, to elicit the extent of satisfaction and with no partum depression [7], posttraumatic stress disorder [8, psychometric controls applied. No other information 9], bonding disorders [10] and suicidality [11]. Violence was garnered about their experience. during pregnancy can result in pregnancy complications Accordingly, this study aimed to conduct semi-structured such as hypertension, vaginal and cervical bleeding, pla- interviews with postpartum women who received IPV cental problems, severe nausea, and kidney infection screening during pregnancy to investigate women’sexperi- [12]. In addition IPV during pregnancy affects the fetus ences of reading and completing the IPV screening and neonates, such as low birth weight, preterm delivery questionnaire. and neonatal death [13–15]. It may cause life-threatening results or the death of the mother and child [13, 15, 16]. In Japan, the Act on the Prevention of Spousal Vio- Methods lence and the Protection of Victims was promulgated in Design April 2001 in recognition of the high IPV prevalence The first part of this study was a descriptive IPV survey and its adverse social and health outcomes in Japan [17]. with a purposive sample of women. The second part of This was the first law to indicate explicitly that spousal the study was qualitative using content analysis of violence was a criminal act and the perpetrator must be semi-structured interviews of the same sample. punished by the criminal code. It also prescribed that prefectures establish and authorize at least one or more spousal violence counseling and support centers to take Study setting and participants a central role in the support system for IPV victims in This study was conducted in a general hospital that pro- Japan. As a result of the Act, the number of institutions vided antenatal to postpartum care in a city of the Na- such as shelters, women’s counseling centers and IPV gano region. The city has approximately 28,000 people counseling centers increased. By 2001, more than 180 and is located near the Japanese Alps on the large island spousal violence counseling and support centers had of Honshu. Participants eligible for this study were preg- been established in Japan. Counseling by these centers nant women whose due day was from the beginning of in 2007 numbered 62,078, about double the number in October through the end of November 2011 and plan- 2002 [18]. This indicates that given the opportunity, ning on giving birth at the general hospital, and who women in Japan seek help and receive support about were: (1) Japanese speaking, (2) had no severe complica- IPV and that support has been expanding. tions and (3) able to participate in the informed consent A systematic review concluded that there was evidence process. that IPV screening increased identification of women ex- After approval by the Institutional Review Board of St. periencing IPV, however, there was insufficient evidence Luke’s College of Nursing (Approval No.: 11-039) the of an effect for other outcomes such as recurrence of study commenced. Eligible women were invited to par- IPV or health measures [19]. Recently some evidence ticipate. Between September and December 2011, we from antenatal care settings suggested that advocacy and consecutively recruited pregnant women face-to-face at empowerment interventions that followed IPV screening their pregnancy checkup who matched inclusion criteria. provided results in improved mental health outcomes of We excluded one woman who was unable to read Japa- women [20, 21]. Based on this, WHO guidelines recom- nese. IPV screening was conducted at the prenatal mended IPV screening for women during their antenatal checkup at 35 weeks and onwards of pregnancy. Because care [1]. In Japan, the Act on the Prevention of Spousal at 35 weeks checkup women have an opportunity to Violence and the Protection of Victims also stipulated consult with a midwife, we conducted IPV screening the role of medical professionals for early detection and with self-administrated questionnaire at a privacy-secured consultation. However, a survey of four prefectures in room without her partner and other family members after metropolitan areas found that IPV screening is still not midwife’s consultation. Participation was voluntary and widespread, with only 5% of institutions conducting IPV participants were assured of their right to stop participat- screening [22]. The common barriers to conducting IPV ing at any time without harm. They were also assured that screening at health care settings have been reported as their data would be kept confidential and anonymous. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 3 of 9 Instruments of the participant’s partner or other family members. Basic- The screening instrument used was the VAWS [29]. ally Interview was carried out once. VAWS is a 3-point Likert Scale comprised of seven items dealing with physical, psychological and sexual Follow-up of participants violence. Participants could respond: never = 0; some- Before starting this study, the researchers developed the times = 1; or often = 2. A score of 2 points or more indi- support protocol for IPV victims at the hospital partici- cated IVP. Structural concept validity using factor pating in this study and also informed the local Spousal analysis, and concurrent validity of the General Health Violence Counseling and Support Centers about the Questionnaire and the Rosenberg Self Esteem Scale were study. After IPV screening and the interviews, all partici- established. Cronbach’s α was 0.70 for reliability. Kataoka pants in this study were provided information orally and [29] reported that when the Japanese version of the in written form about social resources available in the Index of Spouse Abuse (Japanese ISA) was applied as region surrounding the cooperating hospital. Also, for the optimized standard, sensitivity was 86.7% and speci- women who screened positive and needed support, a ficity was 80.2%. trained midwife was appointed to liaise with this study In addition to the VAWS, demographic information and to provide consultation, safety planning and referral about the participants was also collected such as age, to the IPV support center in the community. marital status, family configuration, educational back- During this study, if a participant experienced some ground, employment status, annual income, parity, and form of physical or mental problem or was judged to be information about the woman’s partner. at risk of IPV requiring specialist intervention, the re- Researchers or a trained midwife distributed the searchers coordinated with university academics self-administered VAWS questionnaire. Participants researching and advising about IPV, with advisors from completed it at a location guaranteeing privacy. After Spousal Violence Counseling and Support Centers, and the questionnaire was completed, researchers or a mid- with the liaison midwife from the general hospital co- wife from the hospital collected it. operating with this study, so that appropriate assistance could be provided with the safety of the women as first Data collection priority. Support was provided in accordance with the Maternity hospital stays are typically 5 – 7 days in Japan. Perinatal Domestic Violence Support Guidelines [30]. If Therefore allowing for physical recovery after childbirth, clear evidence of violence was discovered, after consent the interview to evaluate IPV screening during preg- was obtained from the study participant, the midwife rd nancy was conducted on the 3 - 4th day after vaginal from the general hospital cooperating with this study re- th delivery, or the 5 - 6th day after cesarean delivery dur- ported the matter to the Spousal Violence Counseling ing their hospital stay. and Support Center or the police. In order to obtain data of study participants’ experiences when reading and completing the VAWS, the researchers Data analysis created an interview guide (see Additional file 1), to elicit Frequencies and percentage were used for quantitative participants’ opinions and thoughts concerning IPV screen- data. Qualitative data were analyzed using content analysis ing, acceptability of the VAWS questionnaire items, such as [31]. The recorded contents from the IC recorder were words that participants found difficult to understand and ex- transcribed literally. The transcriptions were read repeat- pressions that participants found distasteful, and responses edly, and divided up for words and phrases that captured to screening methods and timing. Using the interview guide, the meaning of women’s experiences of IPV screening at the researchers conducted semi-structured interviews with the pregnancy checkup, and then labeled with codes that participants for about 30 minutes. The interview contents denoted the meaning. The codes were interpreted and were recorded on an IC recorder with the consent of the compared based on differences and similarities. Codes study participants. In order to confirm the interview con- were sorted into sub-categories, representing a more ab- tents and provide anonymity, ID numbers instead of individ- stract level, and then subsumed into categories regarding ual names were used to identify questionnaires. One of the their similarities. Finally, frequencies and percentages were researchers (MI), a female nurse who was also a graduate calculated by categories. The second author (MI) coded student, visited the cooperating hospital and conducted the each interview, and then discussed the coding with the interviews. Before commencement of this study, researcher first author (YK) until agreement was reached. (MI) did pre-interviews whether she could interview accord- ing to the interview guide and listen to participant’s feeling Results and thought with non-judgmental manner. All interviews Demographic characteristics of participants conducted after childbirth were at a location protecting the Of the 48 women meeting the inclusion criteria during privacy of the survey participant and without the presence the study period and invited to participate in this study, Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 4 of 9 agreement was received from 43 women (89.5%). The Table 1 Demographic characteristics of participants and their partner (N = 43) five not participating had been transferred to another hospital. After this information was provided and written n (%) informed consent was obtained data was collected. The Participants valid response rate for the Violence Against Women Age (year) Screen (VAWS) was 100%. All 43 women were then <20 1 (2.3) interviewed during their postpartum stay in the hospital. 20–29 14 (32.6) Table 1 displays the demographic characteristics of 30< 28 (65.1) participants. The majority (65.1%), of participants were Marital status in their thirties. Slightly over half were multiparas and the majority had vaginal births. All were married and Married 43 (100) most resided with their husbands. Family composition Divorce history was nuclear family for 31 women (72.1%). Slightly over Wife 3 (7.0) one-third of the participants were considered ‘house- Husband 1 (2.3) wives’ and the remainder worked full or part time. Most Living with partner had graduated from high school and some had higher Cohabitated 40 (93.0) education. The couple’s annual income was between ‘$21,000-and $40,000 for half of the participants and be- Separated 3 (7.0) tween $41,000 and $61,000 or more’ for almost the other Family structure half. No one was receiving welfare payments. The partic- Nuclear families 31 (72.1) ipants’ spouses were generally in their thirties (67.4%) Extended families 12 (27.9) and most were employed (90.6%). One man (2.3%) was Educational background suspended from duty, and 3 men (7.0%) were Junior high school graduate 4 (9.3) unemployed. High school graduate 10 (23.3) Results of IPV screening in pregnancy Junior college graduate 17 (39.5) Table 2 indicates the frequency of responses for each University graduate / Graduate school 12 (27.9) question of VAWS during pregnancy. A total 37.2% of Employment status participants responded “sometimes” for the question “Is House duty 15 (34.9) it difficult to settle by talking arguments between you Full-time 16 (37.2) and your partner?”, and 14% of participants responded “sometimes” for “feel frightened by their partner” and Part-time 10 (23.3) “Has your partner screamed and /or yelled at you?” Others 2 (4.7) “Sometimes” was answered by 4.7% for the question of Annual income (dollar) “hit the wall or thrown object”. One woman responded <200,000 2 (4.7) “sometimes” for sexual violence, and also one woman 200,000–400,000 22 (51.2) responded “sometimes” for physical violence. There were 400,000–600,000 9 (20.9) 8 women (18.6%) who screened positive for IPV during pregnancy; in other words their VAWS score exceeded 600,000≦ 9 (20.9) the cut-off of 2 points or greater and one was referred to Missing 1 (2.3) the counseling center. Parity Primipara 19 (44.2) Women’s experiences of IPV screening Multipara 24 (55.8) As a result of in-depth interviews, women’s experiences Partner of participants regarding IPV screening during pregnancy using the VAWS questionnaire were categorized into three Age (year) themes: necessity, acceptability and optimality. The first 20–29 9 (20.9) theme ‘necessity’ included benefits for women through 30–39 29 (67.4) IPV screening. Three categories supported ‘necessity’: re- 40< 5 (11.6) defining the relationship, promoting IPV awareness, and Employment status opportunity to initiate support. The second theme was Full-time 38 (88.4) focused on women’s ‘acceptability’ of IPV screening, es- pecially the VAWS questionnaire, and contained three Part-time 0 (0) categories: comfortable, quickly completed and difficulty. Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 5 of 9 Table 1 Demographic characteristics of participants and ‘Once again, I start to take a look at our relationship, their partner (N = 43) (Continued) and think how to create a good relationship between n (%) me and my husband.’ Suspension from work 1 (2.3) ‘I thought about it (the relationship between us two), Unemployment 3 (7.0) remembering the way of talking with my husband, Others 1 (2.3) times when we have had an argument by doing IPV screening, The third theme, ‘optimality’ referred to IPV screening during pregnancy that had appropriate timing for both women screening positive or negative. These three themes are discussed next in more detail. (2) ‘Promoting IPV awareness’ There were seven women (16.3%) in the category ‘pro- Necessity moting IPV awareness’ due to IPV screening. These Participants talked about the necessity of IPV screening women said as a result of IPV screening, they under- for all women during pregnancy. There were three cat- stood that IPV was a serious social problem and that egories under this theme: ‘redefining the relationship’, there was a large number of women troubled by violence ‘promoting IPV awareness’ and ‘opportunity to initiate and felt sympathy with them, They said ‘I became aware support’ which all indicated benefits of IPV screening for again about IPV’; ‘Women are burdened by troubles not only potential victims but also all pregnant women. such as DV’. (1) ‘Redefining the relationship’ ‘From my opinion as a pregnant woman, women must never be subjected to it (violence). I have not experienced such violence, but if there are such There were 13 (30.2%) participants who discussed ‘re- women, they really are to be pitied. Question items defining the relationship’. For example they expressed (of VAWS) make me aware of it (violence) ’. opinions such as, ‘It caused me to think about my rela- tionship with my partner’. Participants were able to re- view their relationship with their partner and realized thereweremanypositiveattributes.There were also (3) ‘Opportunity to initiate support’ women who said that they felt the importance of sup- port from their partner during pregnancy and child Three women (7%) said that IPV screening ‘provides an rearing. Of particular note was that this category in- opportunity to receive support for women subjected to cluded women who had screened positive on the IPV’. In this category, the women indicated that IPV screen- VAWS during pregnancy. A few women (4.7%) said ing made disclosure easier and provided an opportunity to that IPV screening ‘provided an opportunity to discuss talk, and was linked to being able to get support. The par- their relationship with their partner’.Theyhad told ticipants said that particularly for women who had no one their partner about the IPV screening, and used it as an to consult with, this sort of opportunity was necessary. opening to discuss their relationship. Table 2 Frequency of each question of VAWS during pregnancy Often Sometimes None n% n% n% 1. Is it difficult to settle by talking arguments between you and your partner? 0 (0) 16 (37.2) 27 (62.8) 2. Do you feel frightened by what he does or said? 0 (0) 6 (14.0) 37 (86.0) 3. Has your partner screamed and/or yelled at you? 0 (0) 6 (14.0) 37 (86.0) 4. Has your partner ever hit the wall or thrown objects? 0 (0) 2 (4.7) 41 (95.3) 5. Has your partner ever forced you to have sex? 0 (0) 1 (2.3) 42 (97.7) 6. Has your partner ever pulled your arm, pushed, slapped you? 0 (0) 1 (2.3) 42 (97.7) 7. Has your partner ever hit or kicked you? 0 (0) 0 (0) 43 (100) Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 6 of 9 ‘If there are mothers worried by violence, it would be (3) ‘Difficulty’ good if they can be provided support after giving birth. For women with no one to consult, it is an There were only 2 women (4.7%) who replied that opportunity to talk about it’ ‘There was a question difficult to answer’. One of the reasons was that the contents of screening questions query about topics that are private especially regarding Acceptability sexual violence. This woman screened negative in the Acceptability of using the VAWS questionnaire emerged VAWS test before pregnancy and during pregnancy. from women’s experiences. There were three categories One woman responded that she did not feel discomfort supporting acceptability: ‘comfortable’, ‘quickly com- about the questions, but thought that if her partner saw pleted’ and ‘difficulty’. her answers he would feel uncomfortable, so they were difficult to answer. That woman screened positive in the (1) ‘Comfortable’ VAWS test before pregnancy and during pregnancy. Most of the women, 42 women (97.7%), described some ‘There was a question difficult to answer a bit. That is aspect of ‘comfortable’. In this category, a common ex- about sexual violence. Because it is private matter. I pression was ‘it was not unpleasant’ or ‘I wasn’t particu- can answer it, but I feel like difficult to answer’ larly concerned’. This means women in general accepted being questioned about IPV and about the expressions ‘I didn’t feel uncomfortable. But I feel the question is used for the questionnaire items. Most women did not feel private. I answered yes to the question “Does your uncomfortable about IPV screening, and among the 8 partner hit the wall or scream when he is angry”.If women who were positive for IPV screening during preg- my husband looked at this answer, he would feel nancy, 7 women replied ‘It was not unpleasant’. uncomfortable. I am afraid so.’ ‘Midwife promised that privacy was protected, so it wasn’t unpleasant’. Optimality The majority of the women (95.3%) thought that con- ‘I haven’t experienced this problem, so I wasn’t ducting IPV screening at the prenatal check-up was opti- concerned and uncomfortable. But I don’t know. mal. Those 41 women gave positive responses such as ‘I Women who experienced violence would be think it’s good’,and ‘I would not mind it’. On the other concerned, I am not sure. I don’t feel uncomfortable hand, 2 women gave negative responses such as, ‘It is for the questions (of IPV screening).’ not necessary’, and ‘I don’t think it is much good’.The reason for this was IPV is not an illness, so it is not ne- cessary to deal with it at a hospital. (2) ‘Quickly completed’ ‘I think it’s good. It is helpful for women who have There were 30 women (69.8%) who thought the VAWS experienced violence’ screening tool was easy to read and answer. Participants commented: ‘There were no questions difficult to under- ‘I don’t think it is much good. Because IPV is different stand’, ‘I think it was easy to answer’. The VAWS is a from an illness, so it is not necessary to deal with it at 7-item screening tool and each item is short and simple; a hospital. There are other places to help women like therefore women understood and found there were no shelters’. items that were difficult to understand. Additionally, 40 women (93.0%) thought the IPV screening could be In addition, when participants were asked whether completed quickly, so it was ‘just right’ or ‘appropriate’. they would consult with health care providers about IPV, However, three women thought it was ‘a lot’. only 8 women (18.6%) replied ‘Yes’. Reasons given for replying ‘Yes’ were ‘They seem close at hand’, ‘I want to consult a third party’, and ‘I can accept it if it is the opin- ‘There were no questions where I didn’t understand ion of a specialist’. Four women (9.3%) replied ‘I can’t the intention of the question’ say’. Reasons for replying ‘Ican’t say’ were ‘I don’t know’, ‘It depends on the details’, and ‘It depends on the situ- ‘The same types of questions are repeated. If asking ation’. The majority, 31 women (72.1%), replied ‘No’. these questions at a pregnancy checkup, fewer Reasons for replying ‘No’ were: ‘It is difficult to talk’, ‘I questions are better’ would talk with friends or family first’, ‘I would consult Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 7 of 9 an IPV specialist’, ‘It would be a problem if my partner Benefits and possible problems for IPV screening was informed of the fact that I consulted’, and ‘I don’t Benefits of IPV screening connect nurses with consultation about violence’. IPV affects not only a woman’s health, safety and inde- pendence, but also affects the future of the child(ren). In Discussion addition, Petersen and colleagues [37] indicated that Participants were about the same age, marital status and concern about children’s safety was a strong motivator parity as most pregnant women in Japan [32]. The level for women to seek help or access services. Therefore, it of education and annual income of participants reflected is advantageous to conduct IPV screening at the location the smaller cities and towns across Japan [33]. of perinatal care. Accordingly, in Japan where almost all women have health checkups by health care providers Experiences of women who were screened for IPV during during pregnancy, conducting IPV screening at the loca- pregnancy tion of perinatal care fulfills an important role in linking At the post-birth interviews for this study, concerning with interventions and continuing local support prior to IPV screening using the self-completed VAWS ques- the development into a serious problem. Conducting tionnaire at a pregnancy checkup, 97% of participants IPV screening provides an opportunity for women to replied that ‘They were not uncomfortable’. In earlier disclose about intimate partner violence and an oppor- research, with similar populations, participants who tunity for health professionals to follow-up, and it can replied that ‘They were not uncomfortable’ exceeded be linked to continuing support. 80% in Kataoka’sstudy [27], and the rate was 97% in In addition, we found that IPV screening not only in- the study by Inami et al. [28], similar to the results creased awareness concerning IPV, but also it triggered of our study. These results indicate that IPV screen- some women to think about their relationship with their ing using VAWS questions can be answered without partner. This may be considered a large benefit for the physical or mental burden on pregnant women, and women. IPV screening provides a good opportunity for without them feeling uncomfortable. Our study find- the women to review their relationship with their part- ings should eliminate concerns of health care pro- ner. Furthermore, among women victims, if the woman viders such as fear of offending the woman or the has not identified herself as being subjected to violence, woman’s reaction [26], and assist to promote the the IPV screening may provide the opportunity for that screening in prenatal settings in Japan. Moreover the recognition and awareness. In this study, a positive com- VAWS is a self-administered questionnaire, so it can ment was received from a woman who was screening help women to feel secure. The RCT conducted in positive for IPV. Women who have been victims of IPV Japan [34] indicated that self-completed screening do not always perceive themselves as victims, thereby identified more abused women than face-to-face inter- remaining isolated and alone. Awareness and naming of views. MacMillan et al. [35]alsoreportedthatwomen IPV for women can be considered the link towards re- preferred self-completed approaches instead of covery. Changing their self-perception may take time, face-to-face questioning. The VAWS questions and however it is important from a long-term viewpoint, as the self-completed questionnaire were the basic rea- they can share with other women who are IPV victims. sons why almost all participants felt comfortable in By labeling the woman’s experience as IPV, the woman the study. can finally join a support network [38]. However a few women in our study were uneasy an- swering the questions. When the woman’s partner domi- Possible problems for IPV screening nates her, the woman is deprived of feelings of personal There were several distinct problems found in this IPV control and feelings of safety, so may feel uneasy. The screening. Systematic review of possible barriers of abused health care provider will develop a relationship where woman revealed one of the problems was fear of retali- the woman feels safe. As indicated in the Feder, Hutson, ation by the partner [26]. The partner may accompany the Ramsay & Taket study, it is essential for all health care woman to the perinatal care location, and it may not be professionals to have a nonjudgmental, compassionate easy to guarantee privacy in a busy clinical situation [24]. and sensitive attitude, and to maintain confidentiality In this study, some women worried if her partner knows [36]. Additionally, we found that there was a minority of the IPV screening result. One critical issue is to maintain negative opinions about the VAWS question items, even privacy as much as possible and provide an environment though the question contents can be considered to where a woman can speak freely in peace. Next, the re- present low invasiveness for women. It is also necessary sults of this study clarified that women do not associate to consider revising VAWS, and refine simple question IPV with hospitals, as a health care issue and they are not items so that they can be used amongst a busy medical aware that nurses as health care providers can provide environment. consultation about IPV. One factor for this lack of Kataoka and Imazeki BMC Women's Health (2018) 18:75 Page 8 of 9 women’s awareness may be embedded in the health care Funding Support was provided by a Ministry of Education, Culture, Sports, Science environment itself due to health care providers’ low and Technology Study Support Grant (22390435). The funding body had no awareness about IPV. About 16 years have passed since influence on the study design and collection, analysis, and interpretation of enactment of the IPV Prevention Act. Guidelines for data and on writing the manuscript. nurses were created [30] within several years after that. Availability of data and materials However, nurses who knew the contents of the DV Pre- The data and materials are not available and are not openly shared due to vention Act represented less than 20% of nurses [39], and consent conditions with participants. health care providers who have implemented countermea- Authors’ contributions sures policy are still few [22]. One factor why DV screen- YK was involved in the design of the study, data analysis and manuscript ing has not spread was said to be that the screening writing. MI participated in the design of the study, data collection and data analysis. Both authors read and approved the final manuscript. method itself was not understood [22]. Other researchers pointed out that outcome evidence for conducting DV Ethics approval and consent to participate screening is insufficient and is a factor explaining why This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of St. Luke’s College screening is not widespread [40, 41]. of Nursing (Approval No.: 11-039). All participants gave written informed consent. Consent forms were signed by the study participants. Refusal to give consent did not influence management of the patient involved. Study limitations and future issues It is possible that the small sample size and characteris- Competing interests tics of participants and also location of this study was The authors declare that they have no competing interests. limiting. Accordingly, it is necessary to continue this study with diverse participants from a variety of back- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in grounds across a wider range of regions. Continued published maps and institutional affiliations. work on the questionnaire to eliminate unnecessary re- dundancy and confusing questions is also required. Author details 1 2 St. Luke’s International University, Tokyo, Japan. St. Luke’s International Hospital, Tokyo, Japan. Conclusion Evaluations by women who experienced IPV screening Received: 27 October 2016 Accepted: 16 May 2018 indicated that the majority did not find it uncomfortable. Although there were a few negative opinions about IPV References screening, such as concern if their husband found out, 1. World Health Organization. Violence against women. 2013. http://www.who. int/mediacentre/factsheets/fs239/en/. Accessed 15 Sept 2016. interestingly among the positive opinions were com- 2. 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Published: May 29, 2018

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