Franchek-Road aDepartment of Sociology, University of Utah, Salt Lake City, UT 84112, USA bDepartment of Sociology, Vietnam National University, Ho Chi Minh City, Viet Nam cDivision of P
Trang 1Original Research
Intimate partner violence education for medical
students in the USA, Vietnam and China
A Kamimuraa,*, S Al-Obaydia, H Nguyenb, H.N Trinh a, W Moa,
P Doanc, K Franchek-Road
aDepartment of Sociology, University of Utah, Salt Lake City, UT 84112, USA
bDepartment of Sociology, Vietnam National University, Ho Chi Minh City, Viet Nam
cDivision of Public Health, University of Utah, Salt Lake City, UT, USA
d
Department of Paediatrics, University of Utah, Salt Lake City, UT, USA
a r t i c l e i n f o
Article history:
Received 20 January 2014
Received in revised form
21 December 2014
Accepted 27 April 2015
Available online xxx
Keywords:
Intimate partner violence
Medical education
Women's health
USA
Vietnam
China
a b s t r a c t Objectives: While intimate partner violence (IPV) is a global concern for women's health, there are few comparative studies of IPV training in medical schools The aim of this study was to investigate medical students' knowledge of, and training in, IPV in the USA, Vietnam and China
Study design: Cross-national, cross-sectional study
Methods: US (n ¼ 60), Vietnamese (n ¼ 232) and Chinese (n ¼ 174) medical students participated in a cross-sectional self-administered survey that included demographic characteristics; opinions, training and knowledge regarding IPV against women; and per-sonal experience with IPV victims
Results: Attitudes, knowledge and training about IPV among medical students varied be-tween the three countries US participants reported higher levels of knowledge of IPV, were more likely to believe that IPV was a serious problem, and were more likely to consider IPV
to be a healthcare problem compared with Vietnamese and Chinese participants Chinese participants, in particular, did not appear to appreciate the importance of addressing IPV Differences were found between the Vietnamese and Chinese students
Conclusions: While most medical schools in the USA include IPV training within their core medical curricula, education throughout medical school seems to be necessary to improve medical education regarding treatment of patients with a history of IPV Vietnamese and Chinese medical schools should consider including IPV education in the training of their future physicians to improve the health of women who have experienced IPV Practical opportunities for medical students to interact with women who have experienced IPV are essential to develop effective IPV education
© 2015 The Royal Society for Public Health Published by Elsevier Ltd All rights reserved
* Corresponding author Tel.: þ1 801 581 7858; fax: þ1 801 585 3784
E-mail address:akiko.kamimura@utah.edu(A Kamimura)
Available online at www.sciencedirect.com
Public Health
http://dx.doi.org/10.1016/j.puhe.2015.04.022
0033-3506/© 2015 The Royal Society for Public Health Published by Elsevier Ltd All rights reserved
Trang 2Intimate partner violence (IPV) is a significant public health
threat that causes injury, and acute and chronic physical and
mental health problems.1e3IPV includes physical, sexual and/
or psychological harm inflicted by a current or former
inti-mate partner.4Violence by an intimate partner is a common
experience for women throughout the world, with global
lifetime rates ranging from 15% to 71%.5
Women and children who have experienced IPV suffer
from a wide range of health problems, and use healthcare
services more often than women and children who have
never experienced IPV.6e8To ensure the health and safety of
women who have experienced IPV, future physicians and
healthcare professionals need training regarding
identifica-tion and intervenidentifica-tions for these patients.9In the USA, efforts
to improve IPV education of medical students and residents
have been implemented.10 Active learning strategies are
commonly used in family medicine residency curricula to
students to develop the clinical skills necessary to address
IPV victimization in the healthcare setting, training
should: occur during preclinical and clinical rotations;
include outreach experiences with victims and community
agencies; include education regarding the regulatory
stan-dards for addressing IPV in health care; and provide
knowl-edge about culturally appropriate interventions.12However,
there are a number of barriers to implementing an IPV
cur-riculum in medical schools, including lack of funding,
limited curriculum time, discomfort in discussing IPV with
patients, perception of relevance, training opportunities and
resources.13
While IPV is a global health concern, particularly for
women,14few comparative studies of IPV education in
medi-cal schools have been undertaken The purpose of this study
training in, IPV in the USA, Vietnam and China through a
cross-national comparative study in order to improve IPV
education of future doctors Comparing these countries helps
to elucidate the potential sociocontextual effects of IPV
training for medical students The selection of the countries in
this study was not random Rather, the authors worked with
collaborators who were interested in the issue of violence
against women in the USA, Vietnam and China
Women in the USA, Vietnam and China have similar
lifetime prevalence rates of IPV of 35.6%, 32.7% and 34%,
respectively.15e17While medical schools in the USA often
include IPV education,18to the best of the authors'
knowl-edge, there are no formal IPV curricula at medical schools in
Vietnam and China Studies in Vietnam,16China19and the
USA15,20,21have shown that IPV victims are more likely to be
diagnosed with injuries, chronic pain syndromes, mental
health problems, reproductive health issues, cardiovascular
disease and poorer health overall than individuals who
have never experienced IPV Educating future physicians
about the health effects of IPV is essential to improve their
skills in addressing this important healthcare issue for
women
Methods Study participants and data collection
The cross-sectional data were collected from July to September 2013 at three public medical schools in the USA, Vietnam and China The US medical school included in this study is the only medical school in a western state with a population of approximately three million people The Viet-namese medical school included in this study is one of two medical schools in a city with a population of approximately nine million people The Chinese medical school included in this study is one of 10 medical schools in a city with a popu-lation of approximately 100 million people In addition to differences in population size, the three countries also differ with respect to length of medical training In the US, medical students are college graduates and generally spend four years
in medical school In Vietnam and China, medical education starts after high school and varies from three to five years in China to six years in Vietnam
Prior to data collection, this study was approved as an exempt protocol by the Institutional Review Board of the University of Utah, USA Consent was obtained from each participant before starting the survey In July 2013, third- and fourth-year medical students at the US medical school received an email with a link to an online survey A reminder email was sent out in September 2013 Fifth- and sixth-year medical students in Vietnam and third- or fifth-year (last year at medical school depending on the programme) medical students in China were handed a consent cover letter and a paper survey in September 2013, and were asked to complete
it in class or at a meeting The survey instrument was trans-lated into Vietnamese and Chinese from English The survey was translated by a native Vietnamese/Chinese speaker who
is fluent in Vietnamese/ Chinese and English, and was back-translated by another translator into English The accuracy
of the translation was checked by both translators
At the US medical school, students are required to take a two-semester course that includes IPV education in the first and second years This four credit hour course provides com-munity experience related to several social issues including IPV, death and dying, mental health, human immunodefi-ciency virus/acquired immunodefiimmunodefi-ciency syndrome, home-lessness and substance abuse The students are assigned to a community agency in one of the topics After their community experience, the students meet back in the classroom during the second semester, listen to lectures on the topic, and then break
up into smaller groups for student presentations on their ex-periences in the community At the Vietnamese and Chinese medical schools, to the best of the authors' knowledge, there are no medical-related IPV courses In Vietnam, medical stu-dents learn about laws related to IPV through a lecture course
Measures Demographics
Standard demographic questions regarding sex and age were developed The participants were also asked whether they had
Trang 3heard about or witnessed IPV in the community, and whether
they knew anyone personally who had experienced IPV
General opinions about IPV against women
Opinions regarding IPV against women were extracted from
the Domestic Violence against Women Report.22 Questions
regarding the participants' opinions on the following topics
included: (1) how common IPV against women is in their
country (four-point Likert scale: 1¼ very common, 2 ¼ fairly
common, 3¼ not very common, 4 ¼ not at all common); (2) the
severity of each form of IPV against women (four-point Likert
scale: 1¼ very serious, 2 ¼ fairly serious, 3 ¼ not very serious,
4¼ not at all serious); and (3) whether or not IPV against
women is acceptable (1¼ acceptable in all circumstances,
2¼ acceptable in certain circumstances, 3 ¼ unacceptable but
should not always be punishable by law, 4¼ unacceptable and
should always be punishable by law, 5 ¼ don't know) The
original questionnaire uses ‘domestic violence’ instead of IPV
consistency
Training in IPV and experience with patients
Questions about training were taken from Frank et al.23[e.g
‘How much training have you had in IPV during medical
school and residency?’ (three-point Likert scale: 1 ¼ none,
2¼ some, 3 ¼ extensive)]
Knowledge about IPV
Knowledge about IPV was examined in two ways using
questions extracted from a tool for measuring physician
readiness to manage IPV, which is known to have good
reli-ability.24The first section, designated as ‘background
knowl-edge’ used 16 items on a seven-point Likert scale (1 ¼ nothing,
7¼ very much) to determine current knowledge of
partici-pants about IPV Scoring was based on a grand mean Higher
scores indicate higher levels of background knowledge about
IPV
The second section used two types of questions (four
multiple choice and 11 true/false statements) to determine
how knowledgeable the participants were about IPV, and
included two sets of questions The first set included four
multiple choice questions with multiple answers (e.g ‘Which
of the following are warning signs that a patient may have
been abused by her partner?’) The second set of questions
included 11 true/false statements (e.g ‘Alcohol consumption
is the greatest single predictor of the likelihood of IPV’)
Scoring was based on the number of correct answers, and the highest possible score was 30
Statistical analysis
Data were analysed using Statistical Package for the Social Sciences Version 19.0 (IBM Corp, Armonk, NY, USA) Descriptive statistics were used to describe the distribution of demographic characteristics of participants, and opinions about and training
in IPV Descriptive data are presented as proportions for cate-gorical variables, means with standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables Categorical variables were compared between countries using Chi-squared tests Analysis of vari-ance (ANOVA) was used to compare mean background knowledge and knowledge about IPV among countries Prior
to ANOVA tests, equality of variance was performed None of the items violated assumption of equal variance
Multiple regression analysis was conducted to test the as-sociations between country and levels of knowledge or back-ground knowledge in IPV The US medical students were used
as the reference group for these variables Individual charac-teristics (female sex, witnessed/heard about IPV in the com-munity, know an IPV victim) that may affect levels of knowledge and background knowledge were also added Other measures that do not have a standardized way to quantify as a single measure were not included in the regression analysis, but were used to describe the participants' attitudes toward IPV and training Regression coefficients with standard errors were reported to obtain a 95% confidence interval
Results
The response rate was 37.5% (60/160) for the USA, 80% (240/ 300) for Vietnam and 62.6% (174/278) for China.Table 1 sum-marizes the demographic characteristics of participants, as well as information regarding their experience Approxi-mately half of the participants were women While the per-centage of female participants was very similar to that of female students in the survey populations in Vietnam and China, female participants were oversampled in the USA (the percentage of female students was 46.7% in the survey vs 20%
in the medical school) The percentage of female students in each medical school was obtained from the school On
Table 1e Demographic characteristics
Total
n¼ 466
USA
n¼ 60
Vietnam
n¼ 232
China
n¼ 174
Age (years)
Have heard about or witnessed intimate partner violence in the community 324 (69.5) 49 (81.7) 163 (70.3) 112 (64.4) Know someone who has experienced intimate partner violence 232 (49.8) 35 (58.3) 123 (53.0) 74 (42.5) Data expressed as frequency (%)
Trang 4average, US participants were older than Vietnamese and
Chinese participants More US participants (n¼ 49, 81.7%) had
heard about or witnessed IPV in their community compared
with Vietnamese (n¼ 163, 70.3%) and Chinese (n ¼ 112, 64.4%)
participants Likewise, significantly more US participants
compared with Vietnamese (n¼ 123, 53%) and Chinese (n ¼ 74,
42.5%) participants
Table 2shows the results regarding participants' opinions
about IPV (only extreme answers for each item are listed in the
table) A significant association was found between country
and each item at the 0.01 significance level While 83.3% of the
US participants (n¼ 50) and 74.1% of the Vietnamese
partici-pants (n¼ 172) believed that IPV was ‘very common’ or ‘fairly
common’ in their country, only 32.8% of the Chinese
partici-pants (n¼ 57) believed that this was the case Regarding the
severity of each type of IPV, the percentage of the participants
who indicated ‘very serious’ for the different forms of IPV was
highest among the US participants, and lowest among the
Vietnamese participants Of note, among the US sample, the
percentage of participants who believed that ‘IPV is
unac-ceptable but should not always be punished by law’ (n ¼ 29,
48.3%) and ‘IPV is unacceptable and should always be
pun-ished by law’ (n ¼ 30, 50%) was approximately the same
However, among the Vietnamese and Chinese samples, the
percentage of participants who believed that ‘IPV is
unac-ceptable but should not always be punished by law’ was lower
than that of the participants who believed that ‘IPV is
unac-ceptable and should always be punished by law’ (Vietnam
33.2% vs 60.3%; China 17.8% vs 69.5%, respectively)
Table 3summarizes the participants' opinions about IPV
training There was a significant association between country
and each item at the 0.01 significance level While the majority
of the Vietnamese (n¼ 224, 96.6%) and Chinese (n ¼ 143, 82.2%)
participants had never received IPV training, more than half of the US participants (n¼ 25, 41.7%) had participated in an IPV course An interesting finding is that despite the fact that the majority of the Vietnamese and Chinese participants had not received any IPV training, more than 30% of the Vietnamese participants (n¼ 76) and nearly 60% of the Chinese partici-pants (n¼ 102) indicated that they were ‘somewhat’ or ‘highly confident’ about talking to patients about IPV More than 80%
Table 2e Opinions about intimate partner violence
Total
n¼ 466
US
n¼ 60
Vietnam
n¼ 232
China
n¼ 174
How common do you think intimate partner violence against women is in your country?
Psychological violence
Physical violence
Sexual violence
Threats of violence
Restricted freedom
Is intimate partner violence against women…?
Unacceptable and should always be punishable by law 291 (62.4) 30 (50.0) 140 (60.3) 121 (69.5) Data expressed as frequency (%)
Table 3e Training in intimate partner violence (IPV)
Total
n¼ 466
USA
n¼ 60
Vietnam
n¼ 232
China
n¼ 174
How much training have you had in IPV during medical school? None 392 (84.1) 25 (41.7) 224 (96.6) 143 (82.2) Some 67 (14.4) 34 (56.7) 5 (2.2) 28 (16.1)
How confident are you about talking to patients about IPV? Not at all 240 (51.5) 17 (28.3) 152 (65.5) 71 (40.8) Somewhat 201 (43.1) 38 (63.3) 65 (28.0) 98 (56.3) Highly 20 (4.3) 5 (8.3) 11 (4.7) 4 (2.3) How important is it for physicians to talk to patients about IPV?
Somewhat 123 (26.4) 7 (11.7) 34 (14.7) 82 (47.1) Highly 328 (70.4) 53 (88.3) 191 (82.3) 84 (48.3) How relevant do you think IPV will be in your intended practice? Not at all 136 (29.2) 6 (10.0) 28 (12.1) 102 (58.6) Somewhat 198 (42.5) 33 (55.0) 107 (46.1) 58 (33.3) Highly 125 (26.8) 21 (35.0) 95 (40.9) 9 (5.2) With a typical general medicine patient, how often do you talk to patients about IPV?
Never/rarely 303 (65.0) 33 (55.0) 150 (64.7) 120 (69.0) Sometimes 138 (29.6) 23 (38.3) 76 (32.8) 39 (22.4) Usually/always 9 (1.9) 4 (6.7) 4 (1.7) 1 (0.6) Data expressed as frequency (%)
Trang 5of the US (n ¼ 53, 88.3%) and Vietnamese (n ¼ 191, 82.3%)
participants believed that it is ‘highly important’ for
physi-cians to talk to patients about IPV, compared with 48.3%
(n¼ 84) of Chinese participants While approximately 90% of
the US (n¼ 54) and Vietnamese (n ¼ 202) participants believed
that IPV would be ‘somewhat’ or ‘highly relevant’ in their
intended practice, only 38.5% (n¼ 67) of the Chinese
partici-pants indicated that IPV would be relevant in their practice
Table 4shows the descriptive statistics of the participants'
background knowledge and knowledge about IPV There were
significant differences in background knowledge and
knowl-edge between the three countries (P< 0.01) Although the
Vietnamese participants had the highest self-rating for
knowledge score was the lowest (mean¼ 15.13, SD ¼ 4.54) The
US participants had a higher knowledge score (mean¼ 21.02,
SD¼ 4.00) than the Vietnamese and Chinese (mean ¼ 17.17,
SD¼ 4.62) participants
Table 5shows the results of the regression analysis on the
association between background knowledge and knowledge
about IPV and sex and personal experience Female
partici-pants had higher knowledge scores than male participartici-pants
(P< 0.01) In addition, participants who knew someone who
had experienced IPV had significantly higher knowledge
scores than participants who did not know someone who had
experienced IPV (P< 0.05)
Discussion
This study examined opinions, knowledge and training about
IPV among medical students in the USA, Vietnam and China
US participants reported significantly higher levels of
knowl-edge of IPV, were more likely to believe that IPV was a serious
problem, and more likely to consider IPV as a healthcare
problem compared with Vietnamese and Chinese partici-pants The Chinese participants, in particular, did not appear
to appreciate the importance of addressing IPV Differences were found between the Vietnamese and Chinese students The finding that US participants, who had more IPV training than Vietnamese and Chinese participants, were more knowledgeable about IPV and considered it to be a serious problem suggests that training may improve knowl-edge and awareness of IPV among medical students The finding that the majority of Chinese students did not think that IPV would be relevant in their intended practice indicates that medical school curricula should include information on the relevancy of this topic for patient care Goal-oriented ap-proaches, which have been used to improve medical educa-tion curricula,25,26may be effective in teaching this concept to medical students Future research should examine if including information about how victimization impacts a patient's health within IPV training will improve IPV knowledge levels Although US participants had higher knowledge scores than Vietnamese and Chinese participants, the overall average score of 70% is still suboptimal The finding that approximately 40% of US participants indicated that they had never received training in IPV, while all of them should have taken an IPV training course by the end of their second year at medical school, suggests that there is a need to improve the
US IPV curriculum IPV training in both non-clinical and clinical years of medical school may improve the skills needed
to address this important healthcare issue effectively The results show that the Vietnamese and Chinese par-ticipants may not have self-evaluated their actual levels of knowledge objectively, or may have underestimated the clinical skills needed to treat patients with a history of IPV victimization In particular, the Chinese participants were far less likely to report that ‘it is highly important for physicians
to talk to patients about IPV’ than the US and Vietnamese
Table 4e Background knowledge and knowledge about intimate partner violence
Data expressed as mean (standard deviation)
a Higher score indicates higher background knowledge (range 1e7) or knowledge (range 0e30) levels for intimate partner violence p < 0.01
Table 5e Regression analysis on background knowledge and knowledge of intimate partner violence (IPV)
N.S., not significant
a Higher score indicates higher background knowledge or knowledge levels of IPV
bReference group¼ US participants
Trang 6participants In clinical education, medical students learn by
applying concepts to practice.27 In order for physicians to
improve women's health, it is essential to develop practical
opportunities for medical students to interact with women
who have experienced IPV
Limitations
This study has several limitations It had a cross-sectional
design and did not determine causal relationships between
the variables In addition, there may have been selection bias
as the response rates were relatively low and the surveyed
population was drawn on a convenience basis It is possible
that students with an interest in IPV may have been more likely
to participate in the survey Furthermore, only one medical
school from each country was surveyed; however, there may
be fewer variations between medical students within these
countries as medical schools are accredited and standardized
by a national professional authority or government in each
country Country or medical school level factors, such as the
number of advocacy centres in the cities, were not included,
and these may influence students' responses Reliable data on
IPV-related resources are not available to compare the three
locations In addition, the participants were not asked about
their own experiences with IPV, which could affect the results
Knowledge level may be influenced by factors such as
lan-guage, culture, difficulty of the test and local context Finally,
variations in professional priorities in medical practice across
different cultures28 may have affected the results Future
research should examine such factors in more detail
Conclusions
This study examined medical students' opinions, knowledge
and training related to IPV in the USA, Vietnam and China As
IPV is a significant global public health issue, it is important to
improve training for medical students to better serve patients
who have experienced IPV The results of this study provide
comparative information on IPV education for medical
stu-dents in these countries The results of this study have
sub-stantial implications for medical education in the USA,
Vietnam and China While most medical schools in the USA
include IPV training in their core medical curricula,
contin-uous education on the relevant topics seems to be necessary
to improve physicians' ability to care for IPV victims
Viet-namese and Chinese medical schools should consider
including IPV education in the training of their future
physi-cians to improve the health of women who have experienced
IPV Practical opportunities for medical students to interact
with women who have experienced IPV are essential to
develop effective IPV education
Author statements
Acknowledgements
The authors wish to thank the study participants, and would
like to acknowledge the contributions of Adam Stevenson,
Evelyn Gopez, Wei Xiao, Jinpeng Wu, Yuan Wang, and Ha
Thanh Dat The authors also thank Lenora Olson for her insightful input on the manuscript
Ethical approval
This study was approved as an exempt protocol by the Insti-tutional Review Board of the University of Utah, Salt Lake City, USA
Funding
This work was partially supported by the Asia Center, Uni-versity of Utah
Competing interests
None declared
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