This study yielded important information about the current perceptions and approaches of the health care providers in Malaysia towards the identification and management of domestic violence in the primary care setting. The findings will be useful in guiding the development of appropriate clinical interventions to improve care in primary care settings in general as well as specifically in the UMMC.
However, caution should be taken when interpreting the results of this study in view of several limitations of this study. First, this study was a single study which was carried out in a single primary care location. Thus, the findings may not be applicable to other medical settings, such as in the inpatient or mental health settings. Second, the UMMC is a large public tertiary teaching hospital with its location in a suburban setting and because of this, the findings may not be representative of smaller primary care settings such as the general practice clinics or other medical facilities from non-urban locations. Third, since the data collection was based on self-reporting by the participants, respond and recall bias may result in desirable answer despite the confidential manner of the data collection.
As evident in this study, more than sixty percent of health care providers in UMMC believed that the prevalence of domestic violence among patients attending their clinic to be low. This may be one of the many causes of low screening for domestic violence cases. Seventy percents of clinicians have reported screening for their patients but at times only. There was only one doctor among the 61 clinicians who screened all his/her patients for domestic violence.
Despite perception of low prevalence in domestic violence cases, 65% of the clinicians identified an abused victim within the past year. This is contrary to physicians' perception of low prevalence of domestic violence when the actual prevalence of domestic violence was found to be higher in those attending the health care facilities when compared to population . The prevalence of domestic violence cases among patients in various primary care settings varies from 8.5% to 41% [6, 32–36].
Physical injuries related to abuse may be one of the most obvious symptoms presented to medical facilities. However, only half of the clinicians reported 'always or almost always' asking their patients for any underlying abuse when treating cases of injury. This reported practice of inquiring about abuse is higher when compared to the study finding conducted by Sugg in 1999 . Other presentations of domestic violence related to psychological, psychosomatic or antenatal problems which are more subtle to its relation to domestic violence were asked regarding abuse by the clinicians in a much lesser frequency. This finding is similar the study by Sugg . Clinicians failing to identify and to offer abused women help despite repeated presentations to health care facilities may cause them further abuse when they are send home to the same abusive environment.
Most clinicians in this study reported lack of time as a barrier to ask for domestic violence. This finding is similar to that reported in Sugg et al . Nearly a third of the clinicians were still unsure on how to ask regarding domestic violence among their patients which should raise major concern. It would seem reasonable to suggest that the clinicians have not been fully equipped on how to deal with domestic violence cases during their undergraduate or postgraduate training. The results also suggest the clinicians and the nursing staff received minimal or no training on violence management during their service.
Health care providers possess certain opinions and prejudices based on their own upbringing, culture and religious beliefs. These biases can affect their professional behavior including their intention to ask about abuse and create errors in clinical judgment in domestic violence cases. More than half of the clinicians and a third of the nursing staff reported a fear of offending patients in asking about domestic violence. This may be related to the underlying belief that domestic violence is a 'private matter' and not within the scope of medical treatment . Nearly a third of clinicians and half of nurses endorsed the view that the abused person must have done something to trigger the abuse. This 'blaming the victim' attitude is a very negative way to address the person who has been victimized when the abuser should be the one to be blamed for using violence to resolve conflict .
Traditional beliefs regarding the family privacy, family unity and gender role was found to have posed difficulties to health care providers in their management of domestic violence . However, many abused women do not mind being asked about violence and would like the health care providers to be more pro-active in asking questions on abuse [12, 25, 28, 38]. Furthermore, health care providers need to be aware that domestic violence is indeed a major medical problem and they have important roles to play in its detection and management .
Having a safe environment will also enable the health care providers to identify domestic violence. There should be a place for the health care providers to have a private consultation with the victim without the presence of the abuser. In this study, a very small proportion of the participants expressed concern on their safety but a large proportion was concerned about the safety of their patients with in a violent environment.
Perceived self-efficacy plays an important role in the management of various medical conditions. Most clinicians in this study were more confident in asking about smoking and alcohol intake rather than asking about different kinds of abuse. Most of them perceived lack of self-efficacy in the overall management of domestic violence, including the use of strategies to help the abused person and a lack of access to different management information. All these negatively impact on the health care provider's ability to adequately care for abused person or abusers. Factors, such as inadequate training or the perception of poor success in management of these cases are relevant .
There is no mandatory reporting for domestic violence in Malaysia. However, in this study, a proportion of health care providers have indicated that they would still report cases of abuse to police despite abused women's refusal to give consent. Not respecting the patient's autonomy can be considered as unethical and may represent institutional victimization. There should be support for the abused patients no matter what their decision is at that point of time. This will increase their self-esteem and confidence level, aspects of their self-image that may have been severely undermined by repeated abused by their partner .
Within institutional settings, having enabling factors for the management of domestic violence will make the health care providers more inclined to manage these cases. Less than three-quarters of the participants in this study had access to a social worker, while 10% of the participants were unsure of the availability of social workers to help them manage domestic violence cases. Less than a third of the participants knew of any written protocol for the management of domestic violence. Not even half of the participants knew of the existence of non-governmental organization that can support management of domestic violence. The health care providers may feel inadequate in helping the abused victims with the lack of knowledge on the availability of various domestic violence resources.