A cross-sectional study of Australian chiropractors' and students' readiness to identify and support patients experiencing intimate partner violence

In Australia, intimate partner violence (IPV) is a well-identified societal problem^1,2  which, irrespective of culture, involves any behavior within a personal relationship where physical, emotional, sexual, economic, or social harm occurs to anyone in a relationship.¹ 

The Australian Institute of Health and Welfare reports that from the age of 15, 1 in 6 Australian women and 1 in 16 men have experienced physical, sexual violence, or emotional abuse by a current or previous cohabiting partner. Seventy-two thousand women, 34,000 children, and 9000 men seeking homelessness services reported family and domestic violence (FDV) had caused or contributed to their homelessness, in 2016–2017.²  The clinical presentations of IPV may include physical injury, chronic pain, depression, posttraumatic stress disorder, sexually transmitted infections, and gastrointestinal conditions,³  which are clinical presentations chiropractors are likely to see.⁴  Chiropractors need to be alert to a conflict of interest if they consult with both a suspected perpetrator and their alleged victim as each has a right to autonomy and confidentiality⁵  (notwithstanding statutory requirements to ensure child protection).

Chiropractors may have a role in preventing IPV if they have appropriate screening tools.⁶ 

A chiropractors' knowledge and skills in recognizing IPV is likely to affect their clinical reasoning, decision-making, and clinical outcomes. Furthermore, they are obliged to comply with clinical and legal responsibilities. Even though the practice competencies for chiropractors require an understanding of their patients' health status, social, cultural, and economic circumstances,⁷  there is a dearth of information regarding IPV screening and education for chiropractors. Moreover, chiropractors' ability to identify and manage patients experiencing IPV is central to the guiding principles and practices of patient-centeredness (Universal Competency 1.2) and interprofessional practice (Practice Competency 4.2).⁷  How well are these competencies applied in IPV-related consultations is yet to be established.

Hence this landmark study, the first in chiropractic in Australia as well as the first in an Australian manual therapy profession will generate the initial data to enable robust discourse across the professions and stimulate further research.

Shearer et al⁸  explored Canadian chiropractors' readiness to identify and manage IPV with (n = 99) chiropractors after 3 days of IPV training. Furthermore, studies in other health professions and countries have included medical practitioners,^9–11  dental students,¹²  nurses, nursing students, midwives,^13–15  obstetricians, gynaecologists,¹⁶  and other health professionals.^17,18  One Australian study by Sawyer et al¹⁹  explored the “readiness” of paramedic students.

We do not know the extent to which Australian-registered chiropractors feel prepared to identify and assist patients experiencing IPV. The aim of this cross-sectional study was to explore chiropractors' and final-year students' readiness to screen for and support patients experiencing IPV. We used a purposefully adapted version of the readily available, previously validated tool for health providers to self-assess their capabilities regarding IPV, the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS).²⁰  We anticipate the results will inform the pre-professional and postgraduate chiropractic curricula and positively impact chiropractic practice and improve health care outcomes for those experiencing IPV. We posit chiropractic-specific discourse surrounding these increasing social concerns will highlight the intent of the chiropractic profession to make a substantial contribution to the health care of members of the Australian public who consult them.^21,22 

Ethics clearance for this cross-sectional study with nonprobability sampling was provided by Murdoch University (2021/082) and RMIT University (2021-24892-15753). Consent was inferred by the completed returned survey.

To align with our needs and to comply with ethics, we made some minimal adaptations to the PREMIS.²⁰  We added:

• questions to allow participants to identify as practitioner or student;

• questions about previous IPV training;

• questions about recent encounters during clinical practice with patients exposed to IPV;

• a response option of, “prefer not to answer” for multiple choice style questions we felt might trigger stress in the respondent; and

• a link to resources for support for participants “triggered” by the questions.

In all other ways, the 29-question adaption of the PREMIS we named the Chiro-PREMIS for this study closely replicates the content and format of the PREMIS. Since the questions relating to perceptions, myths, and truths about IPV were unchanged, reliability studies were not repeated. To strengthen validity, a draft of the Chiro-PREMIS was tested with 1 biomechanics academic and 5 clinicians, all of whom provided feedback about the survey instrument's content, clarity, acceptability, and utility on different platforms.

The final version of Chiro-PREMIS was distributed via email invitation, which included a link to the online survey. To avoid possible systematic sampling errors caused by limited coverage, the invitation to participate was distributed to registered chiropractors through electronic media such as emails and advertisements to the researchers' networks and various Australia-wide closed social media platforms such as LinkedIn,²³  Facebook²⁴  groups (Western Australian Chiropractors, Australian Chiropractic discussion groups, Australian Chiropractors Association Special Interest Group of Women in Chiropractic, and Australian Chiropractors), and to directors of multipractitioner clinics. The heads of the respective chiropractic programs at 2 universities ensured the distribution of the invitation email to their entire 5th-year student cohorts. To ensure confidentiality, the researchers did not have direct access to participants' identities at any stage during the study.

There were 3 phases to our analytical strategy. All analyses were conducted using survey monkey (Survey Monkey Enterprises, Momentive). In reporting, for clarity in questions requiring a response on the 5-point Likert Scale, the outer 2 response options were aggregated into 1 level creating 3 categories of responses as described below.

We acknowledge the ongoing debate around the method and wording of questions measuring the presence of IPV,^25,26  and we considered the various interpretations of the meaning of words would affect our analysis in indeterminable ways. Hence, our intent was to take a “snap-shot” of practice. To that end, given the development and assessment of clinical competence in a typical curriculum in the health professions are organized as per Miller's framework in which the student is expected to “know, know how, show how, and do,”²⁷  in the second phase of our analysis, we scrutinized participants' self-assessment reports through Miller's lens, which provides a broad perspective rather than a narrower report of individual practice. Table 1 shows the alignment between the Chiro-PREMIS and Miller's framework. We explored if participants:

• Know the facts, concepts, and principles of IPV.

• Know how to apply that knowledge when engaged in clinical problem solving.

• Show how to perform the required clinical skills.

• Do, that is, they can utilize their skills when appropriate in clinic to identify and support patients who may have IPV-related health care needs.

Domain names underwent re-classification to reflect concepts familiar to academics and clinical education specialists and for greater alignment with our aim to identify gaps, prepare for the discussion, and develop training modules to ensure the achievement of chiropractic graduate competencies, which constituted the third component of our analysis.

We received completed surveys from (n = 99) Australian Registered Chiropractors (response rate, 2%) and (n = 41) from 2 Australian universities (response rate, 28%). Chiropractors' age range was 25–54, 68% female, 32% male with 15% from culturally and linguistically diverse backgrounds (from a non-Anglo Australian background). Students' ages ranged from 18–34, 69% were female, 32% male with 12% from a culturally and linguistically diverse background. Whether or not these figures represent the background and gender profile of the chiropractic profession or student cohort is unknown. No participant identified as Aboriginal or Torres Strait Islander.

Of the chiropractors, 89% graduated from an Australian university, 45% held a baccalaureate chiropractic degree, 38% a master level degree, 7% honors, and 6% doctorates (clinical doctorates from United States). The Australian States in which they practiced were as follows: Western Australia 31%, Victoria 29%, New South Wales 18%, Australian Capital Territory and South Australia 4%, 2 from Tasmania, and 1 from the Northern Territory. Fifty-three percent worked in a group practice with other chiropractors, 39% in solo practice, 28% in a group practice with other health professionals, 5% were casual or full-time academic, and 9% worked as clinical supervisors in an academic setting. Our data analysis did not explore any link between the participants' individual responses and their level of education, the state or situation in which they practiced.

Reports of practice over the 4 weeks prior to completing the survey showed 21% of chiropractors and 20% of the students had consulted with patients who had disclosed they were involved in IPV. Thirty-three percent of chiropractors and 27% of students suspected a patient was involved, but that patient did not disclose any information. Parenthetically, we did not explore what criteria individuals used to identify the patients who reported being involved in IPV, nor did we explore the ethnicity or any other factors about the patients. Such matters may be of concern in future studies.

Eighty-two percent of chiropractors and 59% of students had no training in IPV in the previous 5 years. Furthermore, 98% of chiropractors and 93% of students had no training in IPV in the 6 months prior to taking the survey. Training involved watching videos or attending a talk or lecture with very few attending skill-based training.

Most participants answered all questions correctly; however, there are concerns it would be difficult to make a generalized statement that this cohort “knows” about IPV in any depth as shown in Tables 2 and 3 and explained below.

In Table 2, in responses to Item 1: The strongest single risk factor for becoming a victim of intimate partner violence, shows a high percentage of chiropractors chose the “preferred not to answer” option and this ought to be explored in future studies. A high percentage of participants “don't know” the truth about perpetrators (Q2) or warning signs (Q3). An even higher percent “don't know” appropriate ways to ask about IPV (Q5) or the common injuries (Q6).

Table 3 again shows a high percentage of correct answers together with a very high percentage of response they “don't know” about alcohol consumption (Q1) and strangulation injuries (Q8).

Table 4 shows participants are unprepared to ask appropriate questions (Q1); respond to disclosures of abuse (Q2); document findings (Q8); make appropriate referrals (Q9); fulfill reporting requirements (Q10); or document indicators for IPV in a case history (Q3).

Notwithstanding the issues raised in Q4–Q7 may not be the responsibility of the chiropractor; participants say they are unprepared to take actions such as assess safety, readiness to change, and danger etcetera, which infers participants may not “know how” to use the knowledge they do have about IPV.

Table 5 shows participants' lack of familiarity about IPV regarding what questions to ask to identify IPV (Q8, Q11); why patients may not disclose (Q9); stages of an IPV situation (Q14); legal reporting requirements (Q1); documenting IPV events (Q3); and referral options (Q4).

Again, a high percentage lacked familiarity around the signs and symptoms of IPV (Q2); perpetrators (Q5); relationship with pregnancy (Q6); the chiropractors' role (Q10); determining danger (Q12); safety plans (Q13); and the childhood effects of witnessing IPV (Q7). These results infer this cohort may be unable to “show how” they apply their knowledge of IPV in clinic scenarios.

Further, Table 6 responses suggest participants' experience confusion about their readiness to discuss IPV with patients (Q1) but, not if they are female, male, or from a different culture (Q2); legal literacy (Q3); and the correct information gathering skills (Q4).

The results infer participants' do not “know” about IPV' in any great depth, they do not “know how” to and may not be able to “show how” or “do,” tentatively suggesting overall this cohort may not have the capacity to appropriately identify and manage clinical events related to IPV.

This study showed that during the month prior to completing the Chiro-PREMIS just under a quarter of participants engaged with patients who had disclosed they were involved in IPV and even more, about a third suspected a patient was involved but they did not disclose.

The stakes are high, and chiropractors have an opportunity to make a positive contribution toward assisting with this social problem. The rising incidence and prevalence of IPV is a concern and the chiropractic profession must explore and remedy gaps in practitioners' clinical competencies around all aspects of FDV.

Like the study by Sawyer et al¹⁹  of Australian paramedic students, our participants have tacit knowledge only, and low confidence in their preparation to manage IPV. While the role of a chiropractor is limited to identifying and referring to appropriate professionals or agencies equipped to manage IPV/FDV, a lack of familiarity with clinical assessment and support procedures and practices about IPV could potentially create a reluctance to talk with patients when they suspect it is necessary. This may present an increased barrier to patients accessing help, thereby perpetuating the abuse and its harmful effects. We know that barriers to screening for IPV have been reported among health care providers across diverse specialties and settings,²⁸  and they include a health provider's discomfort with the topic, poor self-efficacy, confidence, and preparation in IPV.²⁹  These issues are concerning and potentially only adds to the problem for those experiencing IPV, and we need to explore chiropractors' approaches more thoroughly. Furthermore, it is well known female patients expect health care professionals to demonstrate a supportive, nonjudgmental, and empathetic approach to discussing IPV.^30–32 We know that health professionals who hold poor attitudes toward women may be less likely to ask about IPV or more likely to ask about it inappropriately, potentially causing further harm.^30,32  These principles can be extrapolated to consultations with men who may also be victims of IPV or FDV.

Many participants in this study reported their lack of competence in legal literacy and in health record-keeping related to IPV. Yet, we know it is critical to document information provided by the patient in a factually accurate way. That is, to note observations of injuries, affect, other health conditions, and anything else such as what the patient said, as close to verbatim as possible, and using quotation marks, plus, behavior observed, for example, “patient cried when they spoke about …”.³³  Accurate and comprehensive documentation is critical for patient-centered care and follow-up should legal proceedings be initiated later.

IPV may have a negative effect on children and all practitioners, including chiropractors, have a mandated responsibility to report child abuse or neglect.^34,35  Mandatory reporting relates primarily to children, but practitioners also have a responsibility to report the abuse of adults, particularly those living in a residential service, such as psychiatric, aged care, or another government-run facility. Chiropractors must be aware of the laws in the Australian state and territory in which they practice, as they differ slightly.

This study identified the minimal amount of time most participants had engaged in clinical education about IPV. Currently, we could identify no published, evidence-based IPV educational packages to develop the required competencies for chiropractors. It is time to develop appropriate programs, and the World Health Organization's recommendations for topics of learning about IPV for frontline health workers are a good place to start.³⁶  The curriculum for chiropractors must include the broader spectrum of FDV as discussed in Australian Reports referred to in the introduction.^1,2  Learning offerings ought to include a discussion of the prevalence of IPV against males and IPV among people of all cultures and identity groups such as lesbian, gay, bisexual, transgender and intersex (LGBTI).

Chiropractors need to know how to work interprofessionally to ensure they practice with a patient-centered care focus.⁷  The clinical presentations of IPV may vary from physical and musculoskeletal injuries to other disorders, which may require a multimodal approach in screening and management. For that reason, interprofessional practices and networks are a necessary component of a chiropractor's strategy for assisting those exposed to IPV.

Yet we know a recent Australian study identified final-year chiropractic and osteopathic students and new graduates found they all lacked interprofessional capabilities.³⁷  Also, Shearer et al⁸  illuminated chiropractors' poor knowledge and awareness of whom to and where to refer patients once identified as IPV victims. Also, studies in other health professions have shown the same.^38–43  Pharmacists acknowledge they have a general lack of training and awareness of proper methods for referrals,⁴⁴  and dentists are the least likely of all health professionals to identify and refer victims of abuse, despite their specialized knowledge and skills to treat the orofacial and dental injuries of IPV victims.^45,46  There is much to be done to prepare chiropractors for their important role in supporting persons experiencing IPV.

We acknowledge the ongoing debate around the method and wording of questions measuring the presence of IPV^25,26 ; thus, we had no way of understanding the extent to which the participants had personal experience with IPV and how that may have influenced interpretations of the meaning of words and the results we received. Our adaptation of the American-designed PREMIS did not include the addition of questions related to FDV, violence against children, or terminology particular to Aboriginal and Torres Strait Islander peoples. Had we made significant changes, we would have altered the PREMIS beyond a simple adaptation, and we did not have the resources to undertake validity studies of a new survey. Future investigators may make these inclusions.

We have no way of knowing how many chiropractors received the invitation. There are currently 5473 registered chiropractors in practice in Australia, which gave us a 2% response rate for practitioners. We administered this survey to n = 144 students at 2 universities, which gave us a 28% response rate. Due to the low response rate and small sample size, readers should interpret the results cautiously, given the possibility of nonresponder bias. Larger studies with a broader sample are needed to avoid any unknown sampling error before drawing firm conclusions.

The correlation between our results and Miller's hierarchy of clinical skills, when applied to engaging with patients who may be experiencing IPV, showed this group were not clear they “know” about IPV in any great depth, and perhaps uncertain they “know how” to and may not be able to “show how” or “do,” suggesting they may not at this time have the capacity to appropriately identify and manage clinical events related to IPV. Further investigations are needed to explore if the participants fully understand the related circumstances of a patient's health status and how to apply the guiding principles of patient-centeredness or interprofessional practice when confronted with alleged victims of IPV, which are competencies expected of practicing chiropractors.⁷ 

These investigators regard best practice in developing students' IPV competence is organizing for them to engage in IPV learning through didactic and experiential learning, simulation, case-based learning, and clinical placements at say social welfare and community clinics that specifically assist IPV victims. We argue that if the pre-professional clinical curriculum allocated time for the student to attend clinics where other health professionals assist IPV victims, it would potentially strengthen graduates' understanding and provide an opportunity to develop interprofessional relationships. Moreover, future research is needed to confirm our finding that 33% of chiropractors and 27% of students suspected a patient was involved, but the patient did not disclose.

By adapting the PREMIS for chiropractic, this cross-sectional study reports the extent of the gap in readiness among Australian-registered chiropractors and final-year students regarding their ability to identify and support patients experiencing IPV. Reports of practice over the 4 weeks prior to completing the survey showed 21% of chiropractors and 20% of the students had consulted with patients who had disclosed they were involved in IPV. Thirty-three percent of chiropractors and 27% of students suspected a patient was involved, but that patient did not disclose any information.

Participants report meager training in IPV. There appears to be a lack of competence in many pertinent clinical skills such as the most appropriate questioning techniques, documentation, referrals, identifying available resources, and in legal literacy. Regarding overall readiness to assist, when analyzed against Miller's hierarchy for the development and assessment of clinical competence, the results tentatively suggest participants lack clarity. Many are uncertain they “know” about IPV in any great depth, they do not “know how” to and may not be able to “show how” to or “do” when it comes to assisting patients who experience IPV.

Clearly, with the right preparation, chiropractors have an opportunity to make a positive contribution to this social problem. We anticipate chiropractic-specific discourse surrounding these escalating growing social concerns will highlight the intent of the chiropractic profession to make a substantial contribution to the health care of the Australian public who consult them. More studies are needed.

The authors acknowledge Dr Barrett Losco, the Chiropractic Discipline Lead at Murdoch University, for his assistance with ethics application and Dr Sandra Gason, Program Manager and Assistant Associate Dean at the School of Health and Biomedical Sciences RMIT University, for her assistance with distributing the survey to students.