p u b l i c h e a l t h x x x ( ) e7 Available online at www.sciencedirect.com Public Health journal homepage: www.elsevier.com/puhe Original Research Intimate partner violence education for medical students in the USA, Vietnam and China A Kamimura a,*, S Al-Obaydi a, H Nguyen b, H.N Trinh a, W Mo a, P Doan c, K Franchek-Roa d a Department of Sociology, University of Utah, Salt Lake City, UT 84112, USA Department of Sociology, Vietnam National University, Ho Chi Minh City, Viet Nam c Division of Public Health, University of Utah, Salt Lake City, UT, USA d Department of Paediatrics, University of Utah, Salt Lake City, UT, USA b article info abstract Article history: Objectives: While intimate partner violence (IPV) is a global concern for women's health, Received 20 January 2014 there are few comparative studies of IPV training in medical schools The aim of this study Received in revised form was to investigate medical students' knowledge of, and training in, IPV in the USA, Vietnam 21 December 2014 and China Accepted 27 April 2015 Study design: Cross-national, cross-sectional study Available online xxx 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 Keywords: characteristics; opinions, training and knowledge regarding IPV against women; and per- Intimate partner violence sonal experience with IPV victims Medical education Results: Attitudes, knowledge and training about IPV among medical students varied be- Women's health tween the three countries US participants reported higher levels of knowledge of IPV, were USA more likely to believe that IPV was a serious problem, and were more likely to consider IPV Vietnam to be a healthcare problem compared with Vietnamese and Chinese participants Chinese China 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.: ỵ1 801 581 7858; fax: þ1 801 585 3784 E-mail address: akiko.kamimura@utah.edu (A Kamimura) 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 Please cite this article in press as: Kamimura A, et al., Intimate partner violence education for medical students in the USA, Vietnam and China, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.022 p u b l i c h e a l t h x x x ( ) e7 Introduction Methods Intimate partner violence (IPV) is a significant public health threat that causes injury, and acute and chronic physical and mental health problems.1e3 IPV includes physical, sexual and/ or psychological harm inflicted by a current or former intimate partner.4 Violence 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.6e8 To ensure the health and safety of women who have experienced IPV, future physicians and healthcare professionals need training regarding identification and interventions for these patients.9 In 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 teach residents how to manage IPV cases.11 For medical 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 standards for addressing IPV in health care; and provide knowledge about culturally appropriate interventions.12 However, there are a number of barriers to implementing an IPV curriculum 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,14 few comparative studies of IPV education in medical schools have been undertaken The purpose of this study was to investigate medical students' knowledge of, and 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.15e17 While medical schools in the USA often include IPV education,18 to the best of the authors' knowledge, there are no formal IPV curricula at medical schools in Vietnam and China Studies in Vietnam,16 China19 and the USA15,20,21 have 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 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 Vietnamese 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 population 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 translated 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 backtranslated 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 community experience related to several social issues including IPV, death and dying, mental health, human immunodeficiency virus/acquired immunodeficiency syndrome, homelessness 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 experiences 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 students 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 Please cite this article in press as: Kamimura A, et al., Intimate partner violence education for medical students in the USA, Vietnam and China, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.022 p u b l i c h e a l t h x x x ( ) e7 heard about or witnessed IPV in the community, and whether they knew anyone personally who had experienced IPV Scoring was based on the number of correct answers, and the highest possible score was 30 General opinions about IPV against women Statistical analysis 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: ¼ very common, ¼ fairly common, ¼ not very common, ¼ not at all common); (2) the severity of each form of IPV against women (four-point Likert scale: ¼ very serious, ¼ fairly serious, ¼ not very serious, ¼ not at all serious); and (3) whether or not IPV against women is acceptable (1 ¼ acceptable in all circumstances, ¼ acceptable in certain circumstances, ¼ unacceptable but should not always be punishable by law, ¼ unacceptable and should always be punishable by law, ¼ don't know) The original questionnaire uses ‘domestic violence’ instead of IPV This was changed to ‘IPV’ in the survey instrument for 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: ¼ none, ¼ some, 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 reliability.24 The first section, designated as ‘background knowledge’ used 16 items on a seven-point Likert scale (1 ¼ nothing, ¼ very much) to determine current knowledge of participants 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’) 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 categorical 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 variance (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 associations between country and levels of knowledge or background knowledge in IPV The US medical students were used as the reference group for these variables Individual characteristics (female sex, witnessed/heard about IPV in the community, know an IPV victim) that may affect levels of knowledge and background knowledge were also added Other measures that 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 summarizes the demographic characteristics of participants, as well as information regarding their experience Approximately half of the participants were women While the percentage 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 e Demographic characteristics Female students Age (years) 20e24 25e30 >30 Have heard about or witnessed intimate partner violence in the community Know someone who has experienced intimate partner violence Total n ¼ 466 USA n ¼ 60 Vietnam n ¼ 232 China n ¼ 174 229 (49.1) 28 (46.7) 113 (48.7) 88 (50.6) 394 60 324 232 14 (23.3) 39 (65.0) (11.7) 49 (81.7) 35 (58.3) 210 20 163 123 (84.5) (12.9) (1.9) (69.5) (49.8) (90.5) (8.6) (0.4) (70.3) (53.0) 171 1 112 74 (98.3) (0.6) (0.6) (64.4) (42.5) Data expressed as frequency (%) Please cite this article in press as: Kamimura A, et al., Intimate partner violence education for medical students in the USA, Vietnam and China, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.022 p u b l i c h e a l t h x x x ( ) e7 Table e Opinions about intimate partner violence Total n ¼ 466 How common you think intimate partner violence against women is in your country? Very common 48 (10.3) Not at all common 17 (3.6) Psychological violence Very serious 251 (53.9) Not at all serious (0.9) Physical violence Very serious 229 (49.1) Not at all serious (1.1) Sexual violence Very serious 246 (52.8) Not at all serious (1.9) Threats of violence Very serious 175 (37.6) Not at all serious (1.7) Restricted freedom Very serious 193 (41.4) Not at all serious 15 (3.2) Is intimate partner violence against women…? Acceptable in all circumstances (1.7) Unacceptable and should always be punishable by law 291 (62.4) US n ¼ 60 Vietnam n ¼ 232 China n ¼ 174 (13.3) 30 (12.9) 10 (5.7) 17 (9.8) 41 (68.3) 104 (44.8) (0.9) 106 (60.9) (1.1) 60 (100) 79 (34.1) (0.9) 90 (51.7) (1.7) 59 (98.3) 86 (37.1) (3.0) 101 (58.0) (1.1) 42 (70.0) 66 (28.4) (2.2) 67 (38.5) (1.7) 41 (68.3) 62 (26.7) 12 (5.2) 90 (51.7) (1.7) (1.7) 30 (50.0) (1.3) 140 (60.3) (2.3) 121 (69.5) Data expressed as frequency (%) average, US participants were older than Vietnamese and Chinese participants More US participants (n ¼ 49, 81.7%) had heard about or witnessed IPV in their community compared with Vietnamese (n ¼ 163, 70.3%) and Chinese (n ¼ 112, 64.4%) participants Likewise, significantly more US participants (n ¼ 35, 58.3%) knew someone who had experienced IPV compared with Vietnamese (n ¼ 123, 53%) and Chinese (n ¼ 74, 42.5%) participants Table shows 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 (n ¼ 50) and 74.1% of the Vietnamese participants (n ¼ 172) believed that IPV was ‘very common’ or ‘fairly common’ in their country, only 32.8% of the Chinese participants (n ¼ 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 unacceptable but should not always be punished by law’ (n ¼ 29, 48.3%) and ‘IPV is unacceptable and should always be punished 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 unacceptable but should not always be punished by law’ was lower than that of the participants who believed that ‘IPV is unacceptable and should always be punished by law’ (Vietnam 33.2% vs 60.3%; China 17.8% vs 69.5%, respectively) Table summarizes 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 (n ¼ 224, 96.6%) and Chinese (n ¼ 143, 82.2%) participants had never received IPV training, more than half of the US participants (n ¼ 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 (n ¼ 76) and nearly 60% of the Chinese participants (n ¼ 102) indicated that they were ‘somewhat’ or ‘highly confident’ about talking to patients about IPV More than 80% Table e Training in intimate partner violence (IPV) Total n ¼ 466 USA n ¼ 60 Vietnam n ¼ 232 China n ¼ 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) (2.2) 28 (16.1) Extensive (0.6) (1.7) (1.1) 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) (8.3) 11 (4.7) (2.3) How important is it for physicians to talk to patients about IPV? Not at all 13 (2.8) (2.6) (4.0) Somewhat 123 (26.4) (11.7) 34 (14.7) 82 (47.1) Highly 328 (70.4) 53 (88.3) 191 (82.3) 84 (48.3) How relevant you think IPV will be in your intended practice? Not at all 136 (29.2) (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) (5.2) With a typical general medicine patient, how often 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 (1.9) (6.7) (1.7) (0.6) Data expressed as frequency (%) Please cite this article in press as: Kamimura A, et al., Intimate partner violence education for medical students in the USA, Vietnam and China, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.04.022 p u b l i c h e a l t h x x x ( ) e7 of the US (n ¼ 53, 88.3%) and Vietnamese (n ¼ 191, 82.3%) participants believed that it is ‘highly important’ for physicians to talk to patients about IPV, compared with 48.3% (n ¼ 84) of Chinese participants While approximately 90% of the US (n ¼ 54) and Vietnamese (n ¼ 202) participants believed that IPV would be ‘somewhat’ or ‘highly relevant’ in their intended practice, only 38.5% (n ¼ 67) of the Chinese participants indicated that IPV would be relevant in their practice Table shows the descriptive statistics of the participants' background knowledge and knowledge about IPV There were significant differences in background knowledge and knowledge between the three countries (P < 0.01) Although the Vietnamese participants had the highest self-rating for background knowledge (mean ¼ 3.78, SD ¼ 1.05), their actual knowledge score was the lowest (mean ¼ 15.13, SD ¼ 4.54) The US participants had a higher knowledge score (mean ¼ 21.02, SD ¼ 4.00) than the Vietnamese and Chinese (mean ¼ 17.17, SD ¼ 4.62) participants Table shows the results of the regression analysis on the association between background knowledge and knowledge about IPV and sex and personal experience Female participants had higher knowledge scores than male participants (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 knowledge 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 participants 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 knowledge 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 approaches, which have been used to improve medical education curricula,25,26 may 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 participants 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 e Background knowledge and knowledge about intimate partner violence Background knowledge Knowledgea a Total USA Vietnam China F 3.34 (1.16) 16.65 (4.89) 3.17 (1.31) 21.02 (4.00) 3.78 (1.05) 15.13 (4.54) 2.81 (1.00) 17.17 (4.62) 40.13 42.47 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 e Regression analysis on background knowledge and knowledge of intimate partner violence (IPV) Dependent variables Background knowledgea b Independent variables (constant) Female Witnessed/heard about IPV in the community Know a victim of IPV Vietnamb Chinab 3.08 À0.19 0.13 0.13 0.64 À0.30 R2 F P-value 0.16 17.32 P < 0.001 P-value N.S N.S N.S