Since the Surgeon General's Workshop on Violence and Public Health (Leesburg, Virginia, October 27-29, 1985), a substantial literature has developed about the limitations of the health care response to family violence. Many contributions have reflected experiences in limited numbers of practice settings (e.g., a single emergency department or hospital). Until 1990, however, there had been no community-based studies. The Robert Wood Johnson Foundation asked a multidisciplinary team from Education Development Center, Inc. and Children's Hospital (Boston) to investigate the health care responses to family violence in five diverse communities. This qualitative study, comprising more than 480 interviews, provided a vivid picture of the barriers facing physicians and other health care providers in identifying, treating, and referring victims of family violence. It also illuminated the relations of the health care systems in these communities with other key sectors, including agencies and the judiciary. The key findings from the five-city study remain relevant because (1) it is the only large-scale, multi-community-based assessment of the barriers facing physicians; (2) it identified, or in some cases confirmed, both institutional and educational barriers limiting the effectiveness of even the most committed physicians; (3) it identified, or in some cases confirmed, specific areas of knowledge, attitudes, and skills development that should be incorporated in medical education; and (4) its conclusions continue to be reflected in subsequent contributions to the literature. In each of these ways, therefore, it informs the other articles in this supplement.
PIP: An exploratory study, initiated in 1990 by the Robert Wood Johnson Foundation in 5 US cities (Atlanta, Georgia; Duluth, Minnesota; Providence, Rhode Island; Riverside, California; and Roswell, New Mexico), identified numerous barriers to an effective response by the health care system to family violence. Over the course of 2 visits to each site, 484 health professionals and community activists were interviewed. Although respondents in all 5 communities agreed that family violence was having a serious impact on the lives and health of women, children, and the elderly, none of the health systems addressed family violence comprehensively in terms of programs, policies, or clinical practice norms. Physicians, nurses, and other health care professionals who worked with victims of family violence reported they were marginalized by their colleagues and identified economic, social, and psychological disincentives to work in this area. The health care system's ability to respond to family violence was significantly impeded by providers' prejudices (e.g., class elitism, racism, sexism, ageism, homophobia) toward both the victims and perpetrators of violence. Overburdened public facilities, the unwillingness of private facilities to serve this clientele, low Medicaid participation rates, underinsured or uninsured status, and poor public transportation further restricted victims' access to services. Service provision was most lacking for victims of elder abuse. Finally, there was a lack of effective coordination among agencies responsible for addressing family violence.