This is the first study that examined HNF injuries in abused Chinese women presenting to AEDs. HNF injuries (77.6%) were the most frequently reported injuries among abused women in this study, which is consistent with previous findings in Caucasian women presenting to AEDs [8, 28]–. Also, it was found that HNF injuries mostly resulted from punching with a fist (60.2%).
Considering the head in terms of five areas, namely the upper third, middle third, and lower third of the face, the vertex of the head, and the back part of the head, the findings showed that the back part of the head was the most frequently affected region. In addition, women who had injuries to the back part of the head had mostly been punched with a fist. Repeated attacks with the fist at any one site can generate enough force to cause fractures . In our sample of IPV women, we fortunately did not observe any fracture to the back part of the head, which may be because the punches were few or exerted with less force. However, haematomas were commonly found on the back part of the head, mainly in the parietal and occipital regions. All the women with haematomas had soft tissue injuries rather than subdural or epidural hematomas, as identified from X-rays or CT scans, which are much more severe injuries. The relationship between soft tissue injuries and severity of trauma has been examined and found that the formation of a haematoma indicated moderate trauma, while massive haematoma indicated severe trauma . With moderate to severe blunt force, it may be possible to cause micro-structural tissue damage inside the parietal and occipital lobes of the brain, which may affect the somatosensory and visual functioning. Unfortunately, this micro-structural tissue damage may not be easily recognized by current routine investigations (i.e. X-rays or CT scans) for head injuries at AEDs. Therefore, the exact level of brain damage cannot be determined. Magnetic resonance imaging (MRI) or functional MRI may provide further evidence on the neuroanatomical impact in abused women.
The lower third of the facial region was the second most frequently affected region among all HNF injuries. This finding is inconsistent with the previous studies conducted in clinical and community samples in Western countries, which found that injuries were most commonly found in the middle third of the facial region [30, 33]. Moreover, neither punching with a fist nor slapping were significant aetiologies of lower third maxillofacial injuries. It may be possible that the lower third maxillofacial injuries is the consequence of either a fall or knock down followed by punches or slaps.
IPV-related injuries occurred repeatedly among abused women presenting to AED. Around 70% of women reported that the abuse was not the first episode. This is consistent with the findings in many studies conducted in abused women [8, 34, 35]. An important finding to be noted is that almost 80% of the women with IPV-related physical injuries returned home after AED visits. It is likely that these women will return to their abusive partners for a variety of reasons such as financial dependence, emotional dependence, and protection of their children [36, 37]. Although women’s choice of staying in or leaving their abusive relationships should be respected, the stay can be dangerous especially for women with repeated episodes of IPV-related injuries. Therefore, AED physicians and nurses play a vital role in early intervention and empowering women with personal safety issues.
More than half of the women reported HNF injuries combined with other injuries of different body regions; thus, we repeated the structured multiphase logistic regression analysis with multiple injuries as the dependent variable. The woman’s relationship with the perpetrator was found to be a significant factor associated with multiple injuries. In particular, unmarried cohabitating women were 3.3 times more at risk of having multiple injuries than married cohabiting women. A population-based study also found that cohabiting couples had more violent relationships than married couples . It may be possible that cohabiting couples with lower levels of violence tend to move from cohabitation to marriage, whereas couples with higher levels of violence tend to be trapped in violent cohabiting relationships. In addition, women who had former partners as perpetrators were much more at risk of having multiple injuries. It is also possible that separation may be involved in and initiated the abuse. Indeed, previous studies found that separation after a cohabiting relationship or marriage was associated with a higher risk of physical abuse and homicide [21, 39, 40].
Several limitations were found in this study. Firstly, this study relies on secondary clinical data from medical charts with missing values ranging from 0% to 32%. The accuracy and integrity of the data abstracted remained a shortcoming. However, the hospitals chosen for data collection were two main hospitals in the region with the highest reported number of abused women. Also, the hospitals have kept completed medical charts and IPV assessment records. Hence, incompleteness and inadequate information were kept to a minimum. In addition, efforts have been made to minimize misinterpretation of information from medical charts by using two independent reviewers and consensus meetings. Furthermore, the standard chart abstraction sheet specially designed in this study aimed to facilitate data collection and minimize missing data. Secondly, little information regarding the problem, conflict or dispute that initiated the abuse could be found from the clinicians’ notes. A prospective study to investigate the conflicts, dispute and communication patterns immediately before the episode of abuse would be essential to develop warning signs of physical abuse. Thirdly, data collected were based on physical examinations and women’s self-report of injuries. It is possible that the women neglected to mention what they regard as minor injuries. Therefore, underestimation of physical injuries in abused women may occur. In addition, the findings of the present study may not be generalizable to women in the community because the physical injuries reported at AEDs tend to be those that are much more severe. It is possible that replication of this study by using a community sample would yield more non-HNF injuries among abused women. Future study to investigate the pattern of physical injuries in the primary care setting is recommended.
Implications for research
Although HNF injuries are commonly found in abused women presenting to AEDs, limited studies investigated the long term effect on physical and mental health of women after HNF injuries. Some cross-sectional studies assessed for cognitive functioning (such as memory, attention, executive functions and learning) among abused women [28, 41, 42]. Therefore, future research in longitudinal design is necessary to test for the temporal relationship between cognitive functioning and HNF injuries in abused women experiencing abuse and violence.
Apart from obtaining archival data from AEDs, screening of HNF injuries in community-dwelling women is recommended. It can provide a better understanding of physical injuries among abused Chinese women. We anticipated that having a community sample would yield more non-HNF injuries among abused women.
Implications for practice and/or policy
This is the first study to document detailed information on HNF injuries in abused Chinese women. It provides descriptions of the relationships between injuries and its aetiology. Therefore, the present study contributed valuable information regarding the features of physical injuries experienced by abused Chinese women.
The study collected data from two local hospitals with a standard protocol for IPV assessment. This provided evidence that direct questioning for IPV-related patients with physical injuries at AEDs, and the history and details of the mechanism of injuries, are important for early identification in order to prevent further abuse. Although it is the women’s choice to stay in or leave abusive relationships, women sometimes underestimate the danger and risks of situations . It is recommended that health care professionals should increase the screening of women with physical injuries to better identify survivors and promote awareness of IPV dangers. The U.S. Preventive Services Task Force recently released a report and recommended to do IPV screening to asymptomatic women (women who do not have signs or symptoms of abuse) of reproductive age, elderly and vulnerable adults .
One important finding in this study is that cohabiting and separated women were more likely to have multiple injuries than those who were married. Therefore, when cohabiting or separated women are presented to AEDs, they should be given special attention regarding early identification, intervention, and information of abuse. The extra attention may keep them safe and protect them from further abuse and repeated injuries.