Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration

Twelve-Month Sustainment of IPV Screening and Response Programs in Primary Care: Contextual Factors Impacting Implementation Success

PURPOSE

The Veterans Health Administration (VHA) employed implementation facilitation (IF) as a strategy to boost uptake of intimate partner violence (IPV) screening programs in primary care. This study examined the sustainment of screening uptake 1 year after IF and identified factors impacting sustainment success.

METHODS

A mixed-methods evaluation using quantitative and qualitative data was conducted. IPV screening rates from the conclusion of the IF period (i.e., initial adoption) through the 1-year sustainment period served as the primary outcome. We categorized sites into four groups of screening adoption and sustainment success (high adoption and high sustainment, moderate adoption and moderate sustainment, low adoption and low sustainment, and no adoption and/or no sustainment). Qualitative analysis of key informant interviews was used to identify contextual factors affecting screening 12 months post-IF. A mixed sustainment analysis matrix integrated quantitative and qualitative findings and enabled the identification of cross-site patterns.

MAIN FINDINGS

Seven of the nine sites sustained IPV screening at the most basic level (saw static or increased screening rates). High adopting and high sustaining sites (n = 3) were marked by consistently supportive medical center leadership, ongoing training for clinicians, clear protocols for responding to positive screens, and robust referral options for women experiencing IPV. Nonsustaining sites (n = 2) were marked by a host of barriers including staffing shortages, competing priorities, and inconsistent messaging from leadership regarding the importance of IPV screening.

CONCLUSIONS

Knowing barriers and facilitators to successful IPV screening sustainment can inform health care systems to tailor IF and other implementation strategies to sustain IPV screening in primary care. Sustainment of IPV screening requires attention to a combination of facilitators (e.g., consistent leadership support and robust referral options) as well as addressing key barriers (e.g., staff turnover and competing priorities).

Implementation and Impact of Intimate Partner Violence Screening Expansion in the Veterans Health Administration: Protocol for a Mixed Methods Evaluation

BACKGROUND

Intimate partner violence (IPV) is a significant public health problem with far-reaching consequences. The health care system plays an integral role in the detection of and response to IPV. Historically, the majority of IPV screening initiatives have targeted women of reproductive age, with little known about men's IPV screening experiences or the impact of screening on men's health care. The Veterans Health Administration (VHA) has called for an expansion of IPV screening, providing a unique opportunity for a large-scale evaluation of IPV screening and response across all patient populations.

OBJECTIVE

In this protocol paper, we describe the recently funded Partnered Evaluation of Relationship Health Innovations and Services through Mixed Methods (PRISM) initiative, aiming to evaluate the implementation and impact of the VHA's IPV screening and response expansion, with a particular focus on identifying potential gender differences.

METHODS

The PRISM Initiative is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Consolidated Framework for Implementation Research (CFIR 2.0) frameworks. We will use mixed methods data from 139 VHA facilities to evaluate the IPV screening expansion, including electronic health record data and qualitative interviews with patients, clinicians, and national IPV program leadership. Quantitative data will be analyzed using a longitudinal observational design with repeated measurement periods at baseline (T0), year 1 (T1), and year 2 (T2). Qualitative interviews will focus on identifying multilevel factors, including potential implementation barriers and facilitators critical to IPV screening and response expansion, and examining the impact of screening on patients and clinicians.

RESULTS

The PRISM initiative was funded in October 2023. We have developed the qualitative interview guides, obtained institutional review board approval, extracted quantitative data for baseline analyses, and began recruitment for qualitative interviews. Reports of progress and results will be made available to evaluation partners and funders through quarterly and end-of-year reports. All data collection and analyses across time points are expected to be completed in June 2026.

CONCLUSIONS

Findings from this mixed methods evaluation will provide a comprehensive understanding of IPV screening expansion at the VHA, including the implementation and impact of screening and the scope of IPV detected in the VHA patient population. Moreover, data generated by this initiative have critical policy and clinical practice implications in a national health care system.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/59918.

Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT

INTRODUCTION

The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes.

STUDY DESIGN

A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic.

SETTING/PARTICIPANTS

Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149).

INTERVENTION

Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration.

MAIN OUTCOME MEASURES

Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed.

RESULTS

For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57).

CONCLUSIONS

Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT04106193.

Identifying violence against persons at a safety-net hospital: Evidence from the first 6 months of implementation

OBJECTIVE

To examine the prevalence and predictors of screening for violence against persons and victim service utilization within an integrated safety-net health system.

STUDY SETTING

Emergency Department (ED) at Parkland Hospital-Dallas County's largest safety-net provider of services for minority and underinsured and uninsured patients.

STUDY DESIGN

Prospective, longitudinal study during the first 6 months of a universal violence against persons screener.

DATA COLLECTION

Health records were extracted for all patients with a visit to the ED between January and July, 2021. Modeling described the patient population across screening (screened vs. not screened) and, among those screened, the results (positive vs. negative), average time spent in the ED, and referral patterns for victim services.

PRINCIPAL FINDINGS

During the study period, 65,563 unique patients with 95,555 encounters occurred. Seventy-one percent (n = 67,535) were screened for violence against persons and, of those, 2% screened positive (n = 1349). Of the patients who screened positive, 1178 (87%) were referred to and 806 (60%) received care at victim services. Implementing screening did not increase the length of stay at ED.

CONCLUSIONS

Systematic implementation of comprehensive violence screening at a safety-net system can result in robust identification and timely referrals to victim services.

Leveraging Integrated Primary Care to Enhance the Health System Response to IPV: Moving toward Primary Prevention Primary Care

Intimate partner violence (IPV) is a prominent public health problem in the United States, with significant health impacts that are often severe and persistent. Healthcare systems have been called upon to improve both the systematic identification and treatment of IPV largely by adopting secondary and tertiary prevention efforts. Research to date demonstrates both benefits and challenges with the current strategies employed. In this paper, we summarize current knowledge about the healthcare system's response to IPV and evaluate the strengths, limitations, and opportunities. We offer recommendations to broaden the continuum of healthcare resources to address IPV, which include a population health approach to primary prevention.

Opportunities to More Comprehensively Assess Sexual Violence Experience in Veterans Health Administration Medical Records Data

INTRODUCTION

Experience of sexual violence (SV) is prevalent among the Veteran population and associated with many negative mental and physical health outcomes including suicidal behavior, obesity, post-traumatic stress disorder, anxiety, depression, and poor sexual and reproductive functioning. Although Veterans of any gender may experience SV, women Veterans are particularly at risk. Research on SV among Veterans has focused primarily on the experience of SV during military service (military sexual trauma, MST), although Veterans may also experience SV prior to and following military service. The aim of the current study was to construct a more comprehensive method of identifying SV among Veterans Health Administration (VHA) patients as documented in medical records in a national cohort of 325,907 Veterans who used VHA care between 2000 and 2018 in order to inform future research in this area.

METHOD

We used three indicators to identify SV in VHA medical records: (a) the MST screen, (b) the sexual violence item of the intimate partner violence (IPV) screen, and (c) International Classification of Disorders (ICD) codes (versions 9 and 10) representing adult sexual abuse and assault. Univariate descriptive analyses were conducted to determine the exclusivity and overlap of the SV measures.

RESULTS

The universal MST screen was the most commonly identified indicator of SV in the data. However, including the IPV and ICD indicators identified an additional 5% of Veterans who had experienced SV, accounting for thousands of patients.

DISCUSSION

The results of the current study indicate that using the three-pronged approach of SV collection is a more comprehensive method of identifying patient SV experience through VHA medical records and contributes uniquely to the methodology of studying social factors' impact on health care. Clinical screening and documentation of SV allow for the assessment of health impacts and trends through examination of medical records data.

Recovering from Intimate Partner Violence through Strengths and Empowerment (RISE): Initial Evaluation of the Clinical Effects of RISE Administered in Routine Care in the US Veterans Health Administration

Intimate partner violence (IPV) is a common concern among military Veterans that negatively impacts health. The United States' Veterans Health Administration (VHA) has launched a national IPV Assistance Program (IPVAP) to provide comprehensive services to Veterans, their families and caregivers, and VHA employees who use or experience IPV. Grounded in a holistic, Veteran-centered psychosocial rehabilitation framework that guides all facets of the program, the IPVAP initiated the pilot implementation of a novel intervention called Recovering from IPV through Strengths and Empowerment (RISE). This evidence-based, person-centered, trauma-informed, and empowerment-oriented brief counseling intervention is designed to support those who experience IPV and to improve their psychosocial wellbeing. This program evaluation study describes clinical outcomes from patients who participated in a pilot implementation of RISE in routine care. We examined changes in general self-efficacy, depression, and valued living, as well as treatment satisfaction among patients who received RISE and completed program evaluation measures at VHA facilities during the pilot. Results from 45 patients (84% women) indicate that RISE was associated with significant pretreatment to posttreatment improvements in self-efficacy, depression, and valued living (Cohen's d s of 0.97, 1.09, and 0.51, respectively). Patients reported high satisfaction with treatment. Though preliminary results were similar across gender and IPV types, findings from the evaluation of the pilot implementation of RISE demonstrate the intervention's feasibility, acceptability, and clinical utility in routine VHA care and inform the scalability of RISE. Additionally, findings provide preliminary support for the effectiveness and acceptability of RISE with men. Modification to RISE and its implementation are discussed, which may be useful to other settings implementing IPV interventions.

Preventing Suicide Among Women Veterans: Gender-Sensitive, Trauma-Informed Conceptualization

Purpose of Review

There is growing concern regarding suicide among women veterans, who have experienced an increase in suicide rates that has exceeded that reported for other US adult populations. Recent research has bolstered understanding of correlates of suicide risk specific to women veterans. Yet most existing suicide prevention initiatives take a gender-neutral, rather than gender-sensitive, approach. We offer clinical considerations and suggestions for suicide prevention tailored to the needs, preferences, and experiences of women veterans. Discussion is framed around the White House strategy for preventing suicide among military service members and veterans.

Recent Findings

Considering high rates of trauma exposure among women veterans, we propose that a trauma-informed lens is essential for taking a gender-sensitive approach to suicide prevention with this population. Nonetheless, research to inform evidence-based assessment and intervention remains largely focused on veteran men or gender-neutral. Integral next steps for research are posited.

Summary

Extant research provides an initial foundation for beginning to understand and address suicide among women veterans in a gender-sensitive, trauma-informed manner. Additional research that is specific to women veterans or that examines gender differences is critical to ensure women veterans receive optimal, evidence-based care to prevent suicide.

Women Tell All: A Comparative Thematic Analysis of Women's Perspectives on Two Brief Counseling Interventions for Intimate Partner Violence

Background: Intimate partner violence (IPV) is a significant public health problem that is commonly experienced by women and associated with psychosocial health issues. Recovering from IPV through Strengths and Empowerment (RISE) is a brief, clinician-administered, variable-length (1–6 sessions), modular, individualized psychosocial counseling intervention developed for women experiencing IPV. We present qualitative feedback and quantitative helpfulness ratings from women patients of the Veterans Health Administration who completed a randomized clinical trial (RCT) comparing RISE to a clinician-administered advocacy-based Enhanced Care as Usual (ECAU; a single structured session consisting of psychoeducation, safety-planning, resources, and referrals). Methods: 58 participants (_Mage = 39.21) completed post-intervention semi-structured qualitative interviews, including helpfulness ratings, at two follow-up assessments (10- and 14-weeks post-enrollment) to assess the acceptability, usefulness, and perceived fit of the interventions for women’s needs. Interviews were transcribed and analyzed using a hybrid deductive-inductive analytic approach. Results: While both the RISE and ECAU interventions were deemed helpful (interventions were rated as ‘highly helpful’ by 77% of RISE and 52% of ECAU participants), differences were identified in perceived impacts of the intervention, application of content, approach to patient-centeredness, and implementation recommendations. Conclusions: Findings shed light on women Veterans’ experiences and preferences for IPV psychosocial counseling interventions. Such knowledge can inform evidence-based, trauma-informed, and individualized care for women Veterans who experience IPV and may have relevance to other populations of women who experience IPV.

Intimate Partner Violence Screening for Women in the Veterans Health Administration: Temporal Trends from the Early Years of Implementation 2014-2020

Thousands of women Veterans experience intimate partner violence (IPV) each year. The Veterans Health Administration (VHA) has encouraged IPV screening in Veterans Affairs medical centers (VAMCs) since 2014. Through retrospective analysis of VHA administrative data from fiscal year (FY) 2014 into FY2020, we examined IPV screening implementation outcomes of reach and adoption, as well as screen-positive rates using descriptive and multivariate linear regression analyses. We examined reach and screen-positive rates overall and as a function of childbearing age (18-44 vs. 45+ years). In FY2014 only one VAMC was screening women for IPV; by FY2020, over half of VAMCs had adopted IPV screening. This rollout of IPV screening was associated with a large increase in the number of women primary care patients screened (from fewer than 500 in FY2014, to nearly 35,000 in early FY2020). Overall, among women screened, 6.7% screened positive for IPV; this rate was higher among women of childbearing age (8.1% vs. 5.6%). Despite the spread of IPV screening practices during the early years of implementation in VHA, additional work is needed. This study is the first comprehensive analysis of implementation outcomes associated with VHA's IPV screening efforts, and lays the groundwork for ongoing evaluation and quality improvement.

Awareness, Knowledge, and Screening for Intimate Partner Violence Among Orthopedic Surgeons in Israel

This study examines factors associated with screening of female patients for intimate partner violence (IPV) by orthosurgeons in a sample of 100 Israeli orthosurgeons. Findings reveal positive attitudes toward screening female patients but a significant lack of knowledge. Arab orthosurgeons held slightly more negative attitudes toward screening for IPV and had a more prominent lack of knowledge regarding screening for IPV, compared to their Jewish counterparts. Nationality and feeling uncomfortable asking female patients about IPV predicted screening for IPV. The importance of training orthosurgeons on the assessment and treatment of IPV cannot be overemphasized, especially among Arab orthosurgeons.

Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review

Background

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. Screening for IPV within healthcare settings can identify women who experience IPV and inform counseling, referrals, and interventions to improve their health outcomes. Unfortunately, many screening programs used to detect IPV have only been tested in research contexts featuring externally funded study staff and resources. This systematic review therefore investigated the utility of IPV screening administered by frontline clinical personnel.

Methods

We conducted a systematic literature review focusing on studies of IPV screening programs for women delivered by frontline healthcare staff. We based our data synthesis on two widely used implementation models (Reach, Effectiveness, Adoption, Implementation and Maintenance [RE-AIM] and Proctor's dimensions of implementation effectiveness).

Results

We extracted data from 59 qualifying studies. Based on data extraction guided by the RE-AIM framework, the median reach of the IPV screening programs was high (80%), but Emergency Department (ED) settings were found to have a much lower reach (47%). The median screen positive rate was 11%, which is comparable to the screen-positive rate found in studies using externally funded research staff. Among those screening positive, a median of 32% received a referral to follow-up services. Based on data extraction guided by Proctor's dimension of appropriateness, a lack of available referral services frustrated some efforts to implement IPV screening. Among studies reporting data on maintenance or sustainability of IPV screening programs, only half concluded that IPV screening rates held steady during the maintenance phase. Other domains of the RE-AIM and Proctor frameworks (e.g., implementation fidelity and costs) were reported less frequently.

Conclusions

IPV is a population health issue, and successfully implementing IPV screening programs may be part of the solution. Our review emphasizes the importance of ongoing provider trainings, readily available referral sources, and consistent institutional support in maintaining appropriate IPV screening programs.

Plain language abstract

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. IPV screening and response can identify women who experience IPV and can inform interventions to improve their health outcomes. Unfortunately, many of the screening programs used to detect IPV have only been tested in research contexts featuring administration by externally funded study staff. This systematic review of IPV screening programs for women is particularly novel, as previous reviews have not focused on clinical implementation. It provides a better understanding of successful ways of implementing IPV screening and response practices with frontline clinical personnel in the context of routine care. Successfully implementing IPV screening programs may help mitigate the harms resulting from IPV against women. Findings from this review can inform future efforts to improve implementation of IPV screening programs in clinical settings to ensure that the victims of IPV have access to appropriate counseling, resources, and referrals.

Intimate Partner Violence and the Role of Breast Imaging Centers

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient's upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

Strides Toward Recovery From Intimate Partner Violence: Elucidating Patient-Centered Outcomes to Optimize a Brief Counseling Intervention for Women

Women in the United States continue to experience intimate partner violence (IPV) at unprecedented rates, necessitating the development and implementation of personalized, effective healthcare-based interventions. Methods of developing patient-centered interventions for IPV should elicit the voice of the target population (i.e., women who experience IPV) while assuring that outcomes identified as important are incorporated into the refined intervention. This pilot study is part of a multiphase, larger study aiming to refine an IPV intervention and clinical outcome measurements prior to formal evaluation of the effectiveness of the intervention. Specifically, this study elucidates patient-centered outcomes identified by women who have experienced IPV. Women patients of the Veterans Health Administration (VHA) in New England participated in focus groups to provide feedback and desired outcomes of a new IPV intervention. Patient-centered outcomes were defined by the participants. Focus groups were transcribed and analyzed using conventional content analysis and matrix analysis. A total of 25 women participated in focus groups (n = 5) at two large VHA facilities. Participant feedback revealed five common themes related to desired outcomes. Women opined increased feelings of empowerment as a key outcome of engaging in an IPV intervention. Women desired increased social connectedness and support to be gained during treatment, citing providers and other survivors of IPV as exemplary sources. Self-esteem was viewed as critical to enhancing recovery, as was increased knowledge across domains of IPV (e.g., warning signs, the link between mental and physical health for self and children). Finally, women identified valued action and goal setting, such as achieving more independence, as an optimal outcome. Addressing IPV against women requires patient-centered interventions that specifically target the types of outcomes deemed important by the end users: women who experience IPV. Findings have implications for tailoring treatments for IPV and selecting measures that tap into women's desired outcomes.

Survivors' Input on Health Care-Connected Services for Intimate Partner Violence

Background: Intimate partner violence (IPV) is increasingly recognized as a social factor impacting health, and health care providers are encouraged to routinely screen and refer patients for needs related to IPV. Health care settings are often challenged, however, in their ability to connect patients with community-based IPV services. Some organizations have invested in on-site programs to facilitate identification and connection. Methods: The goal of this study was to understand IPV survivors' experiences with and perspectives on health care-connected IPV services. Semistructured in-depth interviews were conducted in-person by a trained and experienced interviewer and were audio-recorded and transcribed verbatim. Interview transcripts were analyzed using team-based qualitative thematic content analysis. Participants included 68 individuals who had experienced IPV, recruited through one of two settings: (1) a health care organization with embedded IPV services or (2) a community-based IPV service organization that partners with health care settings. Results: Interviews revealed benefits of having health care-connected IPV services, including that the health care setting can be critical for providing information about IPV programs and that survivors may need assistance with navigation of community services. Survivors further highlighted recommendations for trauma-sensitive care that includes providing clarification about the role and scope of IPV services, following-up with but not forcing intervention, and ensuring privacy, confidentiality, and trust in interactions. Conclusions: Findings support health care settings having in-house or close partnership with IPV advocates to adequately support patients' needs in connecting with and navigating community based IPV-related services.

A Multisite Quality Improvement Initiative to Enhance the Adoption of Screening Practices for Intimate Partner Violence Into Routine Primary Care for Women Veterans

OBJECTIVE

The Veterans Health Administration established comprehensive women's health clinics (CWHCs) to provide coordinated, high-quality primary care to women veterans. Intimate partner violence (IPV) is prevalent among women using these clinics. The Veterans Health Administration recommends screening women for IPV, yet screening uptake is low in CWHCs nationwide. We describe a multisite quality improvement initiative to enhance the adoption of IPV screening practices in the Veterans Health Administration's CWHCs.

METHODS

This quality improvement initiative, implemented in 2017-2018, included 4 steps in which we (1) conducted a baseline survey of screening practices at CWHCs throughout the United States; (2) selected and tailored evidence-based implementation strategies based on identified barriers and facilitators; (3) deployed multicomponent implementation support, targeting low-adopting facilities; and (4) conducted a follow-up survey to evaluate changes in IPV screening practices from baseline (winter 2017) to 1-year follow-up (winter 2018) using quantitative and qualitative analyses.

RESULTS

Responders from 62 CWHC sites provided information on IPV screening practices and barriers; 42 low-adopting sites were targeted for implementation support. At follow-up, responders provided information on IPV screening practices, perceived usefulness of implementation support strategies, and continued barriers. Among sites that responded to both surveys (n = 47), the number of sites that implemented recommended screening practices increased by 66.7%, from 15 at baseline to 25 at follow-up (P = .02). Emergent themes reflected barriers and facilitators for IPV screening implementation.

CONCLUSIONS

Improvement in IPV screening practices in CWHCs is a pivotal step toward enhancing care for women. Yet, even with numerous implementation supports, barriers to adoption persist at many sites. Findings on modifiable barriers and unique facilitators can inform next steps for increasing screening uptake.

Middle-aged Women's Experiences of Intimate Partner Violence Screening and Disclosure: "It's a private matter. It's an embarrassing situation"

BACKGROUND

National guidelines indicate that healthcare providers should routinely screen women of reproductive age for experience of intimate partner violence. We know little about intimate partner violence (IPV) screening and disclosure experience among women older than reproductive age.

OBJECTIVE

To examine the perspectives of middle-aged women who had experienced past-year IPV regarding IPV screening and disclosure in the healthcare setting.

DESIGN

Individual semi-structured qualitative interviews were conducted in-person as part of a larger study examining IPV screening and response services through the Veterans Health Administration.

PARTICIPANTS

Twenty-seven women aged 45-64 (mean age 53) who experienced past-year IPV and received care at one of two Veterans Affairs Medical Centers.

APPROACH

Interviews were digitally recorded and transcribed. Data were sorted and analyzed using templated notes and line-by-line coding, based on codes developed by the study team through an initial review of the data. Themes were derived from further analysis of the data coded for "screening" and "disclosure" for respondents aged 45 and older.

KEY RESULTS

Barriers to disclosure of IPV to a healthcare provider included as follows: (a) feelings of shame, stigma, and/or embarrassment about experiencing IPV; (b) screening context not feeling comfortable or supportive, including lack of comfort with or trust in the provider and/or a perception that screening was conducted in a way that felt impersonal and uncaring; and (c) concerns about privacy and safety related to disclosure. Provider demonstrations of care, empathy, and support facilitated disclosure and feelings of empowerment following disclosure.

CONCLUSIONS

Middle-aged women may benefit from routine IPV screening and response in the healthcare setting. Such interventions should be sensitive to concerns regarding stigma and privacy that may be prevalent among this population.

Patient and provider barriers, facilitators, and implementation preferences of intimate partner violence perpetration screening

BACKGROUND

The substantial prevalence and consequences of intimate partner violence (IPV) underscore the need for effective healthcare response in the way of screening and follow up care. Despite growing evidence regarding perspectives on healthcare-based screening for IPV experiences (i.e., victimization), there is an extremely limited evidence-base to inform practice and policy for detecting IPV use (i.e., perpetration). This study identified barriers, facilitators, and implementation preferences among United States (US) Veterans Health Administration (VHA) patients and providers for IPV use screening.

METHODS

We conducted qualitative interviews with patients enrolled in VHA healthcare (N = 10) and focus groups with VHA providers across professional disciplines (N = 29). Data was analyzed using thematic and content analyses.

RESULTS

Qualitative analysis revealed convergence between patients' and providers' beliefs regarding key factors for IPV use screening, including the importance of a strong rapport, clear and comprehensive processes and procedures, universal implementation of screening, and a self-report screening tool that assesses for both IPV use and experiences concurrently.

CONCLUSIONS

Findings provide foundational information regarding patient and provider barriers, facilitators, and preferences for IPV use screening that can inform clinical practice and next steps in this important but understudied aspect of healthcare.

Intimate Partner Violence Among Female OEF/OIF/OND Veterans Who Were Evaluated for Traumatic Brain Injury in the Veterans Health Administration: A Preliminary Investigation

Many female veterans have deployed to Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), and some experience traumatic brain injury (TBI). Although TBI is increasingly recognized as an important health issue for female OEF/OIF/OND veterans, there is little attention to stressful experiences that may exacerbate health problems or hinder recovery among veterans who may have experienced TBI. Lifetime intimate partner violence (IPV) is common among general samples of female veterans. Given the negative implications of IPV on women's health, it is important to understand whether there is a relationship between lifetime IPV and health functioning among female veterans who have experienced possible TBI. This study provides an exploration of lifetime IPV and its associations with physical and mental health, as well as community reintegration, among female OEF/OIF/OND veterans who have been evaluated for TBI. The sample comprised 127 female veterans who participated in a larger study that examined reintegration among OEF/OIF/OND veterans who received a TBI evaluation in the Veterans Heath Administration (VHA) and completed an assessment of lifetime IPV. Primary and secondary data sources included survey responses (e.g., health symptoms and reintegration) and VHA administrative data (e.g., health diagnoses). Results indicated that nearly two thirds (63.0%) of women who completed a TBI evaluation reported lifetime IPV, though clinician-confirmed TBI was not associated with IPV. Women who experienced IPV, compared with those who did not, reported higher levels of neurobehavioral symptoms and were significantly more likely to have diagnoses of back pain (48.6% vs. 30.0%, respectively) and substance abuse (12.2% vs. 0%, respectively). Notwithstanding, women with and without lifetime IPV reported similar levels of reintegration. Findings provide evidence that lifetime IPV may be common among female OEF/OIF/OND veterans who are evaluated for TBI, and that IPV is associated with several treatable health problems among this population.

Assessing the Veterans Health Administration's response to intimate partner violence among women: protocol for a randomized hybrid type 2 implementation-effectiveness trial

BACKGROUND

Intimate partner violence (IPV) against women in the United States (US) remains a complex public health crisis. Women who experience IPV are among the most vulnerable patients seen in primary care. Screening increases the detection of IPV and, when paired with appropriate response interventions, can mitigate the health effects of IPV. The Department of Veterans Affairs (VA) has encouraged evidence-based IPV screening programs since 2014, yet adoption is modest and questions remain regarding the optimal ways to implement these practices, which are not yet available within the majority of VA primary care clinics.

METHODS/DESIGN

This paper describes the planned evaluation of VA's nationwide implementation of IPV screening programs in primary care clinics through a randomized implementation-effectiveness hybrid type 2 trial. With the support of our VA operational partners, we propose a stepped wedge design to compare the impact of two implementation strategies of differing intensities (toolkit + implementation as usual vs. toolkit + implementation facilitation) and investigate the clinical effectiveness of IPV screening programs. Using balanced randomization, 16-20 VA Medical Centers will be assigned to receive implementation facilitation in one of three waves, with implementation support lasting 6 months. Implementation facilitation in this effort consists of the coordinated efforts of the two types of facilitators, external and internal. Implementation facilitation is compared to dissemination of a toolkit plus implementation as usual. We propose a mixed methods approach to collect quantitative (clinical records data) and qualitative (key informant interviews) implementation outcomes, as well as quantitative (clinical records data) clinical effectiveness outcomes. We will supplement these data collection methods with provider surveys to assess discrete implementation strategies used before, during, and following implementation facilitation. The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will guide the qualitative data collection and analysis. Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

DISCUSSION

This research will advance national VHA efforts by identifying the practices and strategies useful for enhancing the implementation of IPV screening programs, thereby ultimately improving services for and health of women seen in primary care.

TRIAL REGISTRATION

NCT04106193. Registered on 23 September 2019.

Mental health care in the context of intimate partner violence: Survivor perspectives

Experience of violence or abuse from an intimate partner (intimate partner violence, IPV) can result in a variety of psychological and mental health impacts for which survivors may seek psychotherapy or other mental health services. Individuals experiencing IPV may have specific needs and preferences related to mental health care, yet the question of how to best provide client-centered mental health care in the context of IPV has received little attention in the literature. In this article, we report on findings from qualitative interviews with 50 women reporting past-year IPV who received care through the Veterans Health Administration regarding experiences with and recommendations for mental health services. Participants described client-centered mental health care in the context of recent or ongoing IPV as being characterized by flexibility and responsiveness around discussion of IPV; respect for the complexity of clients' lives and support for self-determination; and promoting safety and access to internal and external resources for healthy coping. We discuss findings in terms of their implications for the mental health field, highlighting the need for flexibility in application of evidence-based treatments, improved coordination between therapeutic and advocacy services, and training to enhance competencies around understanding and responding to IPV. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

When user-centered design meets implementation science: integrating provider perspectives in the development of an intimate partner violence intervention for women treated in the United States' largest integrated healthcare system

BACKGROUND

Intimate partner violence (IPV) against women is a global health problem that is a substantial source of human suffering. Within the United States (US), women veterans are at high risk for experiencing IPV. There is an urgent need for feasible, acceptable, and patient-centered IPV counseling interventions for the growing number of women treated in the US's largest integrated healthcare system, the Veterans Health Administration (VHA). Implementation science and user-centered-design (UCD) can play an important role in accelerating the research-to-practice pipeline. Recovering from IPV through Strengths and Empowerment (RISE) is a flexible, patient-centered, modular-based program that holds promise as a brief counseling intervention for women veterans treated in VHA. We utilized a UCD approach to develop and refine RISE (prior to formal effectiveness evaluations) by soliciting early feedback from the providers where the intervention will ultimately be implemented. The current study reports on the feedback from VHA providers that was used to tailor and refine RISE.

METHOD

We conducted and analyzed semi-structured, key-informant interviews with VHA providers working in clinics relevant to the delivery of IPV interventions (n = 23) at two large medical centers in the US. Participants' mean age was 42.6 years (SD = 11.6), they were predominately female (91.3%) and from a variety of relevant disciplines (39.1% psychologists, 21.7% social workers, 17.4% physicians, 8.7% registered nurses, 4.3% psychiatrists, 4.3% licensed marriage and family therapists, 4.3% peer specialists). We conducted rapid content analysis using a hybrid inductive-deductive approach.

RESULTS

Providers perceived RISE as highly acceptable and feasible, noting strengths including RISE's structure, patient-centered agenda, and facilitation of provider comfort in addressing IPV. Researchers identified themes related to content and context modifications, including requests for additional safety check-ins, structure for goal-setting, and suggestions for how to develop and implement RISE-specific trainings.

CONCLUSIONS

These findings have guided refinements to RISE prior to formal effectiveness testing in VHA. We discuss implications for the use of UCD in intervention development and refinement for interventions addressing IPV and other trauma in health care settings globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03261700; Date of registration: 8/25/2017, date of enrollment of first participant in trial: 10/22/2018. Unique Protocol ID: IIR 16-062.

Intimate Partner Violence Screening Programs in the Veterans Health Administration: Informing Scale-up of Successful Practices

OBJECTIVES

Screening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA).

DESIGN

Descriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women's health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners.

PARTICIPANTS

Thirty-two administrators and clinician key informants (e.g., Women's Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide.

MAIN MEASURES

Participants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites.

KEY RESULTS

Five successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified.

CONCLUSIONS

Findings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women's health.

Suicidal ideation and behaviors among women veterans with recent exposure to intimate partner violence

OBJECTIVE

Women veterans have disproportionately high risk for both suicide and intimate partner violence compared to women non-veterans. The objective of this study was to assess the relationship between intimate partner violence (IPV) and suicidal ideation and suicidal or self-harm behaviors among women veterans.

METHOD

Veterans Health Administration (VHA) electronic medical records were extracted for 8427 women veterans who completed screening for past-year IPV between April 2014 and 2016. Risk for suicidal ideation and self-harm behaviors were estimated as function of screening results using logistic regression.

RESULTS

Overall, 8.4% screened positive for IPV. Suicidal ideation or self-harm behaviors were recorded for 3.2%. Positive IPV screen was associated with double the odds for suicidal ideation (AOR = 2.04; 95% CI = 1.47-2.86) and self-harm behaviors (AOR = 2.05, 95% CI = 1.10-3.83). Risks did not significantly differ by IPV type. Suicide-related ICD codes were most often recorded prior to IPV screening.

CONCLUSIONS

There is a strong association between positive IPV screen and suicidal ideation and self-harm behaviors among VHA-engaged women veterans. Documentation of either event is an important marker for the other. Integration of suicide prevention with IPV services may enhance identification of women at risk and speed service uptake. Suicidal ideation and behaviors should be assessed among women with positive IPV screens, and identification of suicide risk should trigger IPV assessment.

Women's Healthcare Utilization Following Routine Screening for Past-Year Intimate Partner Violence in the Veterans Health Administration

BACKGROUND

Experience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system.

OBJECTIVE

The objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV-) and to examine the timing and types of healthcare services accessed among women screening IPV+.

DESIGN

A retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016.

MAIN MEASURES

Demographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes).

KEY RESULTS

In the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV-. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV-. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening.

CONCLUSIONS

Women who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of emergency department utilization and inpatient stays among women screening IPV+ may indicate adverse health outcomes related to IPV experience.

Going direct to the consumer: Examining treatment preferences for veterans with insomnia, PTSD, and depression

Inclusion of consumer preferences to disseminate evidence-based psychosocial treatment (EBPT) is crucial to effectively bridge the science-to-practice quality chasm. We examined this treatment gap for insomnia, posttraumatic stress disorder (PTSD), depression, and comorbid symptoms in a sample of 622 young adult veterans through preference in symptom focus, treatment modality, and related gender differences among those screening positive for each problem. Data were collected from veteran drinkers recruited through targeted Facebook advertisements as part of a brief online alcohol intervention. Analyses demonstrated that veterans reported greater willingness to seek insomnia-focused treatment over PTSD- or depression-focused care. Notably, even when participants screened negative for insomnia, they preferred sleep-focused care to PTSD- or depression-focused care. Although one in five veterans with a positive screen would not consider care, veterans screening for both insomnia and PTSD who would consider care had a preference for in-person counseling, and those screening for both insomnia and depression had similar preferences for in-person and mobile app-based/computer self-help treatment. Marginal gender differences were found. Incorporating direct-to-consumer methods into research can help educate stakeholders about methods to expand EBPT access. Though traditional in-person counseling was often preferred, openness to app-based/computer interventions offers alternative methods to provide veterans with EBPTs.

Recent Intimate Partner Violence and Housing Instability Among Women Veterans

INTRODUCTION

Women Veterans are at increased risk of both housing instability and intimate partner violence compared with their non-Veteran counterparts. The objectives of the present study were (1) to assess the relationship between women Veterans' experience of intimate partner violence and various indicators of housing instability, and (2) to assess what correlates help to explain experiences of housing instability among women Veterans who experienced past-year intimate partner violence.

METHODS

Data were collected from U.S. Department of Veterans Affairs electronic medical records for 8,427 women Veterans who were screened for past-year intimate partner violence between April 2014 and April 2016 at 13 Veterans Affairs' facilities. Logistic regressions performed during 2017 assessed the relationship between past-year intimate partner violence and housing instability.

RESULTS

A total of 8.4% of the sample screened positive for intimate partner violence and 11.3% for housing instability. Controlling for age and race, a positive intimate partner violence screen increased odds of housing instability by a factor of 3. Women Veterans with past-year intimate partner violence were more likely to have an indicator of housing instability if they identified as African American, had screened positive for military sexual trauma, or had a substance use disorder; receiving compensation for a disability incurred during military service and being married were protective.

CONCLUSIONS

For women Veterans, intimate partner violence interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with intimate partner violence programs to address common barriers to resources.

Training reproductive health providers to talk about intimate partner violence and reproductive coercion: an exploratory study

To explore the effect of provider communication-skills training on frequency of intimate partner violence (IPV) and reproductive coercion (RC) assessment, four family planning clinics were randomized to IPV/RC communication-skills building workshop or standard knowledge-based IPV/RC training and compared to historical controls from the same clinics (before any training). Female patients aged 16-29 completed after-visit surveys. Primary outcomes included provider discussion about IPV/RC, receipt of safety card with IPV/RC resources and patient disclosure of IPV/RC. Chi-square tests were used to compare groups that received training and historical controls. Participants (training: n = 103; historical control: n = 576) were predominantly white with mean age of 22. More patients reported discussion about healthy relationships in both training groups (78-90%) compared to historical controls (49-52%, P < 0.001 for both). Discussion on birth control sabotage and pregnancy coercion was infrequent with patient-participants in both groups (6-17 and 4-13%, respectively). More patients in the clinics that received training reported receiving a safety card (72-84%) as compared to historical controls (9%, P < 0.001 for both). Overall, in this exploratory study, both communication-skills and standard training improved frequency of IPV communication when compared to historical controls but with few differences when compared to each other.

Adoption, penetration, and effectiveness of a secondary risk screener for intimate partner violence: Evidence to inform screening practices in integrated care settings

OBJECTIVE

Veterans Health Administration (VHA) has implemented screening for past-year intimate partner violence (IPV) in some healthcare facilities along with secondary screening of risk for severe violence among those screening positive in order to facilitate follow-up care for high-risk patients. We evaluated the adoption, penetration, and effectiveness of secondary screening as a tool to facilitate timely follow-up services.

METHODS

Retrospective review of medical records (screening and healthcare use) of 774 women screening positive for past-year IPV (IPV+) at 11 facilities nationwide from April 2014-April 2016. Chi-square and t-tests examined factors related to secondary screening.

RESULTS

Three of eleven (27.3%) facilities that implemented primary IPV screening adopted secondary screening. At adopting sites, 56.4% eligible (i.e., IPV+) women received secondary screening. Among 185 IPV+ women who completed secondary screening, 33.0% screened positive for severe IPV. Screening positive during secondary screening was associated with higher rate of psychosocial care within 60 days (73.8% vs. 54.0% of IPV+ patients screening negative; p < .05), posttraumatic stress disorder diagnosis (31.1% vs. 15.3%; p < .05), and being physically threatened or harmed (>50% vs. <15%; p < .001).

CONCLUSIONS

Secondary risk assessment following IPV screening may expedite access to psychosocial follow-up care in integrated healthcare settings. However, program uptake needs to be enhanced.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Disproportionate Mental Health Burden Associated With Past-Year Intimate Partner Violence Among Women Receiving Care in the Veterans Health Administration

Experience of intimate partner violence (IPV) can lead to mental health conditions, including anxiety, depression, and unhealthy substance use. Women seen in the Veterans Health Administration (VHA) face high rates of both IPV and mental health morbidity. This study aimed to identify associations between recent IPV experience and mental health diagnoses among women VHA patients. We examined medical records data for 8,888 female veteran and nonveteran VHA patients across 13 VHA facilities who were screened for past-year IPV between April, 2014 and April, 2016. Compared with women who screened negative for past-year IPV (IPV-), those who screened positive (IPV+; 8.7%) were more than twice as likely to have a mental health diagnosis, adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) [1.95, 2.64]; or more than two mental health diagnoses, AOR = 2.29, 95% CI [1.93, 2.72]). Screening IPV+ was also associated with significantly higher odds of each type of mental health morbidity (AOR range = 1.85-3.19) except psychoses. Over half (53.5%) of the women who screened IPV+ had a mental health diagnosis, compared with fewer than one-third (32.6%) of those who screened IPV-. Each subtype of IPV (psychological, physical, and sexual violence) was significantly associated with having a mental health diagnosis (AOR range = 2.25-2.37) or comorbidity (AOR range = 2.17-2.78). Associations remained when adjusting for military sexual trauma and combat trauma among the veteran subsample. These findings highlight the mental health burden associated with past-year IPV among female VHA patients and underscore the need to address psychological and sexual IPV, in addition to physical violence.

Intimate Partner Violence Screening in the Veterans Health Administration: Demographic and Military Service Characteristics

INTRODUCTION

Intimate partner violence (IPV) includes psychological, physical, or sexual aggression by a current or former intimate partner and is associated with a wide range of health and social impacts, especially for women. Women veterans may be at increased risk for experiencing IPV, and some Veterans Health Administration (VHA) facilities have initiated routine screening of female patients for past-year IPV. This study presents the first examination of clinical IPV screening responses recorded from female VHA patients across 13 facilities nationwide, and identifies associations with patient demographic and military service characteristics.

METHODS

Electronic medical record data were extracted for a cohort of 8,885 female VHA patients who completed screening for experience of past-year IPV during a clinic visit between April 2014 and April 2016. Analyses, conducted in 2016, examined the overall proportion of patients screening positive for IPV, as well as associations by demographic and military service characteristics.

RESULTS

Overall, 8.7% of patients screened positive for past-year IPV. Odds of screening positive for IPV were higher among women who were younger (aged <35 years); married; served in the most recent conflict era; experienced sexual assault or harassment during military service; or had not served in the military (non-veterans).

CONCLUSIONS

Study findings indicate a significant proportion of female VHA patients disclosing past-year IPV during clinical screening, and identify characteristics associated with increased vulnerability. Implications for future research and program implementation include addressing high-risk subpopulations and further investigating the impact of screening and follow-up care.

Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care

OBJECTIVES

The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics.

DESIGN

This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey.

PARTICIPANTS

A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study.

MAIN MEASURES

Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data.

KEY RESULTS

The prevalence of past-year IPV among women Veterans was 18.5% (se = 0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se = 1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers.

CONCLUSIONS

The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social services and MST-related care.

Female veterans' preferences for counseling related to intimate partner violence: Informing patient-centered interventions

OBJECTIVE

Female veterans are at high risk for intimate partner violence (IPV). A critical issue in the provision of health care to women who experience IPV is the delivery of effective brief counseling interventions that address women's unique needs. We aimed to identify female veterans' priorities and preferences for healthcare-based IPV counseling.

METHOD

A 2014 Web-based survey was administered to a national sample of US female veterans. Among 411 respondents (75% participation rate), 55% (n=226) reported IPV during their lifetime. These women identified priorities for the content focus of IPV-related counseling and preferences for the delivery of these services.

RESULTS

Women prioritized counseling that focuses on physical safety and emotional health, with learning about community resources being a relatively lower priority. Participants preferred counseling to focus specifically on enhancing coping skills and managing mental health symptoms. In addition, women want counseling to be individualized and preferred the option to meet with a counselor immediately following disclosure. Affordable services and attention to privacy concerns were of paramount importance in the context of IPV-related counseling.

CONCLUSION

These findings can inform patient-centered brief counseling interventions for women who experience IPV, which may ultimately reduce health disparities and violence among this population.

Screening for Intimate Partner Violence

Intimate partner violence (IPV) is a serious concern for women that is associated with significant adverse health effects. Routine screening for IPV is recommended, but there are many barriers to screening that have been identified by providers, including discomfort, lack of training, and not knowing how to respond to a positive screen. This article reviews IPV screening and appropriate techniques for responding to a positive screen. IPV screening best practices include using a systematic protocol, developing a screening script, using a validated screening tool, and considerations for privacy and mandatory reporting. Responding to a positive screen should include acknowledging the experience, asking if the woman desires help, offering support and referrals, encouraging safety planning, and completing additional assessments to determine level of danger and to identify any comorbidities. Using these techniques along with therapeutic communication may increase IPV identification and create an environment in which women feel empowered to get help.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension

The 4-item Hurt/Insult/Threaten/Scream (HITS) tool accurately detects past-year intimate partner violence (IPV) among female Veterans Health Administration (VHA) patients; however, it lacks a sexual IPV item. This study evaluated the accuracy of an extended HITS (E-HITS), which adds a sexual IPV item, in female VHA patients. A sample of 80 female U.S. veteran VHA patients in New England completed a mail survey (50.0% response rate) that included the 5-item E-HITS and the Revised Conflict Tactics Scales (CTS-2). Women were included if they were in an intimate relationship in the past year. The women averaged 49 years of age and 86.0% of the sample was White. Accuracy of the 4-item HITS was compared to the 5-item E-HITS, using the CTS-2 as the reference. There were 20 women (25.0%) who reported past-year IPV on the CTS-2. The receiver operator characteristic curves demonstrated that the HITS and E-HITS performed nearly identically at their optimal cutoff scores of 6 and 7, respectively. At these cutoff scores, the sensitivity of both tools was .75, 95% CI [.55, .95]. The specificities were similar; .83 for the HITS, 95% CI [.73, .92], and .82 for the E-HITS, 95% CI [.72, .90]. Including a sexual IPV item may be clinically beneficial; it also attains the same accuracy of case identification as the HITS.