Asking about intimate partner violence: advice from female survivors to health care providers

Intimate Partner Violence Detected during Abortion-Related Visits: A Systematic Review of Screenings and Interventions

OBJECTIVE

 To perform a systematic review of screening tools and interventions focused on reducing adverse health outcomes associated with intimate partner violence (IPV) at abortion-related visits.

STUDY DESIGN

 Studies were eligible if they included individuals seeking pregnancy options health care services in the United States, screening for or implementation of an intervention for IPV, and were published in English after the year 2000. The primary outcomes were to summarize screening tools, interventions studied, and if interventions led to individuals being connected to IPV-related resources. Secondary outcomes included patient responses to the IPV-related interventions and any other outcomes reported by the studies (PROSPERO #42021252199).

RESULTS

 Among 4,205 abstracts identified, nine studies met inclusion criteria. The majority (n = 6) employed the ARCHES (Addressing Reproductive Coercion in Health Settings) tool for identification of IPV. Interventions included provider-facilitated discussions of IPV, a safety card with information about IPV and community-based resources, and referral pathways to directly connect patients with support services. For the primary outcome, IPV-related interventions were shown to better inform patients of available IPV-related resources as compared to no intervention at all. For the secondary outcomes, screening and intervening on IPV were associated with improvements in patient perception of provider empathy (i.e., caring about safety) and safer responses by patients to unhealthy relationships.

CONCLUSION

 Screening for and intervening on IPV at abortion-related visits are associated with positive outcomes for patient safety and the patient-provider relationship. However, data on effective tools for identifying and supporting these patients are extremely limited. This review emphasizes the unmet need for implementation and evaluation of IPV-specific interventions during abortion-related clinical encounters.

KEY POINTS

· The abortion visit offers a crucial setting to address IPV among a highly affected population.. · This study reviews others that analyzed interventions and associated outcomes for IPV at abortion-related visits.. · Appropriate interventions for IPV can improve patient-provider relationships and connect patients to essential resources..

Reflections on 'common' genetic medical history questions: Time to examine the what, why, and how

OBJECTIVE

A central goal of patient-centered care is to establish a therapeutic relationship. While remaining in tune with patient emotions, genetics providers must ask questions to understand medical histories that will inform the differential diagnosis, evaluation plan, and potential treatments.

METHODS

195 audio-recorded conversations between providers and caregivers of pediatric patients with suspected genetic conditions were coded and analyzed. Coders identified sensitive history-taking questions asked by providers related to exposures and complications during pregnancy; ancestry and consanguinity; educational attainment of the caregiver; and family structure.

RESULTS

We highlight examples of providers: using stigmatizing language about conception or consanguinity; not clarifying the intent behind questions related to caregivers' educational attainment and work history; and making presumptions or assumptions about caregivers' race and ethnicity, family structure, and exposures during pregnancy.

CONCLUSION

Some questions and phrasing considered routine by genetics providers may interfere with patient-centered care by straining attempts to establish a therapeutic, trusting relationship. Additional research is needed to assess how question asking and phrasing impact rapport building and patient experience during genetics encounters.

PRACTICE IMPLICATIONS

Review of the purpose and need for medical history questions common to genetics practice could serve to improve patient-centered care.

Help-Seeking Among Pregnant and Postpartum Women With Lifetime Experiences of Opioid Use Disorder and Intimate Partner Violence

We performed content analysis using a qualitative descriptive approach of 15 semistructured interviews with pregnant and postpartum women who have experienced opioid use disorder (OUD) and intimate partner violence (IPV) regarding their experiences seeking help with both issues. Participants described that their partners impacted their ability to seek OUD care; seeking help for OUD and IPV was siloed; they felt more comfortable disclosing OUD than IPV; they perceived pregnancy as a barrier and facilitator to OUD care; and they wished for integrated services. Pregnant and postpartum women experiencing OUD and IPV acknowledged these phenomena intersect and identified a need for more comprehensive services.

"Gender-based Violence (GBV) and HIV, they are like sister and brother": barriers and facilitators to GBV screening and referral in public HIV treatment settings in Uganda

BACKGROUND

People living with HIV are vulnerable to gender-based violence (GBV), which can negatively impact HIV treatment outcomes. National guidelines in Uganda recommend GBV screening alongside HIV treatment services. We explored barriers and facilitators to providers implementing GBV screening and referral in public antiretroviral therapy (ART) clinics in Uganda.

METHODS

We conducted qualitative in-depth interviews. Providers were purposively sampled from 12 ART clinics to represent variation in clinical specialty and gender. We used the Theoretical Domains Framework to structure our deductive analysis.

RESULTS

We conducted 30 in-depth interviews with providers implementing GBV screening and/or referral. Respondents had a median age of 36 (IQR: 30, 43) years and had been offering post-GBV care to clients for a median duration of 5 (4, 7) years. 67% of respondents identified as female and 57% were counselors. Facilitators of GBV screening and referral included providers having access to post-GBV standard operating procedures and screening tools, trainings offered by the Ministry of Health, facility-sponsored continuing medical education units and support from colleagues. Respondents indicated that referrals were uncommon, citing the following barriers: negative expectations regarding the quality and quantity of referral services; lack of financial resources to support clients, facilities, and referral partners throughout the referral process; and sociocultural factors that threatened client willingness to pursue post-GBV support services.

CONCLUSIONS

Findings from this evaluation support the refinement of GBV screening and referral implementation strategies that leverage facilitators and address barriers to better support individuals living with HIV and who may have heightened vulnerability to GBV.

Supporting Intimate Partner Violence Survivors and Their Children in Pediatric Healthcare Settings

Intimate partner violence (IPV) is a pervasive public health epidemic that influences child health and thriving. In this article, we discuss how pediatric healthcare providers and systems can create healing-centered spaces to support IPV survivors and their children. We review the use of universal education and resource provision to share information about IPV during all clinical encounters as a healing-centered alternative to screening. We also review how to support survivors who may share experiences of IPV, focused on validation, affirmation, and connection to resources. Clinicians are provided key action items to implement in their clinical settings.

Screening for Brain Injury Sustained in the Context of Intimate Partner Violence (IPV): Measure Development and Preliminary Utility of the Brain Injury Screening Questionnaire IPV Module

Abstract Intimate partner violence (IPV) is associated with risk for multi-etiology brain injury (BI), including repetitive head impacts, isolated traumatic brain injuries (TBI), and anoxic/hypoxic injury secondary to nonfatal strangulation (NFS). IPV-related injuries are often unreported, but evidence suggests that survivors are more likely to report when asked directly. There are currently no validated tools for screening of brain injury related to IPV that meet World Health Organization guidelines for this population. Here, we describe measure development methods and preliminary utility of the Brain Injury Screening Questionnaire IPV (BISQ-IPV) module. We culled items from existing IPV and TBI screening tools and sought two rounds of stakeholder feedback regarding content coverage, terminology, and safety of administration. The resulting stakeholder-informed BISQ-IPV module is a seven-item self-report measure that uses contextual cues (e.g., being shoved, shaken, strangled) to query lifetime history of IPV-related head/neck injury. We introduced the BISQ-IPV module into the Late Effects of TBI (LETBI) study to investigate rates of violent and IPV-specific head/neck injury reporting in a TBI sample. Among those who completed the BISQ-IPV module (n = 142), 8% of the sample (and 20% of women) reported IPV-related TBI, and 15% of the sample (34% of women) reported IPV-related head or neck injury events that did not result in loss or alteration of consciousness. No men reported NFS; one woman reported inferred BI secondary to NFS, and 6% of women reported NFS events. Those who endorsed IPV-BI were all women, many were highly educated, and many reported low incomes. We then compared reporting of violent TBIs and head/neck injury events among individuals who completed the core BISQ wherein IPV is not specifically queried (administered from 2015-2018; n = 156) to that of individuals who completed the core BISQ preceded by the BISQ-IPV module (BISQ+IPV, administered from 2019-2021; n = 142). We found that 9% of those who completed the core BISQ reported violent TBI (e.g., abuse, assault), whereas 19% of those who completed the BISQ+IPV immediately preceding the core BISQ reported non-IPV-related violent TBI on the core BISQ. These findings suggest that standard TBI screening tools are inadequate for identifying IPV-BI and structured cueing of IPV-related contexts yields greater reporting of both IPV- and non-IPV-related violent BI. When not queried directly, IPV-BI remains a hidden variable in TBI research studies.

A case series measuring campus and clinic level factors during implementation of a sexual violence prevention intervention in campus health and counseling centers: does environment matter?

OBJECTIVE

This study examined campus and clinic factors that may influence likelihood of implementing sexual violence (SV) prevention for college students seeking care in campus health and counseling centers.

METHODS

Campus-, clinic-, and student-level data were collected from both intervention and control campuses as part of a 28-campus cluster randomized controlled trial. A case series exploratory data analysis assessed differences in the implementation of an SV prevention intervention by campus characteristics.

RESULTS

All large schools were in the top quartile for reporting positive prevention policies regarding SV. At the clinic level, the presence of SV protocols and procedures varied widely with no clear correlation with school size. Students at intervention schools where providers received instruction and tools to facilitate these discussions reported more discussions with providers about SV. Only school size appeared to be associated with positive SV policies on campus and student-reported receipt of SV prevention intervention. Large schools performed well on campus-level policies, yet students reported some of the lowest levels of intervention receipt in the clinics at these larger schools.

IMPLICATIONS

Consistency between campus and clinic environments and implementation of the intervention was not observed. Our findings suggest that high performance regarding SV policy and prevention on a campus do not necessarily translate to implementation of appropriate SV prevention and care for students seeking care on campus, including assessments, resources, referrals, and services.

TRIAL REGISTRATION

NCT registration: NCT02355470.

"You just want to feel safe when you go to a healthcare professional:" Intimate partner violence and patient safety

Since the early 1990s, researchers and policymakers in the United States have addressed the concept of patient safety in healthcare systems. Traditionally, scholars have conceptualized patient safety as health care that is free from medical error and harm. However, sociologists have called for a more complex understanding of patient safety that includes relational aspects of safety. Although marginalized groups face unique threats to safety, intimate partner violence (IPV) survivors have been largely overlooked within the literature on patient safety. This study addresses that gap. Using the case of IPV, I find that survivors construct healthcare spaces as ideologically safe, but their experiences do not reflect this. Survivors' narratives reveal that patient safety is complex, multi-faceted, and relational. I argue that experiences of safety, or lack thereof, are situated within larger systems of organizational power, relational power hierarchies, and systems of inequalities. These findings have implications when considering how to improve IPV survivors' safety in healthcare settings.

"Are You Safe at Home?": Clinician's Assessments for Intimate Partner Violence at the Initial Obstetric Visit

Few studies have empirically examined patient-clinician conversations to assess how intimate partner violence (IPV) screening is performed. Our study sought to examine audio-recorded first obstetric encounters' IPV screening conversations to describe and categorize communication approaches and explore associations with patient disclosure. We analyzed 247 patient encounters with 47 providers. IPV screening occurred in 95% of visits: 57% used direct questions, 25% used indirect questions, 17% repeated IPV screening later in the visit, 11% framed questions with a reason for asking, and 10% described IPV types. Patients disclosed IPV in 71 (28.7%) visits. There were no associations between disclosure and any categories of IPV screening.

Lived experience of domestic violence among men with Parkinson's disease: A qualitative study

OBJECTIVES

To explore possible forms of domestic violence suffered by men with Parkinson's disease (PD).

METHODS

A qualitative study was conducted through face-to face interviews, followed by a conceptual content analysis. Forms of violence were predetermined as code categories according to a classification of mistreatment and a lack within Maslow's hierarchy of needs. Data triangulation was performed by two researchers using the "long table" method according to Krueger & Casey.

RESULTS

Eleven men with PD were interviewed to identify experienced forms of domestic violence. Since PD, the men felt neglected by their partners, lived in the fear of the partner's reactions, described a mutual sexual and physical distance, suffered from mockeries, humiliations, physical violence, and had a feeling of abandon while facing and managing PD.

CONCLUSIONS

Domestic violence against men with PD exists and should be screened during communication with healthcare professionals.

PRACTICE IMPLICATIONS

Domestic violence has different faces and is not always identified by the victims themselves. Spouses with profiles at risk for domestic violence against men with PD should be identified. Domestic violence can be triggered by female gender, alcoholism, anxiety and depression, a low educational level, low interest in and low knowledge about PD.

Exploring Definitions of Consent and Healthy Relationships Among College Students with Disabilities: "I think it's fuzzy"

Purpose

College students with disabilities (SWDs) experience elevated rates of sexual violence and intimate partner violence compared with their non-disabled peers. While tailored interventions for these pressing health issues are needed, current research lacks investigation into how SWDs conceptualize relevant key concepts, such as consent and healthy relationships.

Method

This descriptive qualitative study explored these concepts through semi-structured interviews with college SWDs (n=49), 18-24 years old, in Pennsylvania and West Virginia.

Results

The results culminated in six rich, descriptive themes addressing: 1) interpersonal and intrapersonal skills necessary for relationship health; 2) normalization of unhealthy treatment by a partner due to manipulation, denial, and love for the partner; 3) how dichotomous definitions of consent interfere with practical application in lived experiences; 4) how active consent can be both facilitated and hindered within the context of a romantic relationship; 5) perceptions that healthcare providers aim to elicit disclosures of abuse rather than initiate a discussion about relationship health; and 6) students' reticence to disclose abuse to healthcare providers due to mistrust and fear over loss of agency.

Conclusions

These results contradict historic narratives that SWDs do not have the same sexual and relationship beliefs and experiences as other students and highlight the perspectives of this marginalized population. Implications for campus prevention programming and healthcare practices include incorporating intersections of disability and violence, discussing the nuances of consent and substance use, and creating conversations about relationship health that are transparent, non-judgmental, and include a broad range of types of abuse.

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004–August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care.

Women's experiences and expectations of intimate partner abuse identification in healthcare settings: a qualitative evidence synthesis

OBJECTIVES

To explore women's experiences and expectations of intimate partner abuse (IPA) disclosure and identification in healthcare settings, focusing on the process of disclosure/identification rather than the healthcare responses that come afterwards.

DESIGN

Systematic review and meta-synthesis of qualitative studies DATA SOURCES: Relevant studies were sourced by using keywords to search the databases MEDLINE, EMBASE, CINAHL, PsychINFO, SocINDEX and ASSIA in September 2021.

ELIGIBILITY CRITERIA

Studies needed to focus on women's views about IPA disclosure and identification in healthcare settings, use qualitative methods and have been published in the last 5 years.

DATA EXTRACTION AND SYNTHESIS

Relevant data were extracted into a customised template. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the methodological quality of included studies. A thematic synthesis approach was applied to the data, and confidence in the findings was appraised using The Confidence in the Evidence from Reviews of Qualitative research methods.

RESULTS

Thirty-four studies were included from a range of healthcare settings and countries. Three key themes were generated through analysing their data: (1) Provide universal education, (2) Create a safe and supportive environment for disclosure and (3) It is about how you ask. Included papers were rated overall as being of moderate quality, and moderate-high confidence was placed in the review findings.

CONCLUSIONS

Women in the included studies articulated a desire to routinely receive information about IPA, lending support to a universal education approach that equips all women with an understanding of IPA and options for assistance, regardless of disclosure. Women's suggestions for how to promote an environment conducive to disclosure and how to enquire about IPA have clear implications for clinical practice.PROSPERO registration numberCRD42018091523.

IPV, PrEP, and Medical Mistrust

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention method for women experiencing intimate partner violence (IPV). This study aimed to examine (1) relationships between physical, sexual, and psychological IPV and women's PrEP communication with a health care provider and domestic violence advocate; and (2) how IPV-specific medical mistrust modifies the association between IPV and PrEP communication.

METHODS

Data were from 2 studies conducted in Connecticut and Baltimore, MD on adult women experiencing IPV (N = 272). Logistic regressions examined associations between IPV, PrEP communication, and IPV-specific medical mistrust.

RESULTS

The average age was 25.7. The most common identity was non-Hispanic black (37.1%), followed by non-Hispanic white (33.8%), Hispanic (20.6%), and non-Hispanic another racial group (8.5%). Higher severity of psychological IPV was associated with more embarrassment to initiate a PrEP discussion with a health care provider (P = 0.009) or domestic violence advocate (P = 0.026). However, women with more severe psychological IPV were more willing to accept a PrEP recommendation from a health care provider (P = 0.033) or domestic violence advocate (P = 0.044). IPV-specific medical mistrust modified the association between physical IPV and willingness to accept a PrEP recommendation by a domestic violence advocate, such that women with physical IPV were significantly less likely to accept a PrEP recommendation by a domestic violence advocate, but only for women with high IPV-specific medical mistrust (P = 0.021).

CONCLUSIONS

PrEP initiation among women experiencing IPV may be strengthened by addressing and dismantling systems that perpetuate IPV-specific medical mistrust and stigma against IPV survivors.

'If the Partner Finds Out, then there's Trouble': Provider Perspectives on Safety Planning and Partner Interference When Offering HIV Pre-exposure Prophylaxis (PrEP) to Women Experiencing Intimate Partner Violence (IPV)

Pre-exposure prophylaxis is an effective women-controlled HIV prevention strategy but women experiencing intimate partner violencefear partners' interference and subsequent violence could limit its utility. This study explores provider perceptions of safety planning strategies to prevent escalating violence, mitigate partner interference, and promote daily oral PrEP adherence. We conducted interviews (N = 36) with healthcare providers (n = 18) and IPV service providers (n = 18) in Baltimore and New Haven. Using the Contextualized Assessment for Strategic Safety Planning model we organized data into two categories: the appraisal process and strategic safety planning. Themes revealed during the appraisal process, providers conduct routine IPV screening, facilitate HIV risk perception, and offer PrEP. Strategic safety planning utilizes concealment tactics, informal sources of support, role playing and cover stories. Future interventions to enhance PrEP services among women exposed to IPV should implement safety planning strategies, integrate PrEP care with IPV services, and employ novel PrEP modalities to maximize effectiveness.

"I Did It to Save My Children": Parenting Strengths and Fears of Women Exposed to Intimate Partner Violence

Intimate partner violence (IPV) is experienced by one in four women in the United States, and a wealth of quantitative research has underscored its detrimental effects on women's mental health and parenting practices. Little research, however, has considered ways in which women exposed to IPV retain and foster parenting strengths and ways in which motherhood serves as a source of resilience for these women. The objective of the current study was to conduct a thematic analysis of IPV-exposed women's parenting strengths and concerns as reported through focus groups conducted with IPV-exposed women (n = 22) and service providers (n = 31) in two urban areas in the Mid-West and Mid-South. Results of the thematic analysis indicated the emergence of three core themes: resilience and challenges of parenting in the context of IPV, leaving the violent partner, and intergenerational processes. Overall, service providers recognized far fewer strengths in parenting on all dimensions than did women, suggesting that service providers may be conceptualizing parenting in the context of IPV from a deficit model that underestimates the resilience demonstrated by these women. This has important consequences for the extent to which women may feel stigmatized or blamed when receiving resources and services critical to their families. Future research on parenting among women experiencing IPV would be enhanced by capturing the dynamic interplay between women's parenting strengths and challenges, and the ways in which these capacities are affected by resource access within and across social ecological contexts.

Correlates of reproductive coercion among college women in abusive relationships: baseline data from the college safety study

ObjectiveThe purpose of this study was to examine correlates of reproductive coercion (RC) among a sample of college women in abusive relationships. Participants: 354 college students reporting a recent history of intimate partner violence (IPV). Methods: This study examines baseline data from a randomized controlled trial testing effectiveness of an interactive safety decision aid (myPlan). Results: Almost a quarter (24.3%) of the sample reported RC. Associated factors included races other than White (p = 0.019), relationship instability (p = 0.022), missing class due to relationship problems (p = 0.001), IPV severity (p < 0.001), technology abuse (p < 0.001), traumatic brain injury-associated events (p < 0.001), and depression (p = 0.024). Conclusions: RC was a significant predictor of depression, with implications for providers working with abused college women regarding the need for mental health services concurrent with IPV/RC services. A larger proportion of women who experienced RC sought help from a healthcare provider for contraception, which suggests intervention opportunities for college health providers.

Encouraging Asian Immigrant Women to Disclose Intimate Partner Violence in Primary Care Settings

Risks of intimate partner violence (IPV) often are higher among immigrant women, due to dependency, language barriers, deportation fears, cultural beliefs, and limited access to services. In the United States, Asian immigrant women experiencing IPV often are reluctant to disclose abuse. Viewing videos that depict IPV survivors who have successfully obtained help might encourage disclosure. After conducting formative research, we created brief videos in four Asian languages (Korean, Mandarin Chinese, Thai, and Vietnamese) for use in primary care clinic consultation rooms. We then conducted in-depth interviews with 60 Asian immigrant women in California to get their perspectives on how helpful the videos might be in achieving disclosure. Most participants believed the videos would promote disclosure in clinics, although those who had been abused seemed more skeptical. Many had stereotyped views of victims, who they felt needed to be emotive to be credible. Videos should be upbeat, highlighting the positive outcomes of escaping violence and showing clearly each step of the process. Various types of IPV should be described, so that women understand the violence is not exclusively physical. Victims would need reassurance that they will not be arrested, deported, or forced to leave their abusers. Discussing the benefits of escaping violence to children could be influential. Victims also must be convinced that providers are trustworthy, confidential, and want to help. To assist immigrant populations to disclose IPV to a health provider, videos need to be culturally relevant, explain various types of violence, allay fears, and show clear processes and benefits.

Intimate partner violence and asthma in pediatric and adult populations

OBJECTIVE

To evaluate the relationship between intimate partner violence (IPV) and adult and childhood asthma outcomes.

DATA SOURCES

We conducted a systematic literature review using 4 databases (PubMed, Ovid MEDLINE, Ovid Embase, and Ovid PsycINFO) with asthma and IPV-associated terms.

STUDY SELECTIONS

We included published studies, available in English, to October 2021, which included IPV as an exposure and asthma as an outcome. Both adult and pediatric populations were included in the following settings: community, health care, and home.

RESULTS

There were 37 articles identified. There was evidence among multiple studies to support increased prevalence of asthma in adults exposed to IPV and prevalence and incidence in children with parental IPV exposure. There were fewer studies evaluating IPV exposure and adult asthma morbidity, but they found statistically significant associations between IPV and increased rate of asthma exacerbations and worsened asthma control. There was sparse evidence evaluating a relationship between IPV and adult asthma mortality. There were no studies identified evaluating IPV and childhood asthma morbidity or mortality.

CONCLUSION

The association between IPV and increased asthma prevalence, incidence, and worsened morbidity merits recognition and further investigation into potential mechanisms. Health care providers can implement practical strategies to help mitigate the negative effects of IPV on health and asthma. These include addressing potential impactful biopsychosocial factors and comorbidities, implementing routine screening and referrals, and partnering with community advocacy organizations. Given their positions of respect and power in society, health care providers can have lasting impacts on the lives of pediatric and adult patients affected by IPV.

How to Facilitate Disclosure of Violence while Delivering Perinatal Care: The Experience of Survivors and Healthcare Providers

Gender-based Violence (GBV) during the perinatal period is a serious concern as it is associated with many adverse outcomes for both the mother and the baby. It is well known that violence is under-reported. Thus, official statistics (both police reports and survey data) underestimate the prevalence of violence in general and during the perinatal period specifically. In this study conducted in Canada, we sought to explore the barriers to and facilitators of women disclosing their experiences of GBV within healthcare services to safely facilitate more disclosure in the future and reduce the harms that arise from GBV. We used thematic analysis to analyze in-depth interviews with 16 healthcare providers (nurses, midwives and physicians) and 12 survivors of GBV. The data reflect three main themes: "raising awareness of gender-based violence", "creating a shift in the healthcare system's approach toward gender-based violence" and "providing support for survivors and care providers." Our findings suggest that the healthcare system should increase its investments in raising awareness regarding GBV, training healthcare providers to respond appropriately, and building trust between survivors and healthcare providers. Healthcare providers need to be aware of their role and responsibility regarding identifying GBV as well as how to support survivors who talk about violence. Expanding a relationship-based approach in the care system and providing support for both survivors and health care providers would likely lead to more disclosures.

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.

Family Planning Providers' Assessment of Intimate Partner Violence and Substance Use

Background: Intimate partner violence (IPV) and substance use are intersecting health problems that adversely impact sexual and reproductive health outcomes for women seeking care at family planning (FP) clinics. We aimed to characterize whether and how FP clinic providers (1) assessed for IPV and substance use and (2) combined IPV and substance use assessments. Methods: Providers and patients (female, 18-29 years old, English speaking) at four FP clinics participating in a larger randomized controlled trial on provider communication skills were eligible. Providers received training on universal education, a research-informed IPV assessment approach. Visits were audio recorded, transcribed verbatim, and coded by two independent coders. We used inductive and deductive coding to assess providers' communication approaches and examined codes for patterns and categories. We then converted these approaches into variables to calculate frequencies among recorded visits. Results: Ninety-eight patient-provider encounters were analyzed. In almost all encounters (90/98), providers assessed for IPV. Many providers adopted best practice IPV assessment techniques, such as universal education (68/98) and normalizing/framing statements (45/98). Tobacco use screening was common (70/98), but alcohol (17/98) and other drug use screening (17/98) were rare. In only one encounter did a provider discuss IPV and substance use as intersecting health problems. Conclusion: This study provides insight on how FP clinicians, as key providers for millions of women in the United States, assess patients for IPV and substance use. Results show providers' willingness to adopt IPV universal education messaging and demonstrate room for improvement in substance use assessments and integrated discussions of IPV and substance use. Trial Registration Number: NCT01459458.

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.

Developing Suicide Safety Protocols for Qualitative Research as a Universal Equity Practice

Qualitative research offers a range of approaches to elucidate the health and social experiences of populations and communities that are historically oppressed and repressed, yet is not without ethical and practical challenges that may have unintended consequences and added risks for certain individuals and communities. As a result of experiences of trauma and environmental factors, many oppressed and repressed populations have disproportionately high rates of suicide, but there are no widely accepted standards or best practices for addressing suicidality while conducting qualitative research. We describe an example of a qualitative interview during which a participant reported thoughts of suicide, even though the study topic was not directly related to mental health or suicide. We describe how the research team responded and present a framework for developing suicide safety protocols when conducing qualitative research with oppressed and repressed populations.

A scoping review of recommendations in the English language on conducting research with trauma-exposed populations since publication of the Belmont report; thematic review of existing recommendations on research with trauma-exposed populations

OBJECTIVE

To identify recommendations for conducting public health research with trauma-exposed populations.

METHODS

Researchers searched Embase, PubMed, Scopus, Web of Science, Open Grey, and Google Scholar for recommendations. Trauma that causes psychological impact was our exposure of interest and we excluded clinical articles on treating physical trauma. We reviewed titles and abstracts of 8,070 articles and full text of 300 articles. We analyzed recommendations with thematic analysis, generated questions from the existing pool of recommendations, and then summarized select gaps.

RESULTS

We abstracted recommendations from 145 articles in five categories: community benefit, participant benefit, safety, researcher well-being, and recommendations for conduct of trauma research.

CONCLUSIONS

Gold standards to guide the conduct of trauma-informed public health research do not yet exist. The literature suggests participation in trauma research is not inherently harmful, and current recommendations concern using research to benefit communities and participants, protecting participants and researchers from harm, and improving professional practice. As public health researchers increasingly analyze trauma as a determinant of health, gold standards for the conduct of trauma-informed public health research would be appropriate and timely.

Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research

Domestic violence victims are in frequent contact with the healthcare service yet rarely disclose. Therefore, it is critical to understand victims' experiences and perceptions regarding disclosure in healthcare settings. The goal of this review is to provide an updated synthesis of qualitative research identifying barriers and facilitators, advice, and positive and negative outcomes of adult victims' disclosure of domestic violence to healthcare professionals (HCPs). A systematic search of PsychINFO, CINAHL and Web of Science was conducted in January 2018. Thirty-four eligible studies were identified, including 783 domestic violence victims (781 females). Formal quality assessment indicated variable study quality. Barriers of disclosure included negative HCPs attitudes, victims' perceptions of safety and concerns about the consequences of disclosing. Facilitators of disclosing included a positive relationship with the HCP, HCPs directly asking victims about abuse, and HCPs ensuring that the environment is safe and disclosure is confidential. Victims advised increased awareness of HCPs reactions to disclosure and avoiding mirroring their perpetrators minimization. HCPs were encouraged to engage in direct questioning and maintain a supportive and secure environment. Positive and negative outcomes of abuse were identified, such as being able to leave the abuser or, on the other hand, the victims' situation not changing. Our results indicate that barriers for disclosure of domestic violence in healthcare settings persist despite the widespread implementation of policies and guidelines to counter them. Based on these findings, we provide recommendations for clinical practice and future research to help improve disclosure in healthcare settings.

Promoting Cross-Sector Collaborations to Address Intimate Partner Violence in Health Care Delivery Systems Using a Quality Assessment Tool

Background: As part of a Domestic Violence and Health care Partnership (DVHCP) project in California, 19 leadership teams consisting of representatives from domestic violence agencies and health care delivery systems in California came together to improve care related to intimate partner violence (IPV). We evaluated the impact of a Quality Assessment/Quality Improvement (QA/QI) tool on health care delivery systems' ability to collaborate with victim service agencies to address IPV. Methods: Each leadership team completed the QA/QI tool every 6 months between 2014 and 2017. Fifteen clinics that completed the tool at least twice are included in this analysis. Results: The largest changes noted in the QA/QI tool were having written protocols for assessing for IPV, providers distributing educational safety cards about IPV to patients, scripts for providers on how to assess and support survivors of IPV, trainings led by IPV agency advocates, and support for staff to discuss difficult cases. Conclusions: Implementation of a QA/QI tool can guide health care delivery systems to make changes in provider practices and clinic protocols to improve care and support for survivors of IPV. Such clinic-level changes may support providers to more readily or consistently integrate addressing IPV in clinical encounters while facilitating and promoting cross-sector collaborations with victim service advocacy and related social service agencies.

Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa

BACKGROUND

Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania.

METHODS

Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11).

RESULTS

Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites.

CONCLUSION

Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

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.

Midwives' experiences with screening for intimate partner violence in Santiago, Chile

Although intimate partner violence (IPV) is well-established as a highly prevalent global issue, research examining the experience of health providers who screen women at risk for IPV is scarce. We aimed to explore the experience of midwives in primary health care centers in Santiago, Chile, regarding identification of at-risk women and barriers to screening. We highlight the intersection of complex issues of global relevance, such as culture, language, provider-patient relationships, and allocation of time and resources. In our results, we illustrate the importance of providing midwives extended time, interpreter services, and cross-cultural education to address IPV in their transcultural context.

Trauma-Informed Personalized Scripts to Address Partner Violence and Reproductive Coercion: Follow-Up Findings from an Implementation Randomized Controlled Trial Study

Background: Intimate partner violence (IPV) and reproductive coercion impact women seeking care at family planning (FP) clinics. Interventions to facilitate patient-provider conversations about healthy relationships are needed. We sought to determine the added effect of providing psychoeducational messages to patients compared with tailored provider scripts alone on sexual and reproductive health outcomes at 4-6 months. Materials and Methods: We randomized participants to Trauma-Informed Personalized Scripts (TIPS)-Plus (provider scripts +patient messages) or TIPS-Basic (provider scripts only) at four FP clinics. Eligible patients included English-speaking females aged 16-29 years. Data were collected at initial visits (T1) and 4-6 months (T2) on IPV, reproductive coercion, fear, condom and other contraceptive use, self-efficacy, harm reduction behaviors, and knowledge/use of IPV-related services. We compared frequencies and summary scores between baseline and follow-up with McNemar's test of paired proportions and Signed Rank-Sum, respectively. We compared the difference in differences over time by treatment arm using two-sample t-tests, and used linear, logistic, and ordinal logistic regression to compare intervention effects at follow-up. Results: Two hundred forty patients participated (114 TIPS-Plus, 126 TIPS-Basic), 216 completed follow-up. We detected no differences in outcomes between treatment arms. Between T1 and T2, we observed overall reductions in mean summary scores for reproductive coercion (T1 = 0.08 ± 0.02, T2 = 0.02 ± 0.01, p = 0.028) and increases in contraceptive use (69.6%-87.9%, p < 0.001), long-acting reversible contraceptives (8.3%-20.8%, p < 0.001), and hidden methods (20%-38.5%, p < 0.001). Conclusions: We show no added benefit of patient-activation messages compared with provider scripts alone. Findings suggest potential utility of provider scripts in addressing reproductive coercion and contraceptive uptake (Trial Registration No. NCT02782728).

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.

Actions Taken by Women in Response to Intimate Partner Violence and Intimate Partner Violence Status at 1-Year Follow-Up

BACKGROUND

Intimate partner violence (IPV) is a pervasive public health issue with significant physical and mental health sequelae. A longer duration and greater severity of abuse are associated with adverse health outcomes and increased risk of revictimization. Current research has identified a variety of strategies used by women in response to abuse, but has not established whether the use of these strategies is associated with decreased IPV over time. For this study, we analyzed the associations between the use of specific actions in response to abuse-placating, resistance, informal or formal network help-seeking, safety planning, and substance use-and IPV victimization at the 1-year follow-up.

METHODS

Ninety-five women with past-year IPV at baseline participated in a 1-year follow-up survey measuring their use of specific actions in response to IPV and subsequent IPV status. IPV victimization at the 1-year follow-up was analyzed as a function of types of actions taken and sociodemographic variables.

RESULTS

Among women with past-year IPV at baseline (N = 95), 53% reported no further IPV victimization at the 1-year follow-up. In bivariate analysis, social support was associated with decreased risk of IPV victimization (odds ratio, 0.43; 95% confidence interval [CI], 0.18-0.99). In multivariable analyses, high use of placating (adjusted odds ratio, 9.40; 95% CI, 2.53-34.9), formal network help-seeking (adjusted odds ratio, 7.26; 95% CI, 1.97-26.74), and safety planning (adjusted odds ratio, 2.98; 95% CI, 1.02-8.69) strategies were associated with an increased risk of IPV victimization at the 1-year follow-up.

CONCLUSIONS

Our data demonstrate that IPV exposure can change over time and that the use of specific actions in response to IPV can be indicators of risk of subsequent victimization. Abuse severity is an important potential confounder of action efficacy.

A Novel Intimate Partner Violence Curriculum for Internal Medicine Residents: Development, Implementation, and Evaluation

INTRODUCTION

Intimate partner violence (IPV) is a prevalent problem with profound health consequences. Research suggests that internal medicine (IM) residents are unprepared to screen for and address IPV. We designed a curriculum to improve IM residents' knowledge, attitudes, and practices in caring for IPV survivors.

METHODS

The curriculum was delivered to first-year IM residents from 2016 to 2017 at Johns Hopkins Bayview. Part 1 was 60 minutes long, with a video, evidence-based didactic teaching, and case-based discussion. Part 2 was 90 minutes long, with evidence-based didactic teaching, role-play of patient-provider conversations about IPV, and debriefing about strategies for discussing IPV. We evaluated knowledge, confidence, and self-reported behaviors pre- and postintervention using two-tailed paired t tests.

RESULTS

Thirty-two residents received IPV training. In comparing precurriculum (n = 29, 91% of total participants) and postcurriculum (n = 28, 88% of total participants) surveys, there was significant improvement in knowledge about IPV (p < .001). Postcurriculum, learners reported greater confidence in detecting IPV (p < .001), documenting IPV (p < .001), and referring to resources (p < .001). Participants reported increased comfort with managing difficult emotions about IPV in patients (p < .01) and themselves (p < .001) and increased comfort in discussing IPV with female (p < .001) and male (p < .001) patients. Postcurriculum, all respondents felt they were more skillful in discussing IPV and would be more likely to screen for IPV.

DISCUSSION

Our curriculum improved residents' knowledge, confidence, comfort, and preparedness in screening for and discussing IPV.

Women's Experiences of Being Screened for Intimate Partner Violence in the Health Care Setting

OBJECTIVE

To qualitatively describe experiences of survivors of intimate partner violence (IPV) in being screened for IPV and to identify opportunities to improve screening and response by health care providers.

DESIGN

Qualitative descriptive study.

SETTING/LOCAL PROBLEM

Although it is recommended that nurses and other health care providers screen for IPV, a local needs assessment of IPV screening among health care practices in Houston, Texas, showed inconsistencies in IPV screening practices, a lack of understanding on how to screen for IPV, and low referral rates to IPV agencies.

PARTICIPANTS

Seventeen survivors of IPV from three agencies that provide services to survivors of IPV.

INTERVENTION/MEASUREMENTS

Three focus groups were conducted, and notes were coded and analyzed for content and themes using open coding from the observed data. The constant comparative method was used for the analysis.

RESULTS

Four themes emerged from the focus group data. The first three themes address concepts and dynamics of IPV that affect IPV screening and disclosure of abuse. The final theme addresses screening for IPV in health care settings.

CONCLUSION

Many survivors reported that they were not screened for IPV by health care professionals, and those who were screened were not screened effectively. Compassionate care is needed in these situations, and nurses and other health care providers should be aware that the responses of IPV survivors are dynamic and may change over time.

Trauma-Informed Approaches to Adolescent Relationship Abuse and Sexual Violence Prevention

Adolescent relationship abuse and sexual violence are prevalent throughout adolescence and are associated with serious physical and mental health consequences. Trauma-informed approaches to care balance adolescent confidentiality, autonomy, and a young person's safety. The provision of trauma-informed care can include universal education and brief counseling about healthy relationships with all adolescent patients during clinical encounters to promote healthy adolescent sexual relationships, ensure youth know about resources for relationship abuse and sexual violence, and facilitate connections to advocates who serve survivors of abuse. Providers can integrate evidence-based relationship abuse and sexual violence prevention into their work with adolescents. [Pediatr Ann. 2019;48(7):e274-e279.].

Trauma-Informed Personalized Scripts to Address Partner Violence and Reproductive Coercion: Preliminary Findings from an Implementation Randomized Controlled Trial

Background: Family planning (FP) providers are in an optimal position to address harmful partner behaviors, yet face several barriers. We assessed the effectiveness of an interactive app to facilitate implementation of patient-provider discussions about intimate partner violence (IPV), reproductive coercion (RC), a wallet-sized educational card, and sexually transmitted infections (STIs). Materials and Methods: We randomized participants (English-speaking females, ages 16-29 years) from four FP clinics to two arms: Trauma-Informed Personalized Scripts (TIPS)-Plus and TIPS-Basic. We developed an app that prompted (1) tailored provider scripts (TIPS-Plus and TIPS-Basic) and (2) psychoeducational messages for patients (TIPS-Plus only). Patients completed pre- and postvisit surveys. We compared mean summary scores of IPV, RC, card, and STI discussions between TIPS-Plus and TIPS-Basic using Wilcoxon rank-sum tests, explored predictors with ordinal regression, and compared implementation with historical data using chi-square. Results: Of the 240 participants, 47.5% reported lifetime IPV, 12.5% recent IPV, and 7.1% recent RC. No statistically significant differences emerged from summary scores between arms for any outcomes. Several significant predictors were associated with higher scores for patient-provider discussions, including race, reason for visit, contraceptive method, and condom nonuse. Implementation of IPV, RC, and STI discussions increased significantly (p < 0.0001) when compared with historical clinical data for both TIPS-Basic and TIPS-Plus. Conclusions: We did not find an added benefit of patient activation messages in increasing frequency of sensitive discussions. Several patient characteristics appear to influence providers' likelihood of conversations about harmful partner behaviors. Compared with prior data, this pilot study suggests potential benefits of using provider scripts to guide discussions.

Willing but Not Able: Patient and Provider Receptiveness to Addressing Intimate Partner Violence in Johannesburg Antenatal Clinics

Intimate partner violence (IPV) during pregnancy is associated with maternal and infant health. However, in South Africa, where 20% to 35% of pregnant women report experiencing IPV, antenatal care rarely addresses violence. Little research has explored how clinic staff, community members, or pregnant women themselves view IPV. We conducted formative, qualitative research with 48 participants in urban Johannesburg. Focus group discussions with pregnant women ( n = 13) alongside qualitative interviews with health providers ( n = 10), managers and researchers ( n = 10), non-governmental organizations ( n = 6), community leaders ( n = 4), and pregnant abused women ( n = 5) explored the context of IPV and health care response. Data were analyzed using a team approach to thematic coding in NVivo 10. We found that pregnant women in the urban Johannesburg setting experience multiple forms of IPV, but tend not to disclose violence to antenatal care providers. Providers are alert to physical injuries or severe outcomes from IPV, but miss subtler cues, such as emotional distress or signs of poor mental health. Providers are uncertain how to respond to IPV, and noted few existing tools, training, or referral systems. Nevertheless, providers were supportive of addressing IPV, as they noted this as a common condition in this setting. Providers and managers considered the safety and well-being of mother and infant to be a strong rationale for the identification of IPV. Pregnant women were receptive to being asked about violence in a kind and confidential way. Understaffing, insufficient training, and poorly developed referral systems were noted as important health system problems to address in future interventions. South African patients and providers are receptive to the identification of and response to IPV in antenatal care, but require tools and training to be able to safely address violence in the health care setting. Future interventions should consider the urban South African antenatal clinic a supportive, if under-resourced, entry point for improving the health of pregnant women experiencing violence.

Adolescent and young adult women's recommendations for establishing comfort with family planning providers' communication about and assessment for intimate partner violence

BACKGROUND

Intimate partner violence (IPV) is a serious public health problem that disproportionately affects adolescent women seeking family planning services. Current clinical guidelines recommend routine IPV assessment yet provide limited guidance on how to establish patient comfort in addressing this sensitive issue. Few studies exist describing the perspectives of adolescent female patients who have experienced IPV and their suggestions on how providers should communicate about IPV.

METHODS

This study is a subset of a larger IPV intervention trial in family planning clinics. For this study, we chose a qualitative approach using individual interviews to explore patient perspectives in an open, in-depth manner without limiting potential responses with predetermined answers or investigator-imposed assumptions. We audio recorded clinic encounters for participating providers and patients and interviewed patient participants, asking them to listen to and reflect on how their provider talked about IPV in their audiorecorded clinic encounters.

RESULTS

The mean age for the 44 participants was 22.8 years old. Participants named 'comfort' as a main component for discussing and disclosing IPV in the clinical setting. The sub-themes associated with how to create patient comfort include: Build the patient-provider relationship, Provider should communicate like a friend/be on the patient's level, Patient needs to feel cared for by provider, and Appropriate timing and space.

CONCLUSION

Methods for establishing patient comfort via communication should be incorporated into and examined within sensitive healthcare areas such as IPV and can be extended to HIV, palliative, and oncological care to improve patient health outcomes.

Screening in the Prenatal Period for Intimate Partner Violence and History of Abuse: A Survey of Edmonton Obstetrician/Gynaecologists

OBJECTIVE

This study sought to understand how obstetrician gynaecologists (OB/GYNs) in Edmonton, Alberta screen prenatal patients for intimate partner violence (IPV). It also aimed to explore attitudes, beliefs, and perceptions regarding IPV and identify barriers to screening for IPV. Institutional protocols, resources, and support available to clinicians and patients were also reviewed.

METHODS

All Royal College of Physicians and Surgeons of Canada-certified OB/GYNs practicing general obstetrics in Edmonton were identified and were mailed letters and electronic questionnaires with two follow-up letters or emails at 2-week intervals. Personal and clinical practice demographic information was collected. Physicians' perceptions, screening practices, and barriers to screening were identified. Responses were collected, stored, and analyzed using a secure online database, Research Electronic Data Capture Database; all responses were completely anonymous.

RESULTS

Of 58 physicians surveyed, 49 completed questionnaires (84% response rate). A total of 33% of respondents either never or rarely screened women for IPV during prenatal visits, 69% either never or rarely screened for childhood abuse, 94% did not have a screening protocol, and 77% did not have written materials to provide to patients. Multiple barriers were identified. A total of 94% of OB/GYNs believed that they were inadequately screening for IPV.

CONCLUSION

Screening of pregnant women for IPV and a history of abuse is suboptimal. There are multiple barriers (cultural, societal, economic, and institutional) that prevent women from being screened for IPV and receiving appropriate support services.

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.

Intimate partner violence screening in the dental setting: Results of a nationally representative survey

BACKGROUND

The dental setting is a potential venue for identifying patients experiencing intimate partner violence (IPV). The study objective was to assess dentists' current practices and attitudes about IPV screening.

METHODS

A nationally representative survey of US general dentists assessed dentists' use of health history forms that queried about IPV and their acceptance of IPV screening as part of their professional roles. Parsimonious Poisson regression models were used in multivariable analysis to estimate risk ratios for the 2 dependent variables.

RESULTS

Almost all dentists did not include a question to screen for IPV on their patient history forms. More than one-half of dentists also did not know of a referral place for patients experiencing IPV and did not believe that IPV screening should be part of their professional roles.

CONCLUSIONS

Uptake of IPV screening and favorable attitudes toward screening were low among dentists studied. However, prior IPV training and clinical knowledge plus awareness of IPV referral mechanisms were positively associated with greater screening uptake and attitudes.

PRACTICAL IMPLICATIONS

The inclusion of brief, focused IPV interventions in dental education and the establishment of collaborations between dentists and IPV agencies for referral mechanisms, in conjunction with an overall shift in dentists' attitudes about their professional responsibilities, may facilitate IPV screening uptake in the dental setting.

Provider Screening and Counseling for Intimate Partner Violence: A Systematic Review of Practices and Influencing Factors

BACKGROUND

Primary care providers have an important role in identifying survivors of intimate partner violence (IPV) and providing safety options. Routine screening rates by providers have been consistently low, indicating a need to better understand providers' practices to ensure the translation of policy into clinical practice.

AIM

This systematic review examines common themes regarding provider screening practices and influencing factors on these practices.

METHOD

A literature search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search focused on research articles which met the following criteria: (1) health-care providers as participants, (2) provider reports on screening and counseling practices for IPV, and (3) were in English or Spanish.

RESULTS

A total of 35 studies were included in the review. Across studies, providers commonly acknowledged the importance of IPV screening yet often used only selective screening. Influencing factors on clinic, provider, and patient levels shaped the process and outcomes of provider screening practices. Overall, a great deal of variability exists in regard to provider screening practices. This variability may be due to a lack of clear system-level guidance for these practices and a lack of research regarding best practices.

CONCLUSIONS

These findings suggest the necessity of more facilitative, clearly defined, and perhaps mandatory strategies to fulfill policy requirements. Future research directions are outlined to assist with these goals.

Supporting female survivors of intimate partner violence with disabilities: Recommendations for social workers in the emergency department

Intimate partner violence (IPV) is a pervasive problem with grave consequences. Women with disabilities are among the most vulnerable groups disproportionately affected, with higher IPV rates than either women without disabilities or men with disabilities. The emergency department (ED) in particular affords a gateway into health services for female survivors of IPV, placing ED social workers in a prime position to observe potential signs of IPV and connect survivors to further assistance. This article explores the critical role ED social workers can fill in addressing the needs of female survivors of IPV with disabilities. We begin by providing background on the characteristics of IPV among women with disabilities, followed by a discussion of the opportunities and challenges inherent to assessing and intervening with survivors. We conclude by outlining recommendations for working with female survivors of IPV with disabilities in EDs, using our previous research on the topic as a guide.

Enhanced Versus Basic Referral for Intimate Partner Violence in an Urban Emergency Department Setting

BACKGROUND

Victims of intimate partner violence (IPV) frequently do not disclose abuse to medical providers. Therefore, research has examined the most effective screening and referral methods to help identify victims of abuse and connect them to needed resources.

OBJECTIVES

To determine the efficacy of referrals intended to connect IPV victims with behavioral health resources, while taking into consideration demographic and mental health variables.

METHODS

We examined a convenience sample of medically stable individuals in an emergency department setting. Participants were given the Mini-International Neuropsychiatric Interview and Partner Violence Screen measures to assess mental health and IPV victimization. Individuals that screened positive were randomized to a basic or enhanced referral and given a follow-up interview to determine referral success. Referrals were considered successful if an individual scheduled an appointment with provided behavioral health resources within the follow-up interval.

RESULTS

Two-hundred and one individuals were enrolled. Forty-one (20.4%) participants screened positive for IPV victimization. Male and female participants in the enhanced referral group were more likely to have a successful referral than those in the basic referral group, with a large effect size such that 72.7% of participants in the enhanced referral and 15.7% of participants in the basic referral group contacted referral resources. Both referral type and marital status significantly predicted referral success.

CONCLUSION

Comorbidity with mental health concerns measured as high within those that screened positive for IPV victimization. The enhanced referral showed to be an effective way to encourage participants to contact behavioral health resources.

Impact of an educational intervention for district nurses about preparedness to encounter women exposed to intimate partner violence

AIM

To evaluate the impact of an educational intervention on the preparedness of district nurses at primary healthcare centres to encounter women exposed to intimate partner violence.

METHODOLOGICAL DESIGN

An observational quasi-experimental study. Participants were divided into an intervention group (n = 117) and a control group (n = 204), both from the eastern part of Sweden. A group of nurses from across Sweden (the 'national group,' n = 217) was also recruited. The Violence Against Women Health Care Provider Survey was used pre- and 1 year postintervention to measure the intervention's impact. This survey, which measured preparedness, included eight factors: practitioner preparedness, self-confidence, lack of control, comfort following disclosure, professional support, practice pressures, abuse inquiry and consequences of asking. anova, the paired Wilcoxon test, the Mann-Whitney U test and the Kruskal-Wallis test were used to analyse the data.

FINDINGS

Pre-intervention preparedness was equal in all three groups. In the intervention group, preparedness related to the factor practitioner lack of control increased (p = 0.003), but a comparison of change between the intervention and control groups showed no significant intervention effect (p = 0.069).

CONCLUSIONS

The results indicate that the intervention had a low impact on district nurses' preparedness. The educational intervention must be adjusted; a main focus of changes should be the addition of continuing postintervention supervision and support.