Screening for intimate partner violence by health care providers. Barriers and interventions

INTRODUCTION: Routine screening for intimate partner violence (IPV) is endorsed by numerous health professional organizations. Screening rates in health care settings, however, remain low. In this article, we present a review of studies focusing on provider-specific barriers to screening for IPV and interventions designed to increase IPV screening in clinical settings. METHODS: A review of published studies containing original research with a primary focus on screening for IPV by health professionals was completed. RESULTS: Twelve studies identifying barriers to IPV screening as perceived by health care providers yielded similar lists; top provider-related barriers included lack of provider education regarding IPV, lack of time, and lack of effective interventions. Patient-related factors (e.g., patient nondisclosure, fear of offending the patient) were also frequently mentioned. Twelve additional studies evaluating interventions designed to increase IPV screening by providers revealed that interventions limited to education of providers had no significant effect on screening or identification rates. However, most interventions that incorporated strategies in addition to education (e.g., providing specific screening questions) were associated with significant increases in identification rates. CONCLUSION: Barriers to screening for IPV are documented to be similar among health care providers across diverse specialties and settings. Interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are likely to be more effective if they include strategies in addition to provider education.     

Provider Barriers and Facilitators to Screening for Intimate Partner Violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.     

Provider barriers and facilitators to screening for intimate partner violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.     

Implementing successful intimate partner violence screening programs in health care settings: evidence generated from a realist-informed systematic review

We undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence (IPV) universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work. Our review is informed by a realist review approach, which focuses on program mechanisms. Systematic, realist reviews can help reveal why and how interventions work and can yield information to inform policies and programs. A review of the scholarly literature from January 1990 to July 2010 identified 5046 articles, 23 of which were included in our study. We identified studies on 17 programs that evaluated IPV screening. We found that programs that took a comprehensive approach (i.e., incorporated multiple program components, including institutional support) were successful in increasing IPV screening and disclosure/identification rates. Four program components appeared to increase provider self-efficacy for screening, including institutional support, effective screening protocols, thorough initial and ongoing training, and immediate access/referrals to onsite and/or offsite support services. These findings support a multi-component comprehensive IPV screening program approach that seeks to build provider self-efficacy for screening. Further implications for IPV screening intervention planning and implementation in health care settings are discussed.     

Barriers to screening for intimate partner violence

Background: Health care providers play a vital role in the detection of intimate partner violence among their patients. Despite the recommendations for routine intimate partner violence screening in various medical settings, health care providers do not routinely screen for intimate partner violence. The authors wanted to identify barriers to intimate partner violence screening and improve the understanding of intimate partner violence screening barriers among different health care providers. Methods: The authors conducted a systematic review to examine health care providers' perceived barriers to screening for intimate partner violence. By grouping the studies into two time periods, based on date of publication, they examined differences in the reported barriers to intimate partner violence screening over time. Results: The authors included a total of 22 studies in this review from all examined sources. Five categories of intimate partner violence screening barriers were identified: personal barriers, resource barriers, perceptions and attitudes, fears, and patient-related barriers. The most frequently reported barriers included personal discomfort with the issue, lack of knowledge, and time constraints. Provider-related barriers were reported more often than patient-related barriers. Conclusions: Barriers to screening for intimate partner violence are numerous among health care providers of various medical specialties. Increased education and training regarding intimate partner violence is necessary to address perceptions and attitudes to remove barriers that hinder intimate partner violence screening by health care providers.     

Barriers to Screening for Intimate Partner Violence

Background: Health care providers play a vital role in the detection of intimate partner violence among their patients. Despite the recommendations for routine intimate partner violence screening in various medical settings, health care providers do not routinely screen for intimate partner violence. The authors wanted to identify barriers to intimate partner violence screening and improve the understanding of intimate partner violence screening barriers among different health care providers. Methods: The authors conducted a systematic review to examine health care providers' perceived barriers to screening for intimate partner violence. By grouping the studies into two time periods, based on date of publication, they examined differences in the reported barriers to intimate partner violence screening over time. Results: The authors included a total of 22 studies in this review from all examined sources. Five categories of intimate partner violence screening barriers were identified: personal barriers, resource barriers, perceptions and attitudes, fears, and patient-related barriers. The most frequently reported barriers included personal discomfort with the issue, lack of knowledge, and time constraints. Provider-related barriers were reported more often than patient-related barriers. Conclusions: Barriers to screening for intimate partner violence are numerous among health care providers of various medical specialties. Increased education and training regarding intimate partner violence is necessary to address perceptions and attitudes to remove barriers that hinder intimate partner violence screening by health care providers.     

Women battering in primary care practice.

BACKGROUND: The organization of health care system to emphasize managed care has placed the primary care provider in an ideal position to assess the impact of intimate partner violence (IPV) on the health of women. Primary care practice provides a setting in which women can develop an ongoing relationship with their health care provider in which they feel safe to discuss IPV and possible options to improve their lives. Women's health and safety could be dramatically improved if primary care providers were prepared to assess, intervene and appropriately refer women who are in violent relationships. OBJECTIVES: The purpose of this article is to describe the prevalence of intimate partner violence in primary care populations and review the known physical, mental health and pregnancy consequences of abuse as well as discuss the implications of intimate partner violence on primary care practice.     

How You Screen is as Important as Whether You Screen: A Qualitative Analysis of Violence Screening Practices in Reproductive Health Clinics

Adolescent and young adult women are disproportionately burdened by violence at the hands of dating and intimate partners. Evidence supports routine screening in clinical settings for detection and intervention. Although screening for intimate partner violence in reproductive health care settings is widely endorsed, little is known about screening practices. We conducted qualitative in-depth interviews with healthcare providers (n = 14) in several urban reproductive health clinics in Baltimore City, Maryland to understand screening practices, including related barriers and motivations. Interviews were transcribed verbatim and analyzed using inductive content analysis. Findings demonstrated substantial variation in screening practices as well as related referral and follow-up, despite the existence of a screening tool. Factors that appeared to undermine consistent and successful screening implementation included lack of a common goal for screening, lack of clarity in staff roles, a gap in on-site support services, as well as lack of time and confidence. Findings affirm the value of applying a systems model to intimate partner violence (IPV) screening programs. This research advances the understanding of the implementation challenges for violence-related screening for high-risk populations such as adolescents and young adults in reproductive health care settings and is particularly relevant given the recent endorsement by the DHHS to cover IPV screening under the Affordable Care Act.     

Screening risks for intimate partner violence and primary care settings: implications for future abuse

Most health care intervention models for intimate partner violence (IPV) are crisis driven and targeted to survivors of injury following episodes of physical violence. Knowledge about anticipatory and preventive approaches with women who are at risk for abuse is scarce, limiting professionals' ability to respond fully and effectively to this problem. This paper describes a retrospective, practice-based research study of social work interventions in two hospital-based primary care practices. A total of 431 female patients completed a self-administered questionnaire developed for the early detection of IPV risk factors during routine health care visits. The study showed surprisingly high rates of multiple risk markers in an urban primary care population whose medical presentations ordinarily would not raise provider suspicion about abuse. Findings confirmed the willingness of primary care populations to freely partake in routine screening and support the value of early identification and intervention with populations at risk. Practice implications are discussed.     

Communicating with patients about intimate partner violence: screening and interviewing approaches

Intimate partner violence is a major public health concern; it contributes to poor physical and mental health in affected individuals, primarily women. Due to documented poor detection rates of intimate partner violence by physicians, the medical community has focused increasing attention on the successful identification of victims in all medical contexts. Family medicine educators need to be aware of the current status of knowledge about intimate partner violence and convey this to students and residents. In this article, we review the literature on screening tools to identify victims of partner violence, discuss the pitfalls of relying on screening tools, review barriers to identification of partner violence from clinician and patient perspectives, and recommend a patient-centered methodfor conversing with patients about intimate partner violence.     

The Anatomy of a Community Health Center System-Level Intervention for Intimate Partner Violence

The US Preventive Services Task Force (USPSTF) now recommends screening for intimate partner violence (IPV) as part of routine preventive services for women. However, there is a lack of clarity as to the most effective methods of screening and referral. We conducted a 3-year community-based mixed-method participatory research project involving four community health centers that serve as safety net medical providers for a predominately indigent urban population. The project involved preparatory work, a multifaceted systems-level demonstration project, and a sustainability period with provider/staff debriefing. The goal was to determine if a low-tech system-level intervention would result in an increase in IPV detection and response in an urban community health center. Results highlight the challenges, but also the opportunities, for implementing the new USPSTF guidelines to screen all women of childbearing years for intimate partner violence in resource-limited primary care settings.     

Capacity of AIDS service organisations in Connecticut to respond to intimate partner violence

Although intimate partner violence (IPV) is prevalent among women living with HIV and negatively impacts their health, few studies have examined the ability of AIDS service organisations (ASOs) to address IPV. This study used a qualitative approach to identify facilitators of and barriers to addressing IPV in female clients of ASOs in the United States. In‐depth interviews were conducted between March and August 2011 with 20 ASO staff members and 19 female clients who reported a current or past history of IPV. Interviews were audio recorded, transcribed and analysed using the constant comparative method. These data identify barriers to addressing IPV at the organisation, provider and client levels, and include suggestions from both clients and providers about improving access to care. Client and provider suggestions differed in some areas. While providers emphasised structural changes such as increased training on IPV provided by their organisation, clients highlighted the importance of trusting personal relationships with staff to increase client disclosure of IPV experiences. Given the differing opinions of clients and staff, ASOs should consider involving women with histories of IPV in the process of programme and policy development. ASOs have the unique opportunity to provide comprehensive and holistic care by addressing IPV. The extent to which ASOs are able to recognise and address IPV and strategies for increasing this ability warrant greater attention from funders, ASO administrators and researchers.     

Intimate partner violence: what are physicians' perceptions?

BACKGROUND: Intimate partner violence (IPV) is common in primary care; 11% to 22% of women experienced physical abuse in the past year. Older women experience IPV as well, but it is often undetected. This study examined primary care providers' awareness about IPV in older women, including their screening practices and management. METHODS: Interviews and focus groups were conducted with 44 primary care providers. Thematic analysis was used to identify common themes. RESULTS: Providers fell along a continuum of thoroughness for identifying and managing IPV in older women, ranging from suboptimal to thorough identification of IPV and suboptimal to thorough management of the patient. In addition to the barriers commonly reported about IPV screening in younger women, providers described limited understanding of the diagnoses commonly associated with IPV, frustration with older women's unwillingness to disclose problems and ask for help, and limited community services that accommodate older women with IPV. Providers recommended that communities sponsor public awareness campaigns about IPV as a problem for all women and that aging and IPV agencies work together. CONCLUSIONS: Continued provider training about IPV should include information on identifying older victims and appropriate management options. Participants stressed the importance of community efforts to raise awareness and improve resources available for older women who are victims of IPV.     

Pilot educational outreach project on partner violence

BACKGROUND: To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS: Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING: Three medical offices in an urban community of approximately 1 million. PARTICIPANTS: Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS: Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS: Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS: This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.     

Applying the planned care model to intimate partner violence

PURPOSE: This article presents the steps for organizing a health organization's response to intimate partner violence (IPV) according to the Planned Care Model (PCM). IPV is common and costly and results in poor physical and mental health outcomes for victims and their families. Because most care is not acute, a planned approach that crosses systems may result in more comprehensive and higher quality care. Community collaboration with IPV agencies is especially critical. The health care organization must make IPV a priority and set policies and systems to identify and manage patients, train staff, and measure, monitor, and provide feedback on outcomes. Other key PCM components include: practice design--design systems to identify and track victims, stratify risk, and coordinate care; evidence-based decision support--choose validated IPV screening questions and guidelines for identification, management, and referral and make them available in a systematic way with ongoing assessment and feedback to providers and other members of the health care team; patient self-management--self-man-agement materials should be selected and disseminated to those working with IPV victims; and data information systems--these should support a confidential patient registry and efforts to audit and provide feedback about identification and referral efforts. Process and outcome measures based on the management guidelines and protocols should be developed and monitored, and the results disseminated. CONCLUSION: Adapting PCM for the management of IPV stretches the traditional acute approach to IPV of screen-identify-refer. It expands the PCM into new realms, including embracing new partners, trying innovative ways to measure return on investment, grappling with ethical dilemmas, and designing a multifactorial evaluation across systems.     

Assessing the success of the WomanKind program: an integrated model of 24-hour health care response to domestic violence

PURPOSE: The WomanKind program, a non-profit health care based program for for victims of domestic/intimate partner violence (IPV), seeks to enable and motivate health care providers to identify victims of such violence and refer them to WomanKind's in-house services. An evaluation designed to assess client referral to WomanKind services and the impact of health care provider training was carried out. METHODS: Data were collected at three intervals over a 2-year period at 3 intervention and 2 comparison hospitals located in Minneapolis, MN. The focus of data collection efforts was to assess the providers' knowledge, attitudes, beliefs, and behaviors (KABB) concerning identification and referral of victims of IPV. Hospital staff and volunteer advocate training programs also were evaluated. Chart reviews were conducted and client referrals assessed. RESULTS: Providers at WomanKind hospitals demonstrated significantly higher knowledge, attitudes, beliefs and behaviors than those at comparison hospitals throughout the study. During the data collection period, 1719 IPV victims were identified and referred to the WomanKind program, while only 27 IPV victims were referred to trained social workers at the comparison hospitals. Chart reviews indicated that emergency staff at the intervention sites provide documentation of IPV in patient records twice as frequently as emergency staff at the comparison sites. CONCLUSION: This research underscores the efficacy of a well-structured, multidisciplinary effort to deliver services to IPV victims. The results demonstrate that specialized training and on-site client services create a significant positive impact on the KABB of health care providers.     

Missed opportunities: intimate partner violence in family practice settings

BACKGROUND: For women experiencing partner violence, women health care visits represent opportunities for physicians and patients to address intimate partner violence (IPV), a significant health threat for women. OBJECTIVES: The objectives were to estimate rates of physician documentation of IPV in medical records; characterize IPV+ women most likely to have IPV documented; and determine whether IPV screening increased IPV documentation. METHODS: Subjects were women ages 18-65 receiving primary care in two large family practice clinics. All were screened for IPV by study staff using a modified Index of Spouse Abuse and the Women's Experience with Battering scales. We selected and abstracted medical records for all women experiencing current IPV (N = 144) and a random sample of women never experiencing IPV (N = 147). RESULTS: Of 144 women screened as currently experiencing IPV, 14.7% were documented. Women most likely to have IPV documented were Caucasian, with higher WEB scores, and more likely to have an event that could trigger posttraumatic stress syndrome. Although the majority (41/56) of women currently in physically violent relationships did not plan to disclose IPV, those disclosing were significantly more likely to have IPV documented and documentation occurred after screening for 60% of women experiencing IPV. CONCLUSION: IPV screening increased documentation. IPV screening can provide the opportunity for patients to disclose IPV. Physicians then have the opportunity to compassionately connect patients with appropriate resources.     

Addressing intimate partner violence in primary care practice

Primary care practice provides an ideal opportunity for the discussion of the remarkably prevalent yet often hidden problem of intimate partner violence. Patients report that screening of intimate partner violence is acceptable, yet most providers do not discuss intimate partner violence with their patients. The purpose of this article is 3-fold: to outline what is known about the prevalence and health effects of intimate partner violence and why providers should discuss intimate partner violence with their patients, to review recommended screening policy and how to ask about and intervene in cases of intimate partner violence, and finally to provide suggestions for institutionalizing a clinical response to intimate partner violence.