Partner violence intervention in the busy primary care environment

BACKGROUND: Few studies of intimate partner violence (IPV) interventions have been conducted in primary care settings. Based on recommendations, we implemented a multifaceted IPV intervention that included a sticker placed in medical charts listing screening questions, routine IPV screening by nursing staff, clinician follow-up for women screening positive, and referral to on-site services. METHODS: A prospective cohort study compared multiple measures collected at the intervention site and a center providing usual care. Measures included self-reported IPV, documented IPV screening and IPV experiences, and quantity of IPV materials taken from the centers. RESULTS: Of 746 charts reviewed in a random chart review conducted at the intervention site, 36.6% were tagged for IPV screening, and of those tagged, 86.1% had documentation of screening. Approximately 5% (11 of 235) of women screened positive for IPV; about half had documented clinician follow-up and referral to on-site services. Comparison of survey responses and medical record reviews (intervention site) indicated that the screening protocol primarily identified severely abused women (sensitivity 80%, specificity 98%), but rarely identified women experiencing low to moderate levels of abuse. IPV brochures were taken from the intervention site at a rate of 51 per 1000 visits versus 29 per 1000 visits taken from the control site. CONCLUSIONS: Utilizing screening as the only gateway to on-site services limited access for many IPV victims. The removal of IPV brochures from examination rooms suggests that providing contact information for self-referral to on-site services may improve access.     

Physical partner violence and medicaid utilization and expenditures

OBJECTIVES: Little research has addressed differences in health care expenditures among women who are currently experiencing intimate partner violence (IPV) compared with those who are not. The purpose of this work is to provide estimates of direct medical expenditure for physician, drug, and hospital utilization among Medicaid-eligible women who screened as currently experiencing IPV compared with those who are not currently experiencing IPV. METHODS: In this family practice-based cross-sectional study, women were screened for current IPV using a 15-item Index of Spouse Abuse-Physical (ISA-P) between 1997 and 1998. Consents were obtained from study subjects to review Medicaid expenditure and utilization data for the same time period. RESULTS: Mean physician, hospital, and total expenditures were higher for those women with higher IPV scores compared with those who scored as not currently experiencing IPV, after adjusting for confounders. Higher IPV scores were associated with a three-fold increased risk of having a total expenditure over $5,000 (95% confidence interval [CI] 1.3, 8.4). The mean total expenditure difference between the high IPV and no IPV groups was $1,064 (95% CI $623, $1506). The adjusted risk ratio for high IPV score and the log of total Medicaid expenditures was 2.3 (95% CI 1.2, 4.4). CONCLUSIONS: Women screened as experiencing higher IPV scores had higher Medicaid expenditures compared with women not currently experiencing IPV. Early IPV assessment partnered with effective clinic or community-based interventions may help to identify IPV earlier and reduce the health impact and cost of IPV.     

Partner violence and medical encounters: African-American women's perspectives

OBJECTIVE: To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Community-based, primary care center. PATIENTS: Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter. MEASUREMENTS: Patients' perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV "in the past year." RESULTS: Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers. CONCLUSIONS: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care.     

Partner violence and medical encounters: African-American women’s perspectives

Objective: To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population.Design: Cross-sectional, self-administered, anonymous survey.Setting: Community-based, primary care center.Patients: Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter.Measurements: Patients’ perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV “in the past year.”Results: Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers.Conclusions: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care.     

Risk factors for intimate partner violence initiation and persistence among high psychosocial risk Asian and Pacific Islander women in intact relationships

PurposeThe present study identifies risk factors for intimate partner violence (IPV) initiation and persistence over three years in a high psychosocial risk Asian American and Pacific Islander (AAPI) sample of women with children living in Hawaii.MethodsWe included 378 women in a 3-year relationship with the same partner who reported IPV experiences at baseline and 3 years later. Baseline risk factors included characteristics of each woman, her partner, and their relationship. Bivariate and multivariate regression models were conducted to assess the influence of risk factors on the likelihood of experiencing IPV initiation and persistence.FindingsOf women who experienced no physical violence at baseline, 43% reported IPV initiation. Of women who did experience physical violence at baseline, 57% reported IPV persistence. Being unemployed and reporting poor mental health at baseline are important risk factors for experiencing IPV initiation. Reporting frequent physical violence at baseline increases the likelihood of experiencing IPV persistence. Asian women were significantly less likely to report IPV persistence than other groups of women.ConclusionsOur study indicates that among a high psychosocial risk sample of AAPI women there are different risk factors for IPV initiation and persistence. Future prevention and screening efforts may need to focus on these risk factors.     

Intimate partner violence from the emergency medicine perspective

BACKGROUND: The incidence of acute cases of intimate partner violence (IPV) in the Emergency Department (ED) patients is between 2 and 7.2%. Ongoing IPV may be an immediate cause of presentation for medical care, or it may not be readily apparent. Over the last two decades efforts to improve identification of IPV in the ED have been successful. METHODS: A medline literature search from 1981-2001 was performed. A review of intimate partner violence from the emergency department provider perspective is performed. A discussion of the screening/detection of intimate partner violence and the barriers to improving detection rates is provided. RESULTS: The review of the current literature shows that IPV is a frequent cause of illness or injury in patients presenting in the ED. Screening programs for intimate partner violence have shown to increase the identification of patients experiencing acute episodes of abuse and seeking treatment. The difficulty has been in sustaining the programs and improving the screening of patients. Patient, provider and systems barriers prevent adequate recognition and management of the problem. CONCLUSION: Detection of IPV in patients presenting to the ED can be improved by providing educational programs and screening tools to health care providers. Sustaining the screening programs is more difficult and requires a health care system-wide effort.     

Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan

Intimate partner violence (IPV) during pregnancy can result in adverse outcomes for both mothers and their infants. This cross-sectional study examined the prevalence and risk factors of IPV associated with abuse during pregnancy via a self-administered questionnaire completed by 302 healthy pregnant women. Demographic information was also collected from medical records to analyze risk factors for abuse. Of the 302 women, 48 (15.9%) were identified as experiencing IPV. The identified risk factors were age over 30, multipara, previous abortion experience, and male partner aged under 30.     

Help-seeking for intimate partner violence and forced sex in South Carolina

PURPOSE: In this population-based, random-digit-dial, cross-sectional survey, we assessed the lifetime victimization of intimate partner violence (IPV) and forced or coerced sex among 556 women and men in South Carolina, and the help-seeking behaviors of victims. RESULTS: Among women, 25.3% experienced IPV (sexual, physical, or emotional violence) compared with 13.2% of men. Although women were significantly more likely to report physical or sexual IPV (17.8%) than were men (4.9%), men (8.3%) were as likely as women (7.4%) to report perceived emotional abuse without physical or sexual IPV. One half of men and women with annual incomes <$15, 000 reported IPV. Among women experiencing physical or sexual IPV, 53% sought community-based or professional services for IPV; women with higher education levels and those experiencing more severe violence were most likely to seek services. CONCLUSIONS: These data show that IPV is common and that most victims do not receive services to address this violence.     

Discussions About Intimate Partner Violence During Prenatal Care in the United States: The Role of Race/Ethnicity and Insurance Status

Over 1.5 million women are physically, sexually, and emotionally abused by intimate partners in the U.S. each year. Despite the severe health consequences and costs associated with intimate partner violence (IPV), most health providers fail to assess patients for abuse. It was of interest to examine the occurrence of IPV discussions during prenatal care (PNC) visits among women who experienced IPV. This study analyzed data from the 2004–2008 National Pregnancy Risk Assessment Monitoring System which included 195,687 women who delivered a live birth in the U.S. IPV victimization was measured using four items that addressed physical abuse by a current or former husband/partner in the 12 months before or during pregnancy. Responses were categorized as preconception, prenatal, preconception and prenatal, and preconception and/or prenatal IPV. The outcome was IPV discussions by health providers during PNC. Separate logistic regression models provided odds ratios and 95 % confidence intervals. Women who reported prenatal IPV were less likely to have IPV discussions during PNC (OR = 0.81, 95 % CI = 0.70–0.94). Results were similar for women experiencing IPV during the prenatal and preconception periods. Among racial/ethnic minorities, women who experienced preconception IPV were less likely to have discussions about IPV during PNC. Further, Medicaid recipients who reported preconception and/or prenatal IPV were less likely to report IPV discussions (OR = 0.75, 95 % CI = 0.69–0.82). This study underscores a public health problem and missed opportunity to connect battered victims to necessary services and care. It elucidates the state of current clinical practice and better informs policies on incorporating universal IPV screening.     

Physical violence, intimate partner violence, and emotional abuse among adult American Indian men and women in Montana

BACKGROUND: Little is known about the experience of American Indian communities relative to physical violence (PV), intimate partner violence (IPV), and emotional abuse. METHODS: A random sample of adult American Indians living on or near the seven Montana reservations were interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 2001 (N = 1,006). Victimization from physical violence was defined as PV or sexual assault committed by any person. Respondents who reported experiencing PV and who reported that the perpetrator was a current or former spouse, boyfriend, girlfriend, or date were categorized as experiencing IPV. Emotional abuse was defined as fear for one's safety or being controlled by another individual. RESULTS: Nine, one, and twelve percent of men reported experiencing PV, IPV, and emotional abuse in the past year, respectively. Five percent of women reported PV in the past year, 3% reported IPV, and 18% reported emotional abuse. Men who reported PV in the past year were more likely to be younger and report more days of physical and mental health problems in the past month. Women reporting PV in the past year were more likely to be younger and have more days with mental health problems in the past month. Few men (7%) or women (12%) reported ever being assessed for PV or safety. CONCLUSIONS: Recent PV, IPV, and emotional abuse are prevalent for both American Indian men and women. Strategies to increase screening for PV and effective interventions for violence are needed.     

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.     

Screening for Intimate Partner Violence in Reproductive Health Centers: An Evaluation Study

This study compared rates of intimate partner violence reports on a new, empirically-developed screening tool completed by 385 women in 2007 to those from an older tool completed by 420 women in 2006. Data were obtained from randomly selected medical charts across three health center locations, which were part of the same reproductive health care organization. Chi-square analyses were conducted to test associations between demographic characteristics and partner violence reports. Multiple regression analyses were used to compare odds ratios of disclosure by type of screening tool, adjusting for associated demographic factors associated with partner violence reports. Women completing the old and new tools were similar across all demographic characteristics. After adjusting for age and center location, women completing the new screening form were more than 2.5 times as likely to report any partner violence. When analyzed by mutually exclusive violence history categories, women completing the new screening form were over 2.5 times as likely to report past or current violence and over 4 times as likely to report experiencing both past and current violence. Findings suggest that implementing empirically developed brief screening tools for partner violence in reproductive health settings may elicit more disclosures from patients than more traditional tools.     

Violence Against Women and Reproductive Health: Toward Defining a Role for Reproductive Health Care Services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.     

Intimate partner violence and cervical neoplasia

Intimate partner violence (IPV) is associated with a range of adverse physical health outcomes, including chronic and infectious diseases. An emerging literature suggests that partner violence and specifically sexual violence may be associated with an increased risk of cervical neoplasia. To assess the risk of preinvasive and invasive cervical cancer in a cross-sectional study of women screened for IPV by type, frequency and duration, 1152 women ages 18-65 were recruited from family practice clinics in 1997-1998. They were screened for IPV during a brief in-clinic interview, and health history and current status were assessed in a follow-up interview. Of 1152 women surveyed, 14 (1.2%) reported cervical cancer, and 20. 3% (n = 234) reported treatment for cervical neoplasia. Ever experiencing IPV was associated with an increased risk of invasive cervical cancer (adjusted relative risk [aRR] = 4.28; 95% CI 1.94, 18.39) and with preinvasive cervical neoplasia (aRR = 1.47; 95% CI 1. 16, 1.82). This association was stronger for women experiencing physical or sexual IPV than for women experiencing psychological IPV. Women with cervical cancer reported being in violent relationships longer and experiencing more frequent physical and sexual assaults and more IPV-associated injuries than did controls. This exploratory study suggests that IPV may increase a woman's risk of cervical neoplasia. The mechanism by which IPV effects cervical neoplasia may be indirect through psychosocial stress or negative coping behaviors or direct through sexual assaults and transmission of human papillomavirus (HPV).     

Who tells and what happens: disclosure and health service responses to screening for intimate partner violence

Routine screening of women for intimate partner violence (IPV) has been introduced in many health settings to improve identification and responsiveness to hidden abuse. This cross‐sectional study aimed to understand more about how women use screening programmes to disclose and access information and services. It follows women screened in ten Australian health care settings, covering antenatal, drug and alcohol and mental health services. Two samples of women were surveyed between March 2007 and July 2008; those who reported abuse during screening 6 months previously (122) and those who did not report abuse at that time (241). Twenty‐three per cent (27/120) of women who reported abuse on screening were revealing this for the first time to any other person. Of those who screened negative, 14% (34/240) had experienced recent or current abuse, but chose not to disclose this when screened. The main reasons for not telling were: not considering the abuse serious enough, fear of the offender finding out and not feeling comfortable with the health worker. Just over half of both the positive and negative screened groups received written information about IPV and 35% of the positive group accessed further services. The findings highlight the fact that much abuse remains hidden and that active efforts are required to make it possible for women to talk about their experiences and seek help. Screening programmes, particularly those with established protocols for asking and referral, offer opportunities for women to disclose abuse and receive further intervention.     

Sexual Orientation Disparities in Experiences of Male-Perpetrated Intimate Partner Violence: A Focus on the Preconception and Perinatal Period

IntroductionCompared with their heterosexual counterparts, sexual minority women (SMW), especially those with male partners, are at increased risk for intimate partner violence (IPV). IPV has been linked to a variety of adverse maternal, infant, and child health outcomes. However, to date, no research has examined SMW's experiences of IPV in the context of pregnancy. This study explored whether SMW were more likely than exclusively heterosexual women with only male sexual partners (WSM) to report a variety of forms of IPV perpetrated by their male partner before or during pregnancy.MethodsData are from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Our sample size ranged from 10,081 to 10,328 pregnancies, matched with their male pregnancy partner, reported by 3,828 to 3,873 women.ResultsLogistic regression results indicated that compared with heterosexual-WSM, mostly heterosexual women and heterosexual-women who have sex with women (WSW) were more likely to report any IPV, mostly heterosexual women were more likely to report an IPV-related injury, and heterosexual-WSW were more likely to report sexual assault.ConclusionsResults suggest that mostly heterosexual and heterosexual-WSW are at increased risk of experiencing multiple forms of IPV with their male pregnancy partners, highlighting the need for additional screening and prevention efforts to reduce IPV and its negative sequelae.     

Men’s Controlling Behaviors and Women’s Experiences of Physical Violence in Malawi

In the feminist paradigm, intimate partner violence (IPV) among heterosexual couples is gender asymmetric and largely a tactic of male control. However, research on the relationship between men’s controlling behavior and physical violence against women is limited. This study examines whether having a controlling partner is associated with women’s reports of experiencing physical violence in Malawi. Bivariate and multivariate analyses were conducted using data from 8,385 women who completed the domestic violence module of the Malawi 2004 Demographic and Health Survey. About 18 % of women reported they had experienced moderately severe physical violence and 1 % experienced very severe violence in the past 12 months. A third of women reported their partners had ever been controlling. Results from multivariable ordinal logistic regression showed that women who had controlling partners were significantly more likely to report experiencing physical violence. Other factors significantly associated with women’s experience of physical violence included women who reported initiating physical violence against their partners, women’s work status, partners’ lower education level, and partners’ alcohol consumption. Women with controlling partners were at increased risk of experiencing physical violence in the past year. However, women who reported initiating physical violence in the past year were nearly four times more likely to experience partner violence in the same time period. Future research should attempt to elucidate these two important risk factors for IPV.     

Physical health consequences of physical and psychological intimate partner violence

BACKGROUND: Past studies that have addressed the health effects of intimate partner violence (IPV) have defined IPV as violence based on physical blows that frequently cause injuries. To our knowledge, no epidemiologic research has assessed the physical health consequences of psychological forms of IPV. OBJECTIVE: To estimate IPV prevalence by type and associated physical health consequences among women seeking primary health care. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: A total of 1152 women, aged 18 to 65 years, recruited from family practice clinics from February 1997 through January 1999 and screened for IPV during a brief in-clinic interview; health history and current status were assessed in a follow-up interview. RESULTS: Of 1152 women surveyed, 53.6% ever experienced any type of partner violence; 13.6% experienced psychological IPV without physical IPV. Women experiencing psychological IPV were significantly more likely to report poor physical and mental health (adjusted relative risk [RR], 1.69 for physical health and 1.74 for mental health). Psychological IPV was associated with a number of adverse health outcomes, including a disability preventing work (adjusted RR, 1.49), arthritis (adjusted RR, 1.67), chronic pain (adjusted RR, 1.91), migraine (adjusted RR, 1.54) and other frequent headaches (adjusted RR, 1.41), stammering (adjusted RR, 2.31), sexually transmitted infections (adjusted RR, 1.82), chronic pelvic pain (adjusted RR, 1.62), stomach ulcers (adjusted RR, 1.72), spastic colon (adjusted RR, 3.62), and frequent indigestion, diarrhea, or constipation (adjusted RR, 1.30). Psychological IPV was as strongly associated with the majority of adverse health outcomes as was physical IPV. CONCLUSIONS: Psychological IPV has significant physical health consequences. To reduce the range of health consequences associated with IPV, clinicians should screen for psychological forms of IPV as well as physical and sexual IPV.     

Who gets screened during pregnancy for partner violence?

CONTEXT: Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown. OBJECTIVES: To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened. DESIGN, SETTING, AND PARTICIPANTS: This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998. MAIN OUTCOME MEASURES: Self-reports of violence, health service factors, and sociodemographic characteristics. ANALYSIS: The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors. RESULTS: Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source. CONCLUSIONS: These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care. Arch Fam Med. 2000;9:1093-1099