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.     

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.     

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.     

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.     

Adverse health conditions and health risk behaviors associated with intimate partner violence--United States, 2005

Intimate partner violence (IPV) is defined as threatened, attempted, or completed physical or sexual violence or emotional abuse by a current or former intimate partner. IPV can be committed by a spouse, an ex-spouse, a current or former boyfriend or girlfriend, or a dating partner. Each year, IPV results in an estimated 1,200 deaths and 2 million injuries among women and nearly 600,000 injuries among men. In addition to the risk for death and injury, IPV has been associated with certain adverse health conditions and health risk behaviors. To gather additional information regarding the prevalence of IPV and to assess the association between IPV and selected adverse health conditions and health risk behaviors, CDC included IPV-related questions in an optional module of the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report describes the results of that survey, which indicated that persons who report having experienced IPV during their lifetimes also are more likely to report current adverse health conditions and health risk behaviors. Although a causal link between IPV and adverse health conditions cannot be inferred from these results, they underscore the need for IPV assessment in health-care settings. In addition, the results indicate a need for secondary intervention strategies to address the health-related needs of IPV victims and reduce their risk for subsequent adverse health conditions and health risk behaviors.     

Role of victims' services in improving intimate partner violence screening by trained maternal and child health-care providers--Boston, Massachusetts, 1994-1995

From 1992 to 1996, approximately 1 million incidents of nonfatal intimate partner violence (IPV) occurred each year in the United States; 85% of victims were women. In 1989, pediatric research found a concurrence of victimization of mothers and their children and supported a recommendation that maternal and child health-care providers (HCPs) pursue training and advocate for increased access to services to promote the safety and well-being of mothers and their children. From 1992 to 1997, the Pediatric Family Violence Awareness Project (PFVAP), a training project for maternal and child HCPs, promoted prevention of and intervention for IPV in Massachusetts. In 1994, PFVAP conducted a pilot evaluation in two urban community health centers to determine whether HCPs trained to conduct IPV assessment would increase their screening rates of women at risk for IPV if an on-site referral service for victims was available. This report summarizes the results of the pilot project, which indicate that IPV screening rates did not increase after implementing on-site victim service.     

A scoping review of interventions to address intimate partner violence in sub-Saharan African healthcare

ABSTRACT

Intimate partner violence (IPV) is a widespread global health problem, with negative effects on women’s health and HIV transmission and treatment. There is little evidence on how to address IPV effectively in lower-resourced healthcare settings, particularly those that are impacted by significant HIV epidemics. We conducted a scoping review to provide an overview of the literature on IPV screening and intervention programmes in sub-Saharan African healthcare. The included studies used mainly qualitative methods. We identified five main themes: the acceptability to female clients, the importance of confidentiality, provider concerns, barriers due to gender norms, and need for referrals and comprehensive services. Research in this field is limited, and a robust research agenda is needed to provide effective IPV interventions for women seeking healthcare in sub-Saharan Africa.     

Addressing substance abuse and violence in substance use disorder treatment and batterer intervention programs

ABSTRACT: BACKGROUND: Substance use disorders and perpetration of intimate partner violence (IPV) are interrelated, major public health problems. Methods: We surveyed directors of a sample of substance use disorder treatment programs (SUDPs; N=241) and batterer intervention programs (BIPs; N=235) in California (70% response rate) to examine the extent to which SUDPs address IPV, and BIPs address substance abuse. Results: Generally, SUDPs were not addressing co-occurring IPV perpetration in a formal and comprehensive way. Few had a policy requiring assessment of potential clients, or monitoring of admitted clients, for violence perpetration; almost one-quarter did not admit potential clients who had perpetrated IPV, and only 20% had a component or track to address violence. About one-third suspended or terminated clients engaging in violence. The most common barriers to SUDPs providing IPV services were that violence prevention was not part of the program's mission, staff lacked training in violence, and the lack of reimbursement mechanisms for such services. In contrast, BIPs tended to address substance abuse in a more formal and comprehensive way; e.g., one-half had a policy requiring potential clients to be assessed, two-thirds required monitoring of substance abuse among admitted clients, and almost one-half had a component or track to address substance abuse. SUDPs had clients with fewer resources (marriage, employment, income, housing), and more severe problems (both alcohol and drug use disorders, dual substance use and other mental health disorders, HIV+ status). We found little evidence that services are centralized for individuals with both substance abuse and violence problems, even though most SUDP and BIP directors agreed that help for both problems should be obtained simultaneously in separate programs. Conclusions: SUDPs may have difficulty addressing violence because they have a clientele with relatively few resources and more complex psychological and medical needs. However, policy change can modify barriers to treatment integration and service linkage, such as reimbursement restrictions and lack of staff training.     

Comparison of Screening and Referral Strategies for Exposure to Partner Violence

BackgroundAlthough under debate, routine screening for intimate partner violence (IPV) is recommended in health care settings. This study explored the utility of different screening and referral strategies for women exposed to IPV in primary health care.MethodsUsing a randomized controlled trial design we compared two screening strategies (health care providers [HCP] versus audio computer-assisted self-interviews [A-CASI]) and three referral strategies (HCP alone, A-CASI referral with HCP endorsement, and A-CASI alone). English-speaking women who were 18 years and older and were attending women's health clinics at a public hospital were eligible to participate. Participants were randomly assigned to one of three study groups (HCP screen and referral, A-CASI screen and referral with HCP referral endorsement, and A-CASI screen and referral). Women were reinterviewed by telephone 1 week later. The primary outcome was rate of IPV disclosure; secondary outcomes were screening mode preference, reactions to IPV screening, and use of referral resources.ResultsOf the 129 eligible women, 126 women were enrolled (98%); 102 women (81% of those enrolled) completed the follow-up telephone interview. Disclosure rates were higher for women screened with A-CASI compared with HCP-screened women (21% vs. 9%; p = .07). Screening mode preference, impact of screening (positive and negative reactions), and rates of use of referral resources were similar between study groups.ConclusionA-CASI tended to yield higher rates of IPV disclosure and similar rates of use of referral resources. A-CASI technology may be a practical way to screen for IPV.     

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.     

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.     

Intimate partner violence screening and counseling in the health care setting: Perception of provider-based discussions as a strategic response to IPV

Intimate partner violence (IPV) affects women worldwide, and is addressable in the health care setting not only via screening, but also through provider-based counseling and referral to legal or social services, as appropriate. We conducted a study in Pennsylvania (USA) examining factors associated with receipt of IPV screening and women's perceptions of counseling discussions as a strategic response. We found that women with past-year IPV were more likely to receive screening (aOR: 2.0, 95%CI: 1.2,3.5) and to consider counseling discussions to be a strategic response to IPV exposure (aOR: 2.7, 95%CI: 1.008,7.2) than women with a more distant history of IPV. Scholars and clinicians may learn that, especially for women with a recent history of IPV, screening may provide a conduit to meaningful counseling discussions and referrals that women view as a helpful strategy in responding to IPV.     

Detecting intimate partner violence during pregnancy: awareness-raising indicators for use by primary healthcare professionals

BACKGROUND: Given the deleterious consequences of intimate partner violence (IPV) for gestation, it is important to promote a more effective and amicable approach that engenders greater receptiveness, stimulates more open communication and, ultimately, facilitates addressing the problem. In this regard, active primary care professionals need to be educated about the different profiles of violence found in domestic environments. The aim of this study is to make the identification of those subgroups of pregnant women most likely to be living in IPV situations both practical and simple. Its ultimate goal is to give healthcare professionals who work directly with the public the tools to anticipate such events. To this end, this study presents a profile of IPV during pregnancy according to different characteristics observed among primary health service users. METHODS: Five hundred and twenty-seven women who carried children to term in Rio de Janeiro were interviewed. A Portuguese version of the Revised Conflict Tactics Scale (CTS2) was used to detect IPV. Several sociodemographic factors, life habits and reproductive health characteristics of pregnant women and their partners were scrutinized. Prevalence projections by subgroup were obtained using a multinomial logit model. RESULTS: The projected prevalences for negotiation, psychological violence, minor physical violence and severe physical violence were, respectively, 0.1% [95% confidence interval (CI) 0.0-0.6], 2.6% (95%CI 0.7-6.9), 7.0% (95%CI 1.7-18.5) and 90.3% (95%CI 77.2-96.8) for the extreme scenario, i.e. women <20 years of age, non-White, living in house with inadequate garbage disposal, previous history of abortion, reporting fear of someone, reporting lack of affective social support, and reporting drug use by woman or spouse. In the absence of these characteristics, the projected prevalences were 51.3% (95%CI 38.5-64.6), 40.0% (95%CI 28.5-51.9), 7.6% (95%CI 4.2-12.7) and 1.1% (95%CI 0.3-2.4), respectively. CONCLUSION: This study found that knowledge of certain characteristics of pregnant women who attend health services can alert professionals to the high probability of IPV, facilitating early identification of the problem and subsequent implementation of proactive measures.     

Intimate Partner Violence,Depression, PTSD,and Use of Mental Health Resources Among Ethnically Diverse Black Women

This study examined exposure to violence and risk for lethality in intimate partner relationships as factors related to co-occurring MH problems and use of mental health (MH) resources among women of African descent. Black women with intimate partner violence (IPV) experiences (n?=?431) were recruited from primary care, prenatal or family planning clinics in the United States and the U.S. Virgin Islands. Severity of IPV was significantly associated with co-occurring MH problems, but was not associated with the use of MH resources among African-American women. Risk for lethality and co-occurring problems were also not significantly related to the use of resources. African Caribbean women with severe physical abuse experiences were significantly less likely to use resources. In contrast, severity of physical abuse was positively associated with the use of resources among Black women with mixed ethnicity. Severe IPV experiences are risk factors for co-occurring MH problems, which in turn, increases the need for MH services. However, Black women may not seek help for MH problems. Thus, social work practitioners in health care settings must thoroughly assess women for their IPV experiences and develop tailored treatment plans that address their abuse histories and MH needs.     

Prospective Association of Intimate Partner Violence with Receipt of Clinical Preventive Services in Women of Reproductive Age

BackgroundWomen who experience intimate partner violence (IPV) have a greater risk for adverse health outcomes, suggesting the importance of preventive services in this group. Little prior research has explored how IPV exposure impacts receipt of relevant preventive services. We assess the prospective association of IPV exposure with receiving specific preventive services.MethodsWomen in the Central Pennsylvania Women's Health Study's longitudinal cohort study (conducted 2004–2007; n = 1,420) identified past-year exposure to IPV at baseline and receipt of IPV-relevant preventive services (counseling for safety and violence concerns, tests for sexually transmitted infections [STIs], counseling for STIs, Pap testing, counseling for smoking/tobacco use, alcohol/drug use, and birth control) at 2-year follow-up. Multiple logistic regression analysis assessed the impact of IPV on service receipt, controlling for relevant covariates.FindingsWomen exposed to IPV had greater odds of receiving safety and violence counseling (adjusted odds ratio [AOR], 2.40; 95% confidence interval [CI], 1.25–4.61), and tests for STIs (AOR, 2.46; 95% CI, 1.41–4.28) compared with women who had not been exposed to IPV. Independent of other predictors, including IPV, women who saw an obstetrician-gynecologist were more likely to receive Pap tests, STI/HIV testing and counseling, and birth control counseling, compared with women who had not seen an obstetrician-gynecologist.ConclusionOverall rates of preventive service receipt for all women in the sample were low. Women exposed to IPV were more likely to receive safety and violence counseling and STI testing, and seeing an obstetrician-gynecologist increased the odds of receiving several preventive services.     

Moving beyond disclosure: women's perspectives on barriers and motivators to seeking assistance for intimate partner violence

To investigate women's perceptions of motivators and barriers to seeking help or accessing intimate partner violence (IPV), services six focus groups were conducted in rural and urban settings in North Carolina between June and August of 2002. Coding and theme analysis were used to summarize themes among the 67 focus group participants.The majority of participants were African-American (87%). Participants reported three main categories of motivators: gaining knowledge; reaching an emotional or physical breaking point; and growing concern about children's safety. Participants reported six main categories of barriers: pressure not to talk about, or address IPV; failure to recognize events as IPV, or that IPV was wrong; self-doubt and low self-esteem; fear of losses; fear of perpetrator; or desire to protect the perpetrator. This study documents the difficulties that women face accessing or using services related to IPV. We need to address perceived barriers and better use the opportunity when women experience motivation to seek help and access services.     

Childhood family violence history and women's risk for intimate partner violence and poor health

BACKGROUND: There is growing evidence for associations between generations in family violence and between family violence in both childhood and adulthood and women's health. Most studies focus on a subset of family violence (child abuse, witnessing intimate partner violence [IPV] as a child, and/or adult IPV), and few examine possible differences associated with the nature of abusive experiences, such as physical versus sexual abuse. METHODS: A population-based telephone survey, the 1999 and 2001 Washington State Behavioral Risk Factor Surveillance System, asked a representative sample of 3527 English-speaking, non-institutionalized adult women whether they had been physically or sexually assaulted or witnessed interparental violence in childhood, and whether they had experienced physical assault or emotional abuse from an intimate partner in the past year. The survey also asked about current general health and mental distress in the past month. RESULTS: The risks associated with childhood family violence experiences varied depending on the nature of those experiences. Women reporting childhood physical abuse or witnessing interparental violence were at a four- to six-fold increase in risk of physical IPV, and women reporting any of the experiences measured were at three- to four-fold increase in risk of partner emotional abuse. In contrast, women reporting childhood sexual abuse only were not at increased risk of physical IPV. Women reporting childhood physical abuse were at increased risk of poor physical health, and women reporting any type of childhood family violence were at increased risk of frequent mental distress. Approximately one third of women reporting poor general health and half of women reporting frequent mental distress also reported at least one of the childhood experiences measured. CONCLUSIONS: These findings underscore the role of childhood experiences of abuse and of witnessing family violence in women's current risk for IPV, poor physical health, and frequent mental distress.     

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.     

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.