Occurrence, characteristics, and impact of chronic pain in formerly abused women

Intimate Partner Violence Against Women and Labor Productivity: The Mediating Role of Morbidity

This study determines that morbidity presents a mediating impact between intimate partner violence against women and labor productivity in terms of absenteeism and presenteeism. Partial least squares structural equation modeling (PLS-SEM) was used on a nationwide representative sample of 357 female owners of micro-firms in Peru. The resulting data reveals that morbidity is a mediating variable between intimate partner violence against women and absenteeism (β = 0.213; p < .001), as well as between intimate partner violence against women and presenteeism (β = 0.336; p < .001). This finding allows us to understand how such intimate partner violence against women negatively affects the workplace productivity in the context of a micro-enterprise, a key element in many economies across the world.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/59918.

The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review

Women experience persistent pain at higher rates than men; however, women are less likely to be provided with adequate or appropriate care and more likely to have their pain experiences dismissed. The purpose of this review is to consider the complex interaction of the biopsychosocial factors in the experience of persistent pain in order to inform improved models of care. Given persistent pain is among the most frequently reported health consequences of intimate partner violence (IPV), this review focused on studies exploring the association between persistent pain and IPV. Three reviewers independently and systematically searched seven databases. Qualitative and quantitative studies describing the association between IPV and persistent pain published between January 2000 and June 2018 were included. Twelve studies met the inclusion criteria. The included studies demonstrated that a history of IPV places an additional burden on women who experience persistent pain that cannot be explained by an underlying psychological condition. Health care practitioners should be aware of this phenomena to ensure diagnosis, assessment, and treatment plans are targeted accordingly. Future policy directives and research should account for and seek to elucidate this additional burden.

Longitudinal Analysis of Persistent Postconcussion Symptoms, Probable TBI, and Intimate Partner Violence Perpetration Among Veterans

OBJECTIVE

To determine veterans' intimate partner violence (IPV) perpetration following report of traumatic brain injury (TBI) and persistent postconcussion symptoms (PPCSs).

SETTING

Five Department of Veterans Affairs (VA) medical centers.

PARTICIPANTS

Veterans with nonmissing data on main measures, resulting in N = 1150 at baseline and N = 827 at follow-up.

DESIGN

Prospective cohort study with secondary data analysis of self-reported TBI, PPCSs, and IPV perpetration, controlling for common predictors of IPV, including binge drinking, marijuana use, pain intensity, and probable posttraumatic stress disorder.

MAIN MEASURES

VA TBI Screening Tool to assess for probable TBI and PPCSs; Conflict Tactics Scale-Revised (CTS-2S) to assess for IPV perpetration.

RESULTS

Almost half (48%) of participants reported IPV perpetration at follow-up. Both probable TBI and higher PPCSs at baseline were associated with overall IPV perpetration and more frequent IPV perpetration at follow-up. Only PPCSs significantly predicted IPV perpetration after controlling for common predictors of IPV perpetration. Neither probably TBI nor PPCSs predicted frequency of IPV perpetration.

CONCLUSION

When considered alongside common risk factors for IPV perpetration, PPCS was uniquely associated with the likelihood of IPV perpetration in this veteran sample. Given post-9/11 veterans' elevated risk for head injury, findings emphasize the distinctive value of PPCSs in understanding risk for IPV perpetration. We recommend increased assessment for PPCSs in clinical practice among veterans enrolled in VA care and highlight several important areas for future research and intervention development.

Toward Community Coverage on Self-Screening, Diagnosis, and Help-Seeking Behavior for Both Gender Victims of Intimate Partner Violence (IPV) in a Kenyan Setting: The Development of IPV-Brief Self-Screener (IPV-BSS) Version of the WHO-IPV Instrument

Intimate partner violence (IPV) is a major public health concern. The prevalence of IPV in women in Kenya is in the range of 41% to 45% but has also been reported in 20% of men. The most widely used instrument for the screening and diagnosis of IPV is the World Health Organization-Intimate Partner Violence (WHO-IPV). However, it is lengthy for routine large-scale screening and is administered by a trained person, thus limiting the number it can reach for screening. There is therefore a need for a shorter screening version that can be self-administered to reach critical masses. Those who screen positive can then be subjected to the longer version. In addition, the short version should be culturally sensitive, can be used by either gender, can be used in busy clinical settings as the patients wait to be attended to, and can be used for large-scale community populations to raise awareness and promote help-seeking behavior. It should be applicable in similar cultural settings and is aligned to the longer version of the WHO-IPV instrument. This study aimed to develop such a tool. We administered the WHO-IPV to two groups: firstly, postnatal mothers attending postnatal clinics and secondly, men and women attending general clinics to which they had been referred. These referrals were by traditional healers (TH), faith healers (FH), and community health workers (CHW) who had been trained to screen for mental disorders using the Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG) master checklist. Using factor analysis of the scores, we came up with questions that had the highest predictive value for different types of IPV diagnosis and which could therefore be used for self-screening purposes. We call the tool the Intimate Partner Violence-Brief Self-Screener (IPV-BSS; Adapted by the Africa Mental Health Research and Training Foundation from the WHO-IPV).

Predicting pain among female survivors of recent interpersonal violence: A proof-of-concept machine-learning approach

Interpersonal violence (IPV) is highly prevalent in the United States and is a major public health problem. The emergence and/or worsening of chronic pain are known sequelae of IPV; however, not all those who experience IPV develop chronic pain. To mitigate its development, it is critical to identify the factors that are associated with increased risk of pain after IPV. This proof-of-concept study used machine-learning strategies to predict pain severity and interference in 47 young women, ages 18 to 30, who experienced an incident of IPV (i.e., physical and/or sexual assault) within three months of their baseline assessment. Young women are more likely than men to experience IPV and to subsequently develop posttraumatic stress disorder (PTSD) and chronic pain. Women completed a comprehensive assessment of theory-driven cognitive and neurobiological predictors of pain severity and pain-related interference (e.g., pain, coping, disability, psychiatric diagnosis/symptoms, PTSD/trauma, executive function, neuroendocrine, and physiological stress response). Gradient boosting machine models were used to predict symptoms of pain severity and pain-related interference across time (Baseline, 1-,3-,6- follow-up assessments). Models showed excellent predictive performance for pain severity and adequate predictive performance for pain-related interference. This proof-of-concept study suggests that machine-learning approaches are a useful tool for identifying predictors of pain development in survivors of recent IPV. Baseline measures of pain, family life impairment, neuropsychological function, and trauma history were of greatest importance in predicting pain and pain-related interference across a 6-month follow-up period. Present findings support the use of machine-learning techniques in larger studies of post-IPV pain development and highlight theory-driven predictors that could inform the development of targeted early intervention programs. However, these results should be replicated in a larger dataset with lower levels of missing data.

#WhyIDidntReport: Women Speak Out About Sexual Assault on Twitter

BACKGROUND

In September 2018, Dr. Christine Blasey Ford accused then-nominee to the U.S. Supreme Court Brett Kavanaugh of sexual assault. When then-U.S. President Donald Trump questioned her credibility on Twitter, sexual assault survivors began tweeting their reasons for not reporting using the hashtag #WhyIDidntReport. This study examined how these posts were discussed on Twitter and to what extent the tweets fit within levels of the Social Ecological Model (SEM).

METHOD

This study used quantitative content analysis to code 1,000 tweets with #WhyIDidntReport for violence type, reasons for not reporting, and SEM levels.

RESULTS

Overall, 68.7% of posts mentioned a specific reason for not reporting; of these, 24.1% referred to the perpetrator being in a position of power, 36.3% feared not being believed, and 20.6% mentioned that others invalidated the assault. In addition, 47.6% mentioned a specific form of violence. Within the SEM, 47.6% referred to individual, 52.6% to relational, 43.2% to community, and 21.7% to societal reasons for not reporting.

CONCLUSION

Reading social media content allows healthcare providers to directly discover how survivors talk about their experiences, priorities in the care environment, and how to support a patient-centered and trauma-informed approach.

IMPLICATIONS

Understanding reasons people do not report sexual assault is critical for healthcare professionals to engage patients in open, honest screening and intervention efforts.

Cumulative Lifetime Violence Severity and Chronic Pain in a Community Sample of Canadian Men

OBJECTIVE

To create a descriptive profile of chronic pain severity in men with lifetime cumulative violence histories, as a target and/or a perpetrator, and investigate how chronic pain severity is associated with and predicted by lifetime cumulative violence severity and known determinants of chronic pain.

METHODS

Analysis of variance and binary logistic regression were performed on data collected in an online survey with a community convenience sample of 653 men who reported experiences of lifetime violence.

RESULTS

The prevalence of high-intensity / high-disability pain in men with lifetime violence was 35.8%. Total Cumulative Lifetime Violence Severity-44 (CLVS-44) scores were significantly associated with high-intensity / high-disability chronic pain measured by the Chronic Pain Grade Scale (odds ratio= 8.40). In a model with 10 CLVS-44 subscale scores, only psychological workplace violence as a target (adjusted odds ratio [aOR]= 1.44) and lifetime family physical violence as a target (aOR= 1.42) significantly predicted chronic pain severity. In a multivariate model, chronic pain severity was predicted by CLVS-44 total score (aOR= 2.69), age (aOR= 1.02), injury with temporary impairment (aOR= 1.99), number of chronic conditions (aOR= 1.37), and depressive symptoms (aOR= 1.03).

CONCLUSION

The association between lifetime cumulative violence severity and chronic pain severity in men is important new information suggesting the need for trauma- and violence-informed approaches to assessment and intervention with men. This is the first analysis using CLVS-44 subscales to understand which configurations of lifetime cumulative violence may be most predictive of chronic pain severity; further investigation is needed to confirm these findings.

Structural violence: A concept analysis to inform nursing science and practice

This analysis is meant to elucidate the concept of structural violence and its implications for nursing science and practice. The concept of structural violence, also known as indirect violence, was first identified in the literature by peace researcher Johan Galtung. According to Galtung, structural violence broadly represents harm done to persons and groups through inequitable social, political, or economic structures. Such inequitable structures, such as systemic discrimination based on race, ethnicity, religion, gender, sexual orientation, etc. create conditions within society that directly disadvantage and oppress members of certain groups. This oppression can inflict profound physical, psychological, and socioeconomic harm on individuals, leading to disparate health outcomes. Using techniques for developing conceptual meaning as outlined in Chinn and Kramer (2018), our analysis seeks to specify meanings and applications of structural violence for application to nursing. This analysis draws on literature from clinical, historical, and other social sciences. Databases including CINAHL, PubMed, JSTOR, and PsychInfo were explored for references to structural violence. Structural violence is readily identified in specific contexts where individuals or groups are disadvantaged by socially constructed systems, such as those of race, gender, and economic privilege. Structural violence can result in health disparities and the development of conditions that predispose individuals to health risks. Nurses must be familiar with the concept to address these issues with patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of intimate partner violence among Ugandan women with pelvic floor dysfunction

OBJECTIVE

To assess the occurrence of intimate partner violence (IPV) among women seeking surgery for pelvic floor dysfunction (PFD) in a rural African community.

METHODS

A prospective questionnaire-based study was conducted among women with obstetric fistula, unrepaired obstetric anal sphincter injuries (OASIS), or severe (stage 3 or 4) pelvic organ prolapse (POP) who attended surgical camps at Kagando Hospital in western Uganda between July 15, 2016, and September 14, 2017. The control group comprised women without PFD. Participants completed the Hurt, Insult, Threaten, and Scream (HITS) tool and the Woman Abuse Screening Tool (WAST) to screen for IPV.

RESULTS

117 of the 312 women interviewed reported current IPV: 73/214 (34.1%) in the PFD group and 44/98 (44.9%) in the control group. The PFD group comprised unrepaired OASIS (n=85, 39.7%), obstetric fistula (n=75, 35.1%), and severe POP (n=54, 25.2%). All groups experienced high levels of IPV. The frequency of positive screening results for IPV with WAST (score ≥13.0) and/or HITS (score ≥10.5) were: severe POP (n=17, 31.5%), obstetric fistula (n=28, 37.3%), unrepaired OASIS (n=30, 35.3%), and control group (n=44, 44.9%).

CONCLUSION

Women in western Uganda experienced high rates of IPV, regardless of whether or not they had PFD. ANZCTR number: ACTRN12617001073392.

Trauma-Informed Care Education in Baccalaureate Nursing Curricula in the United States: Applying the American Association of Colleges of Nursing Essentials

The practice of trauma-informed care (TIC) allows nurses in any setting to identify and intervene with traumatized individuals and to create a continuum of care when forensic nursing services are needed. The purpose of this article is to suggest ways to incorporate TIC content into baccalaureate nursing programs. We begin with an overview of baccalaureate nursing curricula and common types of traumatic experience important for students to understand. We then propose specific strategies for inclusion of TIC content in baccalaureate nursing education, using the American Association of Colleges of Nursing Essentials of Baccalaureate Education for Professional Nursing Practice. With a solid foundation in TIC, baccalaureate-prepared nursing students can provide effective patient care and better support forensic nursing practice. This will increase the capacity of the nursing profession in general to meet the needs of those affected by trauma, violence, and abuse.

Accuracy and Acceptability of a Screening Tool for Identifying Intimate Partner Violence Perpetration among Women Veterans: A Pre-Implementation Evaluation

OBJECTIVES

Veterans are at heightened risk for perpetrating intimate partner violence (IPV), yet there is limited evidence to inform practice and policy for the detection of IPV perpetration. The present study evaluated the accuracy and acceptability of a potential IPV perpetration screening tool for use with women veterans.

DESIGN

A national sample of women veterans completed a 2016 web-based survey that included a modified 5-item Extended-Hurt/Insult/Threaten/Scream (Modified E-HITS) and the Revised Conflict Tactics Scales (CTS-2). Items also assessed women's perceptions of the acceptability and appropriateness of the modified E-HITS questions for use in healthcare settings. Accuracy statistics, including sensitivity and specificity, were calculated using the CTS-2 as the reference standard.

MAIN OUTCOME MEASURES

Primary measures included the Modified E-HITS (index test), CTS-2 (reference standard), and items assessing acceptability.

RESULTS

This study included 187 women, of whom 31 women veterans (16.6%) reported past-6-month IPV perpetration on the CTS-2. The Modified E-HITS demonstrated good overall accuracy (area under the curve, 0.86; 95% confidence interval, 0.78-0.94). In addition, the majority of women perceived the questions to be acceptable and appropriate.

CONCLUSIONS

Findings demonstrate that the Modified E-HITS is promising as a low-burden tool for detecting of IPV perpetration among women veterans. This tool may help the Veterans Health Administration and other health care providers detect IPV perpetration and offer appropriate referrals for comprehensive assessment and services.

Employment Maintenance and Intimate Partner Violence

Intimate partner violence (IPV) is a major public health problem in the United States. Negative outcomes of IPV affect women's attainment and maintenance of employment. The purpose of this study was to develop a theoretical framework that described and explained the process by which women who have experienced IPV attain and maintain employment. Grounded theory methodology was used to analyze interviews of 34 women who had experienced IPV. Analysis suggested that women who had experienced IPV could attain employment; however, they had difficulty maintaining employment. Entanglement of work and IPV was experienced by all 34 participants because of the perpetrator controlling their appearance, sabotaging their work, interfering with their work, or controlling their finances. Some women described ways in which they disentangled work from IPV through a dynamic unraveling process, with periods of re-entanglement, resulting in job security and satisfaction.

Depression and Self-Rated Health Among Rural Women Who Experienced Adolescent Dating Abuse: A Mixed Methods Study

This study used mixed methods to examine the experiences and health of rural, young adult women (N = 100) who self-reported past experience of physical, emotional and verbal, sexual, and relational abuse in adolescent dating relationships. Few studies have examined the lasting health ramifications of adolescent dating abuse adolescent dating abuse in rural populations, and almost no mixed methods studies have explored adolescent dating abuse. Participants completed questionnaires on demographics, relationship behaviors, and mental health symptoms. A subsample (n = 10) of participants also completed semi-structured, in-depth interviews with the primary investigator. Results suggest that depressive symptoms and self-rating of health in these women are associated with particular kinds and severity of abusive experiences, and that adolescent dating abuse has ramifications for health and development beyond the duration of the original relationship. Self-rated health (SRH) was inversely associated with abusive behaviors in the relationship, whereas depressive symptoms were positively correlated with such behaviors. Self-rated health was also negatively correlated with depressive symptoms. The results of this study represent an important step toward establishing lifetime health risks posed by adolescent dating abuse.

Screening and intervening: evaluating a training program on intimate partner violence and reproductive coercion for family planning and home visiting providers

Project Connect training aims to reduce barriers to screening for and intervening with women with histories of intimate partner violence and reproductive coercion. This study sought to assess the effectiveness of trainings, provider facility with Project Connect tools, and areas for improvement in a pilot state. Results indicated that providers found training useful, and those in supervisory roles particularly appreciated the universal tools and skill set given to participants. Providing these tools supports the provision of trauma-informed care. Areas for improvement included increased emphasis on initiating screening, enhancing training for different types of providers, and developing follow-up training.

Bridging intimate partner violence and the human brain: a literature review

Past studies mainly focused on the physical and structural brain injuries in women survivors with a history of intimate partner violence (IPV), but little attention has been given to the biological impact and cognitive dysfunction resulting from such psychological stress. In this article, we aim to establish the connection between IPV and the brain by reviewing current literature examining (1) the biological mechanisms linking IPV, stress, and the brain; (2) the functional and anatomical considerations of the brain in abused women; and (3) the abused women's behavioral responses to IPV, including fear, pain, and emotion regulation, by utilizing functional neuroimaging. The major significance of this study is in highlighting the need to advance beyond self-reports and to obtain scientific evidence of the neurological impact and cognitive dysfunction in abused women with a history of IPV, an area in which current literature remains at a descriptive level.

Clinical utility of an intimate partner violence screening tool for female VHA patients

OBJECTIVES

Female Veterans are at high risk for physical, sexual, and psychological forms of intimate partner violence (IPV) victimization. This study evaluated the accuracy of a brief IPV victimization screening tool for use with female Veterans Health Administration (VHA) patients.

DESIGN

Participants completed a paper-and-pencil mail survey that included the four-item Hurt/Insult/Threaten/Scream (HITS) and the 39-item Revised Conflict Tactics Scales (CTS-2). Operating characteristics, including sensitivity and specificity, were calculated using the CTS-2 as the reference standard for past-year IPV.

PARTICIPANTS

Female veterans from a roster of randomly selected female patients of the New England VA Healthcare System. Women must have reported being in an intimate relationship in the past year to be included.

MAIN MEASURES

Primary measures included the HITS (index test) and the CTS-2 (reference standard).

KEY RESULTS

This study included 160 women. The percentage of women who reported past-year IPV, as measured by any physical assault, sexual coercion, and/or severe psychological aggression on the CTS-2, was 28.8 %. The receiver-operator characteristic curve demonstrated that the HITS cutoff score of 6 maximizes the true positives while minimizing the false positives in this sample. The sensitivity of the optimal HITS cutoff score of 6 was 78 % (95 % CI 64 % to 88 %), specificity 80 % (95 % CI 71 % to 87 %), positive likelihood ratio 3.9 (95 % CI 2.61 to 5.76), negative likelihood ratio 0.27 (95 % CI 0.16 to 0.47), positive predictive value 0.61 (95 % CI 0.47, 0.73), and negative predictive value 0.90 (95 % CI 0.82, 0.95).

CONCLUSIONS

For a low-burden screen, the HITS demonstrated good accuracy in detecting past-year IPV relative to the CTS-2 in a sample of female VHA patients with an optimal cutpoint of 6. The HITS may help VHA and other health-care providers detect past-year IPV and deliver appropriate care for female Veterans.

Experiences of health and health care among women exposed to intimate partner violence: qualitative findings from Germany

Through qualitative interviews with six female survivors of intimate partner violence (IPV) in Germany, we explored their experiences with health and health care within the context of a universal access health system. Using phenomenological analysis, we learned that they view violence as a burden on health; expect health professionals to acknowledge the link between IPV and health with empathy; and experience barriers to acute mental health services despite a lack of financial barriers in seeking treatment. We discuss how our findings compare with other international research, as well as the implications for the health care system's response to IPV.