"Made Me Feel Connected": A Qualitative Comparative Analysis of Intimate Partner Violence Routine Screening Pathways to Impact

'Important, but difficult': Swedish primary care professionals' perceptions and experiences of dealing with violence against women: an interview study

BACKGROUND

Men's violence against women is a global health problem causing physical, mental, sexual and reproductive ill-health. The World Health Organisation has estimated that every third woman in the world has been exposed to physical and/or sexual violence. Swedish primary care is central for victims of violence, as it is normally the first port of call for seeking healthcare. This requires professional competence on violence, and its causes. It also requires resources for working with violence prevention, disclosure and supportive actions. The aim of this study is to deepen the understanding of how primary care professionals in Sweden deal with violence against women. We analyse their viewpoints, experiences and practices of working with violence as a health problem, and especially if, and if so how, they ask patients about violence.

METHODS

A qualitative, explorative research design was adopted. Research interviews were conducted with 18 health professionals at eight primary care clinics. These clinics were located in four different regions, from the south to the north, in large urban areas, middle-size cities and rural areas. The interviews were voice recorded and transcribed verbatim. Thematic analysis was used to analyse the interviews.

RESULTS

Three themes, with a total of ten related sub-themes, were developed. These themes are: (a) Varying understandings and explanations of violence against women; (b) The tricky question of asking about violence; and (c) Multiple suggestions for improving primary care's work with violence against women. The awareness of violence varied considerably, with some practitioners being highly knowledgeable and having integrated violence into their everyday practice, whereas others were less knowledgeable and had not paid much attention to violence. The very naming of violence seemed to be problematic. Several suggestions for improvements at professional, managerial and organisational levels were articulated.

CONCLUSIONS

The results shed important light on the professionals' problems and struggles when dealing with violence against women in primary care. Better support and resources from the healthcare organisation, clearer leadership and more detailed policy would improve and facilitate everyday practice. All of these factors are indispensable for primary care's work with victims of men's violence against women.

Examining Cases of Child Physical Abuse Evaluations to Identify Opportunities to Improve Intimate Partner Violence Screening in Pediatric Emergency Departments

The association between child maltreatment and intimate partner violence (IPV) is well supported. Universal IPV screening has been recommended by the American Academy of Pediatrics and the United States Preventative Task Force, and many children's hospitals have established screening protocols. However, the yield and best screening method in families undergoing a child physical abuse (PA) evaluation have not been fully explored. To determine if there is a discrepancy in IPV disclosures between universal IPV screening completed during pediatric emergency department (PED) triage ("triage screening") and IPV screening by a social worker ("social work screening") in families of children who were evaluated for PA. Caregivers of children who presented to an urban tertiary PED and underwent an evaluation for PA via a child abuse pediatrics consult. A retrospective chart review was completed. Data collection included: caregiver responses to both triage screening and social work screening, interview setting details and participants, the child's injuries, and details of the family's reported IPV experiences. Our study (N = 329) revealed that social work screening produced significantly more positive IPV disclosures than triage screening (14.0% vs. 4.3%, p < .001). Additionally, non-IPV violence concerns were identified in 35.7% (n = 5) of the positive triage screens, whereas social work screens had none. These results highlight the benefits of IPV screening by social work in high-risk scenarios, such as child PA evaluations, regardless of universal IPV screening results. Exploring differences between the two screening methods can inform decisions about screening protocols to improve IPV identification in high-risk populations.

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

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

Exploration of barriers to screening for domestic violence in the perinatal period using an ecological framework

AIMS

To explore Australian healthcare providers' perspectives on factors that influence disclosure and domestic violence screening through the lens of Heise's (1998) integrated ecological framework.

DESIGN

This paper reports the findings that were part of a sequential mixed methods study with survey data informing interview questions. Participants for interviews were recruited after expressing an interest after completing surveys, as well as via snowball sampling.

METHODS

Semi-structured interviews were undertaken in 2017 with 12 practicing healthcare providers delivering care to women in the perinatal period in Greater Western Sydney, NSW, Australia. Data were analysed using Braun and Clarke's (2006) six-step thematic approach.

FINDINGS

The findings were framed within Heise's integrated ecological framework under four main themes. The main themes were 'Ontogenic: Factors preventing women from disclosing'; 'Microsystem: Factors preventing healthcare providers from asking'; 'Exosystem: Organizational structures not conducive to screening'; and 'Macrosystem: Cultural attitudes and socioeconomic influences affecting screening'.

CONCLUSION

Organizational policies are needed for better systems of reminding healthcare providers to enquire for domestic and family violence and mandating this within their practices. Mandatory domestic and family violence education and training that is suitable for the time constraints and learning needs of the healthcare provider is recommended for all healthcare providers caring for perinatal women. Further research is needed in addressing culturally specific barriers for healthcare providers to enquire about domestic and family violence in a culturally appropriate way.

PUBLIC AND PATIENT ENGAGEMENT AND INVOLVEMENT IN RESEARCH (PPEI)

No Patient or Public Contribution was embedded into the research reported in this paper as this research was specifically exploring healthcare providers' perspectives on domestic violence screening within their own practice experience.

Problem-Focused Coping Strategies Used by Victims of Gender Violence Across the Stages of Change

This study compares the problem-focused emotion regulation strategies used by 200 female survivors of intimate partner violence (age: M = 40.16, SD  =  11.27, 18 - 66 years) to cope with violence throughout various stages of change (SOC). It examines the relationship between problem-focused coping strategies and positive and negative affect, and the impact of these variables on the different SOC. Results suggest that victims differ and are flexible in the use of strategies throughout the various SOC. During the initial stages, victims tend to use passive/maladaptive behaviors that hamper change, while in the later stages they use more active/adaptive strategies to leave the abusive relationship.

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

OBJECTIVES

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

DESIGN

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

Effects of the COVID-19 Pandemic and Telehealth on Antenatal Screening and Services, Including for Mental Health and Domestic Violence: An Australian Mixed-Methods Study

Introduction

Australian antenatal care includes specific screening and service provision for domestic and family violence (DFV) and mental health. However, the COVID-19 pandemic resulted in major care changes, including greatly expanded telehealth. Given difficulties in a safe assessment and management of disclosures via telehealth, DFV and mental health service provision might be substantially impacted. This study therefore aimed to assess COVID-19 effects on DFV and mental health screening, as well as broader service provision from the perspective of local maternity service providers.

Methods

Mixed-methods study of staff surveys and interviews of staff directly involved in pregnancy care (doctors, midwives, and allied health) in three Sydney (Australia) maternity units, from October 2020 to March 2021. Surveys and interviews interrogated perceived effects of the COVID-19 pandemic on delivery (ensuring required services occurred), timeliness, and quality of (a) overall maternity care and (b) DFV and mental health screening and care; and also advantages and disadvantages of telehealth. Surveys were descriptively analyzed. Interviews were conducted online, recorded, and transcribed verbatim prior to thematic analysis.

Results

In total, 17 interviews were conducted and 109 survey responses were received. Breakdown of survey respondents was 67% of midwives, 21% of doctors, and 10% of allied health. Over half of survey respondents felt the pandemic had a negative effect on delivery, timeliness, and quality of overall pregnancy care, and DFV and mental health screening and management. Perceived telehealth positives included convenience for women (73%) and reducing women's travel times (69%). Negative features included no physical examination (90%), difficulty regarding non-verbal cues (84%), difficulty if interpreter required (71%), and unsure if safe to ask some questions (62%). About 50% felt telehealth should continue post-pandemic, but for <25% of visits. Those perceived suitable for telehealth were low-risk and multiparous women, whereas those unsuited were high-risk pregnancy, non-English speaking, and/or mental health/psychosocial/DFV concerns. “Change to delivery of care” was the central interview theme, with subthemes of impact on mental health/DFV screening, telehealth (both positive and negative), staff impact (e.g., continuity of care disruption), and perceived impact on women and partners.

Discussion

While telehealth may have an ongoing, post-pandemic role in Australian maternity care, staff believe that this should be limited in scope, mostly for low-risk pregnancies. Women with high risk due to physical health or mental health, DFV, and/or other social concerns were considered unsuited to telehealth.

Who is Being Screened for Intimate Partner Violence in Primary Care Settings? Secondary Data Analysis of a Cluster Randomised Trial

OBJECTIVES

To assess sociodemographic differences in postpartum women screened for intimate partner violence and who disclosed to their Maternal and Child Health nurses.

METHODS

Secondary analyses of survey data from women participating in a cluster randomised trial. The trial tested a nurse-designed, enhanced violence screening model-versus routine screening among eight community nurse clinics in Melbourne, Australia. Self-completion anonymous surveys were sent to all clinic attendees who had given birth in the previous eight months. We measured intimate partner violence with the Composite Abuse Scale and other sociodemographic variables. Multivariable logistic regression was used to analyse characteristics of screened versus unscreened women and those who did or did not disclose.

RESULTS

91 clinics (163 nurses) participated in the trial. 2621/10,472 (25%) women responded to the survey. Notable characteristics, such as level of intimate partner violence (AdjOR 1.14, CI 0.94-1.40), parity (AdjOR 1.13, CI 0.94-1.35), education (AdjOR 1.20 CI 0.91-1.58) and being born in Australia (AdjOR 0.94, CI 0.86-1.03) made no significant difference to screening. However, nurses were significantly less likely to screen women with a lower income than those with a higher one (AdjOR 0.59, CI 0.40-0.87) with a dose response relationship. Women on the lowest levels of income were significantly more likely to disclose abuse (AdjOR 3.06, CI 1.02-9.17), indicating missed opportunities for nurses to provide timely care.

CONCLUSIONS FOR PRACTICE

Despite being required to screen all women, nurses are almost twice as likely to screen more affluent women, who would be less likely to be experiencing or disclose intimate partner violence.

Understanding collaborative interactions in relation to research impact in social sciences and humanities: A meta-ethnography

The number and type of collaborations between researchers and stakeholders has increased significantly. This responds to the demand from policymakers, funders, and citizens that researchers should help to tackle important social issues (e.g. climate change, healthy aging). However, there is little knowledge about how collaboration processes are experienced, how we can theoretically conceptualize them, and how in this way we can develop efficient collaboration methods that contribute to solving urgent societal problems. In this meta-ethnography, we gathered relevant knowledge from carefully selected qualitative studies. A title/abstract analysis of 3422 articles from Web of Science and ProQuest led to the interpretative analysis of qualitative data from eight publications. The results of this study show that despite the need for a better understanding of complex collaborative interactions, the differences (or asymmetry) between organizations to which various partners belong hinder efficient collaboration. Bridging figures (brokers) can play an essential role if they succeed in drawing diverse stakeholders out of their organizational context into a new dimension that allows creativity and mutual understanding, but that also allows conflict and distortion. In ideal circumstances, this leads to a quasi-automatic transfer of knowledge between partners that takes place naturally and in both directions (knowledge diffusion).

Women's experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis

OBJECTIVE

To identify and synthesise the experiences and expectations of women victim/survivors of intimate partner abuse (IPA) following disclosure to a healthcare provider (HCP).

METHODS

The databases MEDLINE, Embase, CINAHL, PsychINFO, SocINDEX, ASSIA and the Cochrane Library were searched in February 2020. Included studies needed to focus on women's experiences with and expectations of HCPs after disclosure of IPA. We considered primary studies using qualitative methods for both data collection and analysis published since 2004. Studies conducted in any country, in any type of healthcare setting, were included. The quality of individual studies was assessed using an adaptation of the Critical Appraisal Skills Programme checklist for qualitative studies. The confidence in the overall evidence base was determined using Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-Confidence in the Evidence from Reviews of Qualitative Research methods. Thematic synthesis was used for analysis.

RESULTS

Thirty-one papers describing 30 studies were included in the final review. These were conducted in a range of health settings, predominantly in the USA and other high-income countries. All studies were in English. Four main themes were developed through the analysis, describing women's experiences and expectations of HCPs: (1) connection through kindness and care; (2) see the evil, hear the evil, speak the evil; (3) do more than just listen; and (4) plant the right seed. If these key expectations were absent from care, it resulted in a range of negative emotional impacts for women.

CONCLUSIONS

Our findings strongly align with the principles of woman-centred care, indicating that women value emotional connection, practical support through action and advocacy and an approach that recognises their autonomy and is tailored to their individual needs. Drawing on the evidence, we have developed a best practice model to guide practitioners in how to deliver woman-centred care. This review has critical implications for practice, highlighting the simplicity of what HCPs can do to support women experiencing IPA, although its applicability to low-income and-middle income settings remains to be explored.

Red flags and gut feelings-Midwives' perceptions of domestic and family violence screening and detection in a maternity department

BACKGROUND

Domestic and family violence (DFV) is known to escalate during pregnancy. Routine screening for DFV in maternity departments is a widely acceptable practice according to staff and women. This study is part of a 3-year follow-up of an organisational intervention evaluation and aimed to identify clinicians' perceptions of current practices, as well as barriers and enablers to DFV antenatal screening.

METHOD

Semi-structured interviews were conducted with ten midwives about conducting DFV screening within the maternity department of a large tertiary public hospital in Queensland, Australia. Interview transcripts were read and thematically analysed by two independent researchers.

RESULTS

Four main themes emerged from the data: uncertainty despite education and training; fear of opening Pandora's Box; working with 'red flags' and 'gut feelings'; and it's all about the relationship.

CONCLUSION

Although clinicians identified the importance of guidelines for managing DFV and knowledge of resources and services, confidence varied. Ongoing, formal, mandatory training in the area of DFV was highlighted. Managing partner presence in the room, building rapport with the woman, and time constraints continue to be challenging barriers to DFV detection. Routine screening, continuity of care, and staff knowledge and experience were major enablers to successful detection and response.

User-Involvement in the Development of a Culturally Sensitive Intervention in the Safe Pregnancy Study to Prevent Intimate Partner Violence

Intimate partner violence (IPV) during pregnancy has negative health impacts on the woman and the fetus. There is a lack of evidence supporting effective interventions to prevent IPV during pregnancy. This user-involvement study was conducted to get feedback on a culturally sensitive, tablet intervention containing questions about violence and safety-behaviors and a video promoting safety behaviors. This resulted in important feedback on the intervention content. Our findings show that women are in favor of disclosing IPV via a tablet. They suggested ways to address barriers for disclosure, such as safeguarding anonymity and creating a trustful relationship with the midwife.

Addressing Intimate Partner Violence and Power in Intimate Relationships in HIV Testing Services in Nairobi, Kenya

Intimate partner violence (IPV) undermines women’s uptake of HIV services and violates their human rights. In a two-arm randomized controlled trial we evaluated a short intervention that went a step beyond IPV screening to discuss violence and power with women receiving HIV testing services during antenatal care (ANC). The intervention included training and support for HIV counselors, a take-home card for clients, and an on-site IPV counselor. One third (35%) of women (N = 688) reported experiencing IPV in the past year; 6% were living with HIV. Among women experiencing IPV, program participants were more likely to disclose violence to their counselor than women receiving standard care (32% vs. 7%, p < 0.001). At second ANC visit, intervention group women were significantly more likely to report that talking with their counselor made a positive difference (aOR 2.9; 95% CI 1.8, 4.4; p < 0.001) and felt more confident in how they deserved to be treated (aOR 2.7; 95% CI 1.7, 4.4; p < 0.001). Exploratory analyses of intent to use ARVs to prevent mother-to-child transmission and actions to address violence were also encouraging.