Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature

Identifying the barriers faced by obstetricians and registrars in screening or enquiry of intimate partner violence in pregnancy: A systematic review of the primary evidence

INTRODUCTION

Intimate partner violence (IPV) disproportionally affects women compared to men. The impact of IPV is amplified during pregnancy. Screening or enquiry in the antenatal outpatient setting regarding IPV has been fraught with barriers that prevent recognition and the ability to intervene.

AIMS

The aim of this systematic review was to determine the barriers that face obstetricians/gynaecologists regarding enquiry of IPV in antenatal outpatient settings. The secondary objective was to determine facilitators.

METHODS

Primary evidence was searched using Ovid MEDLINE, Ovid Maternity and Infant Care, PubMed and Proquest from 1993 to May 2023. The included studies comprised empirical studies published in English language targeting a population of doctors providing antenatal outpatient care. The review was PROSPERO-registered (CRD42020188994). Independent screening and review was performed by two authors. The findings were analysed thematically.

RESULTS

Nine studies addressing barriers and two studies addressing facilitators were included: three focus-group or semi-structured interviews, six surveys and two randomised controlled trials. Barriers for providers centred at the system level (time, training), provider level (personal beliefs, cultural bias, experience) and provider-perceived patient level (fear of offending, patient readiness to disclose). Increased experience and the use of validated tools were strong facilitators.

CONCLUSION

Barriers to screening reflect multi-level obstruction to the identification of women exposed to IPV. Although the antenatal outpatient clinic setting addresses a particular population vulnerable to IPV, the barriers for obstetricians are not unique. The use of validated cueing tools provides an evidence-based method to facilitate enquiry of IPV among antenatal women, assisting in identification by clinicians. Together with education and human resources, such aids build capacity in women and obstetric providers.

Emergency Department staff experiences of screening and response for intimate partner violence in a multi-site feasibility study: Acceptability, enablers and barriers

BACKGROUND

Intimate partner violence is a lead cause of ill health and premature death among Australian women. Abused women are likely to present to Emergency Departments. Routine screening provides opportunities to identify and respond to intimate partner violence.

METHODS

A six-month screening feasibility study was conducted in two rural and one urban NSW Emergency Departments. Surveys with participating nurses, medical officers and social workers, as well as focus groups with nurses and social workers were conducted at each site to understand their experience.

RESULTS

Survey respondents (n = 198) agreed it was appropriate (87%) and acceptable (91%) to screen for intimate partner violence in Emergency Departments. Overall 62% of respondents suggested screening had positive impacts on womens' care. Focus group discussions with 39 nurses and social workers identified enablers of screening as: ease of use of the screening tool; availability of social work response within one hour (as per the study protocol); and executive support. Barriers were: high patient volume; lack of integration with existing processes; lack of privacy and brevity of training.

CONCLUSIONS

Screening in Emergency Departments was strongly supported by health practitioners who responded to the survey. Work is needed to address competing demands, integration of screening processes, and staff training.

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.

Challenges of Using Videos in Exam Rooms of Safety-Net Clinics to Encourage Patient Self-Disclosure of Intimate Partner Violence and to Increase Provider Screening

Identifying intimate partner violence (IPV) in clinics allows for early intervention. We tested a comprehensive approach in five safety-net clinics to encourage female victims to self-identify and providers to screen. The main components were (a) short, multilingual videos for female patients; (b) provider training; and (c) management tools. Although videos were viewed 2,150 times, only 9% of eligible patients watched them. IPV disclosure increased slightly (6%). Lack of internal champions, high turnover, increased patient load, and technological challenges hindered outcomes. Safety-net clinics need feasible methods to encourage IPV screening. Management champions and IT support are essential for video-based activities.

The Implementation of an Interpersonal Violence Screening Program in Primary Care Settings: Lessons Learned

BACKGROUND

Interpersonal violence (IPV) is a public health issue that disproportionately affects women. IPV screening improves likelihood of survivor disclosure and access to additional support. To enhance primary care IPV screening, Technology Enhanced Screening and Supportive Assistance (TESSA) uses integrated technological systems to deliver bidirectional, evidence-informed health navigation, health management, and safety interventions. This study evaluates TESSA implementation in primary care clinics using the Consolidated Framework for Implementation Research (CFIR).

METHOD

CFIR is a metatheoretical framework used for evaluating clinical intervention implementation. Salient constructs within CFIR's five domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified (23 constructs), and pertinent implementation details were examined.

RESULTS

Key lessons learned included intervention characteristic constructs like intervention source (e.g., selecting tablets that can screen for items integral to the program's aims) and adaptability (e.g., ensuring tablets worked with electronic medical records for each clinic), process constructs like engaging champions (e.g., garnering buy-in from key clinic stakeholders and staff), outer setting constructs like patient needs and resources (e.g., addressing pertinent patient resource needs) and external policies and incentives (e.g., incentivizing clinics by addressing clinic needs), and inner setting constructs like leadership engagement (e.g., ensuring buy-in from organizational leaders as leadership changed frequently).

CONCLUSIONS

CFIR identifies important implementation factors for programs like TESSA that screen for high-risk populations and implement in primary care settings. The TESSA program implementation permits increased IPV screening among primary health care populations, thus promoting access to resources for otherwise hard-to-reach populations.

Identification and Management of Domestic and Sexual Violence in Primary Care in the #MeToo Era: an Update

PURPOSE OF REVIEW

We discuss recent evidence around the identification and response to domestic and sexual violence in primary care for perpetrators and victims, in the context of feminist social media movements such as #MeToo.

RECENT FINDINGS

There is no recent research on identification and response to perpetrators in health settings. There is some limited recent evidence for how health settings can address domestic and sexual violence for female victims and their children. Recent studies of mixed quality focus on advocacy and empowerment, integrated interventions (with alcohol and drug misuse) and couples counselling for domestic violence and cognitive behavioural or processing therapy for sexual violence. Further research on perpetrator interventions in primary care is urgent. Larger sample sizes and a focus on sexual violence are needed to develop the evidence base for female survivors. Clinicians need to ask about violence and provide a first-line response depending on the patient's needs.

Screening for social determinants of health in clinical care: moving from the margins to the mainstream

Background

Screening for the social determinants of health in clinical practice is still widely debated.

Methods

A scoping review was used to (1) explore the various screening tools that are available to identify social risk, (2) examine the impact that screening for social determinants has on health and social outcomes, and (3) identify factors that promote the uptake of screening in routine clinical care.

Results

Over the last two decades, a growing number of screening tools have been developed to help frontline health workers ask about the social determinants of health in clinical care. In addition to clinical practice guidelines that recommend screening for specific areas of social risk (e.g., violence in pregnancy), there is also a growing body of evidence exploring the use of screening or case finding for identifying multiple domains of social risk (e.g., poverty, food insecurity, violence, unemployment, and housing problems).

Conclusion

There is increasing traction within the medical field for improving social history taking and integrating more formal screening for social determinants of health within clinical practice. There is also a growing number of high-quality evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels.

Silent Survivors

Early in my medical training, I cared for a patient who survived a brutal sexual assault necessitating ICU level care. Months later, I was raped. This essay is a reflection on my experience as a survivor of sexual violence and as a provider for patients whose wounds from these traumas have flourished in atmospheres of shame and stigma. In this essay, I further explore how physicians and other health care providers can play a central role in restoring the health of individuals who silently suffer after these unspeakable events.

Experience of domestic violence routine screening in Family Planning NSW clinics

BACKGROUND

This study reviewed implementation of the Domestic Violence Routine Screening (DVRS) program at Family Planning NSW and outcomes of screening to determine the feasibility of routine screening in a family planning setting and the suitability of this program in the context of women's reproductive and sexual health.

METHODS

A retrospective review of medical records was undertaken of eligible women attending Family Planning NSW clinics between 1 January and 31 December 2015. Modified Poisson regression was used to estimate prevalence ratios and assess association between binary outcomes and client characteristics.

RESULTS

Of 13440 eligible women, 5491 were screened (41%). Number of visits, clinic attended, age, employment status and disability were associated with completion of screening. In all, 220 women (4.0%) disclosed domestic violence. Factors associated with disclosure were clinic attended, age group, region of birth, employment status, education and disability. Women who disclosed domestic violence were more likely to have discussed issues related to sexually transmissible infections in their consultation. All women who disclosed were assessed for any safety concerns and offered a range of suitable referral options.

CONCLUSION

Although routine screening may not be appropriate in all health settings, given associations between domestic violence and sexual and reproductive health, a DVRS program is considered appropriate in sexual and reproductive health clinics and appears to be feasible in a service such as Family Planning NSW. Consistent implementation of the program should continue at Family Planning NSW and be expanded to other family planning services in Australia to support identification and early intervention for women affected by domestic violence.

Intimate Partner Violence Screening Practices in California After Passage of the Affordable Care Act

Under the Affordable Care Act (ACA), insurance coverage should include screening for intimate partner violence (IPV). In this article, we present self-reported IPV screening practices and provider confidence from a post-ACA cross-sectional survey of 137 primary care clinicians in California. Only 14% of the providers reported always screening female patients for IPV and about one third seemed never to screen. Female providers were more likely to screen and use recommended direct questioning. Most providers lacked confidence in screening, referral, and record-keeping. Serving a low-income population predicted more frequent screening and better record-keeping. Overall, IPV screening in primary care was inadequate and needs attention.

Understanding sustained domestic violence identification in maternal and child health nurse care: process evaluation from a 2-year follow-up of the MOVE trial

AIM

To investigate factors contributing to the sustained domestic violence screening and support practices of Maternal and Child Health nurses 2 years after a randomized controlled trial.

BACKGROUND

Domestic violence screening by healthcare professionals has been implemented in many primary care settings. Barriers to screening exist and screening rates remain low. Evidence for longer term integration of nurse screening is minimal. Trial outcomes showed sustained safety planning behaviours by intervention group nurses.

DESIGN

Process evaluation in 2-year follow-up of a cluster randomized controlled trial.

METHODS

Evaluation included a repeat online nurse survey and 14 interviews (July-September 2013). Survey analysis included comparison of proportionate group difference between arms and between trial baseline and 2 year follow-up surveys. Framework analysis was used to assess qualitative data. Normalization Process Theory informed evaluation design and interpretation of results.

RESULTS

Survey response was 77% (n = 123/160). Sustainability of nurse identification of domestic violence appeared to be due to greater nurse discussion and domestic violence disclosure by women, facilitated by use of a maternal health and well-being checklist. Over time, intervention group nurses used the maternal checklist more at specific maternal health visits and found the checklist the most helpful resource assisting their domestic violence work. Nurses' spoke of a degree of 'normalization' to domestic violence screening that will need constant investment to maintain.

CONCLUSION

Sustainable domestic violence screening and support outcomes can be achieved in an environment of comprehensive, nurse designed and theory driven implementation. Continuing training, discussion and monitoring of domestic violence work is needed to retain sustainable practices.

Creating a Trauma-Sensitive Practice: A Health Care Response to Interpersonal Violence

Interpersonal violence has a profoundly negative impact on individuals and our society. Health care providers are in a unique position to identify interpersonal violence, support survivors, and to contribute to violence prevention. The purpose of this article is to describe the nature, scope, and impact of interpersonal violence, its subsequent trauma on individuals, families, and society, and to delineate how providers can apply trauma-sensitive practice. The authors provide definitions, examples and prevalence rates and review theories of violence and violence prevention. They describe how to create a trauma-sensitive practice by being aware of the trauma that accompanies violence, the barriers to violence prevention, and how to intervene with patients about violence. Providers are urged to adopt universal screening practices, educate themselves on the nature of interpersonal violence and engage in screening, education, collaboration, and social justice activities to reduce interpersonal violence. Resources are provided to assist health care organizations, providers, and patients in addressing interpersonal violence.

Screening women for intimate partner violence in healthcare settings

BACKGROUND

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects.

OBJECTIVES

To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm.

SEARCH METHODS

On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI).

MAIN RESULTS

We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.Only one study reported on women's health with no differences observable at 18 months.Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation.

AUTHORS' CONCLUSIONS

The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, lack of harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings.

Maternal and child health nurse screening and care for mothers experiencing domestic violence (MOVE): a cluster randomised trial

BACKGROUND

Mothers are at risk of domestic violence (DV) and its harmful consequences postpartum. There is no evidence to date for sustainability of DV screening in primary care settings. We aimed to test whether a theory-informed, maternal and child health (MCH) nurse-designed model increased and sustained DV screening, disclosure, safety planning and referrals compared with usual care.

METHODS

Cluster randomised controlled trial of 12 month MCH DV screening and care intervention with 24 month follow-up. The study was set in community-based MCH nurse teams (91 centres, 163 nurses) in north-west Melbourne, Australia. Eight eligible teams were recruited. Team randomisation occurred at a public meeting using opaque envelopes. Teams were unable to be blinded. The intervention was informed by Normalisation Process Theory, the nurse-designed good practice model incorporated nurse mentors, strengthened relationships with DV services, nurse safety, a self-completion maternal health screening checklist at three or four month consultations and DV clinical guidelines. Usual care involved government mandated face-to-face DV screening at four weeks postpartum and follow-up as required. Primary outcomes were MCH team screening, disclosure, safety planning and referral rates from routine government data and a postal survey sent to 10,472 women with babies ≤ 12 months in study areas. Secondary outcomes included DV prevalence (Composite Abuse Scale, CAS) and harm measures (postal survey).

RESULTS

No significant differences were found in routine screening at four months (IG 2,330/6,381 consultations (36.5 %) versus CG 1,792/7,638 consultations (23.5 %), RR = 1.56 CI 0.96-2.52) but data from maternal health checklists (n = 2,771) at three month IG consultations showed average screening rates of 63.1 %. Two years post-intervention, IG safety planning rates had increased from three (RR 2.95, CI 1.11-7.82) to four times those of CG (RR 4.22 CI 1.64-10.9). Referrals remained low in both intervention groups (IGs) and comparison groups (CGs) (<1 %). 2,621/10,472 mothers (25 %) returned surveys. No difference was found between arms in preference or comfort with being asked about DV or feelings about self.

CONCLUSION

A nurse-designed screening and care model did not increase routine screening or referrals, but achieved significantly increased safety planning over 36 months among postpartum women. Self-completion DV screening was welcomed by nurses and women and contributed to sustainability.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12609000424202, 10/03/2009.

Medical Students’ Beliefs About Screening for Intimate Partner Violence

Researchers have found that medical students who have received training on intimate partner violence (IPV) report greater comfort with screening for IPV and improved IPV interviewing skills than their counterparts. However, less is known about medical students’ beliefs toward screening female patients for IPV and behavioral intention to screen. Semistructured, qualitative interviews were conducted with medical students to assess their beliefs, using the theory of planned behavior and social cognitive theory as theoretical frameworks for the interview questions. Most students felt that screening for IPV could help identify victims but could also potentially offend patients. Perceived barriers to screening included time and negative patient reactions, while perceived facilitators to screening included receiving IPV training and provision of IPV screening questionnaires while interviewing patients. Interviewees identified physicians as both supporters and nonsupporters of IPV screening. Behavioral intention scores ranged from 17 to 50 out of a possible 11 to 55. Findings from the study can help inform the IPV training needs of medical students.

Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial

BACKGROUND

Evidence for a benefit of interventions to help women who screen positive for intimate partner violence (IPV) in health-care settings is limited. We assessed whether brief counselling from family doctors trained to respond to women identified through IPV screening would increase women's quality of life, safety planning and behaviour, and mental health.

METHODS

In this cluster randomised controlled trial, we enrolled family doctors from clinics in Victoria, Australia, and their female patients (aged 16-50 years) who screened positive for fear of a partner in past 12 months in a health and lifestyle survey. The study intervention consisted of the following: training of doctors, notification to doctors of women screening positive for fear of a partner, and invitation to women for one-to-six sessions of counselling for relationship and emotional issues. We used a computer-generated randomisation sequence to allocate doctors to control (standard care) or intervention, stratified by location of each doctor's practice (urban vs rural), with random permuted block sizes of two and four within each stratum. Data were collected by postal survey at baseline and at 6 months and 12 months post-invitation (2008-11). Researchers were masked to treatment allocation, but women and doctors enrolled into the trial were not. Primary outcomes were quality of life (WHO Quality of Life-BREF), safety planning and behaviour, mental health (SF-12) at 12 months. Secondary outcomes included depression and anxiety (Hospital Anxiety and Depression Scale; cut-off ≥8); women's report of an inquiry from their doctor about the safety of them and their children; and comfort to discuss fear with their doctor (five-point Likert scale). Analyses were by intention to treat, accounting for missing data, and estimates reported were adjusted for doctor location and outcome scores at baseline. This trial is registered with the Australian New Zealand Clinical Trial Registry, number ACTRN12608000032358.

FINDINGS

We randomly allocated 52 doctors (and 272 women who were eligible for inclusion and returned their baseline survey) to either intervention (25 doctors, 137 women) or control (27 doctors, 135 women). 96 (70%) of 137 women in the intervention group (seeing 23 doctors) and 100 (74%) of 135 women in the control group (seeing 26 doctors) completed 12 month follow-up. We detected no difference in quality of life, safety planning and behaviour, or mental health SF-12 at 12 months. For secondary outcomes, we detected no between-group difference in anxiety at 12 months or comfort to discuss fear at 6 months, but depressiveness caseness at 12 months was improved in the intervention group compared with the control group (odds ratio 0·3, 0·1-0·7; p=0·005), as was doctor enquiry at 6 months about women's safety (5·1, 1·9-14·0; p=0·002) and children's safety (5·5, 1·6-19·0; p=0·008). We recorded no adverse events.

INTERPRETATION

Our findings can inform further research on brief counselling for women disclosing intimate partner violence in primary care settings, but do not lend support to the use of postal screening in the identification of those patients. However, we suggest that family doctors should be trained to ask about the safety of women and children, and to provide supportive counselling for women experiencing abuse, because our findings suggest that, although we detected no improvement in quality of life, counselling can reduce depressive symptoms.

FUNDING

Australian National Health and Medical Research Council.

Posttraumatic stress and depression symptoms as correlates of deliberate self-harm among community women experiencing intimate partnerviolence

Deliberate self-harm (DSH) among women in the general population is correlated separately with posttraumatic stress, depression, and abuse during childhood and adulthood. The prevalence of these DSH correlates is particularly high among women exposed to intimate partner violence (IPV), yet few studies have examined DSH among this high-risk population and none have examined these correlates simultaneously. Two hundred and twelve IPV-victimized women in the community participated in a 2-h retrospective interview. One-third reported current or past DSH. Discriminant analysis was used to examine which posttraumatic stress and depression symptoms and types of current IPV and childhood abuse were uniquely associated with current DSH. Findings show that women who currently use DSH reported greater severity of posttraumatic stress numbing symptoms and more severe sexual IPV compared to women who used DSH only in the past. Examining factors that are associated with women's current DSH in this population is critical so that a focus on DSH can be integrated into the treatment plans of women who are receiving mental health care, but also so that women who are not receiving such care can be referred to adequate mental health services.

Enhanced maternal and child health nurse care for women experiencing intimate partner/family violence: protocol for MOVE, a cluster randomised trial of screening and referral in primary health care

BACKGROUND

Intimate partner violence (IPV) can result in significant harm to women and families and is especially prevalent when women are pregnant or recent mothers. Maternal and child health nurses (MCHN) in Victoria, Australia are community-based nurse/midwives who see over 95% of all mothers with newborns. MCHN are in an ideal position to identify and support women experiencing IPV, or refer them to specialist family violence services. Evidence for IPV screening in primary health care is inconclusive to date. The Victorian government recently required nurses to screen all mothers when babies are four weeks old, offering an opportunity to examine the effectiveness of MCHN IPV screening practices. This protocol describes the development and design of MOVE, a study to examine IPV screening effectiveness and the sustainability of screening practice.

METHODS/DESIGN

MOVE is a cluster randomised trial of a good practice model of MCHN IPV screening involving eight maternal and child health nurse teams in Melbourne, Victoria. Normalisation Process Theory (NPT) was incorporated into the design, implementation and evaluation of the MOVE trial to enhance and evaluate sustainability. Using NPT, the development stage combined participatory action research with intervention nurse teams and a systematic review of nurse IPV studies to develop an intervention model incorporating consensus guidelines, clinical pathway and strategies for individual nurses, their teams and family violence services. Following twelve months' implementation, primary outcomes assessed include IPV inquiry, IPV disclosure by women and referral using data from MCHN routine data collection and a survey to all women giving birth in the previous eight months. IPV will be measured using the Composite Abuse Scale. Process and impact evaluation data (online surveys and key stakeholders interviews) will highlight NPT concepts to enhance sustainability of IPV identification and referral. Data will be collected again in two years.

DISCUSSION

MOVE will be the first randomised trial to determine IPV screening effectiveness in a community based nurse setting and the first to examine sustainability of an IPV screening intervention. It will further inform the debate about the effectiveness of IPV screening and describe IPV prevalence in a community based post-partum and early infant population.

TRIAL REGISTRATION

ACTRN12609000424202.

Council-based approaches to reforming the health care response to domestic violence: promising findings and cautionary tales

Councils are commonly formed to address social issues including intimate partner violence (IPV). Research suggests that councils may be well positioned to achieve proximal outcomes, but that their success may depend on contextual factors. The current study compared providers and health care settings at two points in time to explore the degree to which the Health Care Council achieved proximal outcomes in the health care response to IPV, including: (a) providers' reported capacity to screen for IPV, (b) providers' beliefs about IPV as a health care issue and about the IPV screening process, (c) providers' screening behaviors and (d) organizational policies and protocols to encourage screening. This study, while preliminary, provides support for council-based efforts to stimulate change in the health care response to IPV and also highlights the central role that organizational environment plays in shaping desired outcomes.

Nurses' preparedness to care for women exposed to Intimate Partner Violence: a quantitative study in primary health care

BACKGROUND

Intimate partner violence (IPV) has a deep impact on women's health. Nurses working in primary health care need to be prepared to identify victims and offer appropriate interventions, since IPV is often seen in primary health care. The aim of the study was to assess nurses' preparedness to identify and provide nursing care to women exposed to IPV who attend primary health care.

METHOD

Data was collected using a questionnaire to nurses at the primary health care centres. The response rate was 69.3%. Logistic regression analysis was used to test relationships among variables.

RESULTS

Shortcomings were found regarding preparedness among nurses. They lacked organisational support e.g. guidelines, collaboration with others and knowledge regarding the extensiveness of IPV. Only half of them always asked women about violence and mostly when a woman was physically injured. They felt difficulties to know how to ask and if they identified violence they mostly offered the women a doctor's appointment. Feeling prepared was connected to obtaining knowledge by themselves and also to identifying women exposed to IPV.

CONCLUSION

The majority of the nurses were found to be quiet unprepared to provide nursing care to women exposed to IPV. Consequences might be treatment of symptoms but unidentified abuse and more and unnecessary suffering for these women. Improvements are needed on both at the level of the organisation and individual.

Comparison of screening and referral strategies for exposure to partner violence

BACKGROUND

Although 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.

METHODS

Using 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.

RESULTS

Of 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.

CONCLUSION

A-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.

Physician practices in response to intimate partner violence in southern India: insights from a qualitative study

Health care providers in India are often the only institutional contact for women experiencing intimate partner violence, a pervasive public health problem with adverse health outcomes. This qualitative study was among the first to examine Indian primary care physicians' intimate partner violence practices. Between July 2007 and January 2008, 30 in-depth interviews were conducted with physicians serving low-to-middle income women aged 18-30 in southern India. A modified grounded theory approach was used for data collection and analysis. Study findings revealed a distinct subset of 'physician champions' who responded to intimate partner violence more consistently, informed women of their rights, and facilitated their utilization of support services. Findings also offered insights into physicians' ability to identify indications of intimate partner violence and use of potentially culturally appropriate practices to respond to intimate partner violence, even without training. However, physician practices were mediated by individual attitudes. Although not generalizable, findings offer some useful lessons which may be transferable for adaptation to other settings. A potential starting point is to study physicians' current practices, focusing on their safety and efficacy, as well as enhancing these practices through appropriate training. Further research is also needed on women's perspectives on the appropriateness of physicians' practices, and women's recommendations for intimate partner violence intervention strategies.

Universal screening for intimate partner violence: a systematic review

Intimate partner violence (IPV) is known to be prevalent among therapy-seeking populations. Yet, despite a growing understanding of the dynamics of IPV and of the acceptability of screening, universal screening practices have not been systematically adopted in family therapy settings. A rapidly growing body of research data-almost entirely conducted in medical settings-has investigated attitudes and practices regarding universal screening for IPV. This article is a systematic review of the IPV universal screening research literature. The review summarizes literature related to IPV screening rates and practices, factors associated with provider screening practice, the role of training and institutional support on screening practice, impact of screening on disclosure rates, client beliefs and preferences for screening, and key safety considerations and screening competencies. Implications for family therapy and recommendations for further inquiry and screening model development are provided.

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

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

Pandora doesn't live here anymore: normalization of screening for intimate partner violence in Australian antenatal, mental health, and substance abuse services

Routine screening for intimate partner violence (IPV) has been widely introduced in health settings, yet screening rates are often low. A screening policy was introduced statewide in Australia in antenatal, mental health, and substance abuse services. Annual snapshot indicates a sustained screening rate of 62%-75% since 2003. Focus group research with health care workers from 10 services found that initial introduction of screening was facilitated by brief, scripted questions embedded into assessment schedules, training, and access to referral services. Over time, familiarity and women's favorable reactions reinforced practice. Barriers remain, including lack of privacy, tensions about limited confidentiality, and frustration when women remain unsafe. Screening added to the complexity of work, but was well accepted by workers, and increased awareness of and responsiveness to IPV.

The elusive search for definitive evidence on routine screening for intimate partner violence

Routine screening for intimate partner violence (IPV) has been introduced in many health settings to improve identification and responsiveness to IPV. The debate about the level of evidence required to warrant routine screening continues. Three assumptions have impeded progress in measuring the impact of screening. The first is that routine screening is a test only which does not of itself have an impact on patients. The second is that it can be assessed by evaluating interventions provided to women after abuse is identified through screening. The third is that there can be an agreed appropriate intervention for IPV. Each of these assumptions is problematic. In addition, there are significant impediments to evaluating screening as an intervention through a randomized control trial. These include identification of the study group, isolating the control group from the intervention, ethics, lack of baseline data, and recall bias. A range of study designs is required and a rethink of assumptions is needed in researching this area.

Domestic Violence Screening and Treatment in the Workplace

The purpose of this study was to survey occupational health nurses about their perceived ability to screen for and treat domestic violence in the workplace. Occupational health nurses providing direct care or case management anonymously responded to the mailed Occupational Health Nurses' Survey on Screening for Domestic Violence in the Workplace. Findings indicate that occupational health nurses consider domestic violence screening and treatment to be components of their nursing role, but do not believe they have adequate training to competently care for workers who have experienced domestic violence. The occupational health nurses also did not believe policies existed in their workplace to assist them in treating these workers. Findings from this study can be used as the foundation for domestic violence education, policy development, and intervention research.

The NSW Health routine screening for domestic violence program

Routine questioning of women about abuse by their intimate partner has been progressively introduced in NSW in antenatal, early childhood, alcohol and other drug and mental health services since 2001. This was done because of the serious health consequences of domestic violence and the low identification rate of abuse by health services. Following a pilot that found strong support from female patients, this strategy is now well established in NSW public health services. Recent data indicate that approximately 10,000 women a month are asked these questions and that 7.3% of them report experiences of physical abuse or fear caused by their partner or ex-partner within the past 12 months.

Interactions between victims of intimate partner violence against women and the health care system: policy and practice implications

Intimate partner violence (IPV) affects the use of health care by increasing the risk of poor health outcomes. IPV victims seek health services as often as others but are less likely to receive needed services, more likely to overuse services, and more likely to have a poor relationship with their health care provider. This stems from patient and provider barriers to care that are exacerbated by the lack of a clear and consistent health care system response to IPV. Most health care systems are not equipped to assist either victims or providers seeking to help victims. There are a few models of system-wide interventions, but these are not the current standard. A strong health policy framework is needed, but the decision of the U.S. Preventative Task Force not to recommend universal screening is a setback. Overall, there is limited progress in moving the health care system toward assisting IPV victims.

Health disparities and violence against women: why and how cultural and societal influences matter

This article encourages readers to consider the cultural and societal influences that impact health and health disparities among women survivors of intimate partner violence (IPV). Health consequences caused by IPV are widely documented and broadly discussed. Connections between health disparities and IPV are also discussed as related to women of color. Cultural factors and societal influences are identified to provide the reader with greater awareness of how these issues intersect with and impact IPV. Finally, the implications for scientific research and practice are discussed to include considerations for stronger assessment tools, greater collaboration and community participation, determination of best practices, requirement of cultural competence, mandated accountability, encouragement of mentorship, increased funding for research, increased advocacy, and increased culturally competent media and health promotion campaigns.

Individualized performance feedback to increase prenatal domestic violence screening

OBJECTIVES

Universal domestic violence (DV) screening once per trimester of pregnancy is recommended but rarely accomplished. Clinical leaders in this setting sought to improve adherence with this protocol. This prospective study used medical record audit and individualized performance feedback with peer comparison (IPF) to improve DV screening among first and second year obstetrics and gynecology (ob/gyn) residents.

METHODS

The setting is a northeastern, urban, hospital-based, prenatal clinic serving low-income women. Most patients are Latina (75%); 11% are black and 9% are white. Few begin care in the first trimester (8.5%). We gave all residents DV training. Next we gave IPF-four reports at seven-week intervals. We reviewed medical record notes on patient visits corresponding to the first medical encounter and week 16 and week 28 of pregnancy. We used this data to compare screening immediately before IPF and following each IPF report.

RESULTS

Screening increased steadily over time, from 60% of appropriate visits before IPF to 91% after the fourth report (Chi Square 28.4, p<.001). Adjusting for key factors, the odds of screening after the last IPF report were seven and a half times greater than the odds of screening before IPF (Odds Ratio: 7.6; 95% Confidence Interval: 3.0, 19.0).

CONCLUSIONS

IPF was associated with increased DV screening among first and second year ob/gyn residents in this setting. Increased screening improved compliance with the clinic protocol and increased opportunities for patient disclosure, education, and treatment, critical public health objectives.