Intimate Partner Violence: A Clinical Review of Screening and Intervention

Intimate Partner Violence: A Risk Factor for Gestational Diabetes

The early detection and management of gestational diabetes mellitus (GDM) is an important public health goal. GDM, which is defined as a glucose intolerance that develops during pregnancy, affects about 14% of pregnancies globally, and without effective treatment, it is associated with adverse short- and long-term maternal and neonatal outcomes. Risk-factor screening is an acceptable and affordable strategy to enable risk stratification and intervention. However, common biological risk factors such as overweight or obesity, excessive gestational weight gain, and family history of diabetes often have poor predictive ability, failing to identify a large proportion of women at risk of developing GDM. Accumulating evidence implicate psychosocial factors in contributing to GDM risk. As such, intimate partner violence (IPV), through its contributing effects on maternal stress and depression, presents a plausible risk factor for GDM. Experiencing IPV during pregnancy may dysregulate the hypothalamus-pituitary-adrenal (HPA) axis, leading to increased cortisol secretion and insulin resistance. These effects may exacerbate the insulin-resistant environment characteristic of pregnancy, thus increasing GDM risk. This review explores the relationship between IPV and GDM. We highlight studies that have linked IPV with GDM and propose a biological mechanism that connects IPV and GDM. Recommendations for IPV screening strategies to prevent GDM are discussed.

Computerized intervention for reducing intimate partner victimization for perinatal women seeking mental health treatment: A multisite randomized clinical trial protocol

Intimate partner victimization (IPV) is a significant social and public health problem among perinatal women. Research suggests that 21% to 33% of perinatal women report IPV and there is an enormous amount of morbidity associated with IPV. Moreover, IPV places women at high risk for several psychiatric disorders, which transforms the perinatal period from an already challenging process into a potentially overwhelming one. Further, IPV and untreated mental illness during the perinatal period pose a dual risk of adverse physical and emotional outcomes for women and their developing fetus/infant. Given the high rates of IPV among women who seek mental health treatment, mental health clinics compared to other medical settings are more effective sites for focused case finding and intervention. Our team has successfully tested an innovative, computerized intervention, Strength for U in Relationship Empowerment (SURE). SURE is a brief, interactive program consistent with motivational interviewing and incorporates empowerment strategies. The proposed multisite randomized clinical trial (N = 186) will test whether SURE relative to control is associated with reduced IPV, greater positive affect and well-being, and greater perceived emotional support. We will also evaluate the role of theoretical mediators of empowerment and self-efficacy. Finally, we will estimate the resources needed and costs to deliver SURE, as well as the incremental cost effectiveness of SURE compared with treatment as usual. If SURE is found to be efficacious and cost effective, it can be easily integrated into clinical care and will fill a critical gap for a vulnerable, high-risk population.

A randomized controlled trial of a computer-based brief intervention for victimized perinatal women seeking mental health treatment

Intimate partner victimization (IPV) during the perinatal period is associated with adverse outcomes for the woman, her developing fetus, and any children in her care. Maternal mental health concerns, including depression and anxiety, are prevalent during the perinatal period particularly among women experiencing IPV. Screening and interventions for IPV targeting women seeking mental health treatment are lacking. In the current study, we examine the feasibility, acceptability, and the preliminary efficacy of a brief, motivational computer-based intervention, SURE (Strength for U in Relationship Empowerment), for perinatal women with IPV seeking mental health treatment. The study design was a two-group, randomized controlled trial with 53 currently pregnant or within 6-months postpartum women seeking mental health treatment at a large urban hospital-based behavioral health clinic for perinatal women. Findings support the acceptability and feasibility of the SURE across a number of domains including content, delivery, and retention. All participants (100%) found the information and resources in SURE to be helpful. Our preliminary results found the degree of IPV decreased significantly from baseline to the 4-month follow-up for the SURE condition (paired t-test, p < 0.001), while the control group was essentially unchanged. Moreover, there was a significant reduction in emotional abuse for SURE participants (p = 0.023) relative to participants in the control condition. There were also reductions in physical abuse although non-significant (p = 0.060). Future work will test SURE in a larger, more diverse sample. ClinicalTrials.gov Identifier: NCT02370394.

Health-Sector Responses to Intimate Partner Violence: Fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?

This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: a realist case-study

Background

Despite the progress made on policies and programmes to strengthen primary health care teams’ response to Intimate Partner Violence, the literature shows that encounters between women exposed to IPV and health-care providers are not always satisfactory, and a number of barriers that prevent individual health-care providers from responding to IPV have been identified. We carried out a realist case study, for which we developed and tested a programme theory that seeks to explain how, why and under which circumstances a primary health care team in Spain learned to respond to IPV.

Methods

A realist case study design was chosen to allow for an in-depth exploration of the linkages between context, intervention, mechanisms and outcomes as they happen in their natural setting. The first author collected data at the primary health care center La Virgen (pseudonym) through the review of documents, observation and interviews with health systems’ managers, team members, women patients, and members of external services. The quality of the IPV case management was assessed with the PREMIS tool.

Results

This study found that the health care team at La Virgen has managed 1) to engage a number of staff members in actively responding to IPV, 2) to establish good coordination, mutual support and continuous learning processes related to IPV, 3) to establish adequate internal referrals within La Virgen, and 4) to establish good coordination and referral systems with other services. Team and individual level factors have triggered the capacity and interest in creating spaces for team leaning, team work and therapeutic responses to IPV in La Virgen, although individual motivation strongly affected this mechanism. Regional interventions did not trigger individual and/ or team responses but legitimated the workings of motivated professionals.

Conclusions

The primary health care team of La Virgen is involved in a continuous learning process, even as participation in the process varies between professionals. This process has been supported, but not caused, by a favourable policy for integration of a health care response to IPV. Specific contextual factors of La Virgen facilitated the uptake of the policy. To some extent, the performance of La Virgen has the potential to shape the IPV learning processes of other primary health care teams in Murcia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0899-8) contains supplementary material, which is available to authorized users.

Sex differences in interpersonal violence in Malawi: analysis of a hospital-based trauma registry

BACKGROUND

Although interpersonal violence ("assault") exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care.

METHODS

This is a retrospective cohort analysis of data prospectively collected in the Kamuzu Central Hospital Trauma Surveillance Registry from July 2008 to December 2010 (n = 23,625). We used univariate, bivariate, and logistic regression analyses to measure association of sex with variables of interest, and geospatial mapping to evaluate the association of location of assault on time to presentation for care.

RESULTS

The mean age of our trauma cohort was 27.7 years. Assaults accounted for 26.8 % of all injuries. Of those assaulted, 21.0 % (1299) were female, who were younger (26.2 vs. 28.1 years, p < 0.001), more likely to arrive to the hospital by minibus (p < 0.001), and less likely to arrive by police (p < 0.001). Altogether 62 % of the females were assaulted in their homes-much more often than their male counterparts (p < 0.001). Females were more likely to sustain contusions (p < 0.001) and males more likely to have lacerations and penetrating stab wounds (p < 0.001) or head injury (p < 0.001). Females had delayed hospital presentation following assault (p = 0.001) and were more likely to be treated as outpatients after adjusting for age, injury type, and injury location (adjusted odds ratio 1.74, 95 % CI 1.3-2.3, p < 0.001). Assaults clustered geographically in the Lilongwe district. Delayed presentation of females occurred irrespective of proximity to the hospital.

CONCLUSIONS

This study brings attention to sex differences in assault victims. A prevention strategy focusing on sex roles and domestic abuse of women is paramount. Efforts are needed to stop dischargin female assault victims back into a potentially unsafe, abusive environment.

Primary care-based interventions for intimate partner violence: a systematic review

CONTEXT

Primary care providers are uniquely positioned to respond to patients' disclosure of intimate partner violence (IPV). However, the research on primary care-based IPV interventions has not been systematically synthesized, making it difficult for providers, policymakers, and researchers to understand how to effectively intervene in the primary care setting. This systematic review summarizes primary care-based interventions for patients experiencing IPV.

EVIDENCE ACQUISITION

PubMed, PsycINFO, and CINAHL were searched from their start through September 2012; this search was augmented by bibliographic review and consultation with experts. Eligible studies included English-language, peer-reviewed articles that assessed patient-level impact of IPV interventions that originated from patients' visits to a primary care provider.

EVIDENCE SYNTHESIS

Of 80 potentially eligible studies, 17 met eligibility criteria. The majority of interventions recruited women from reproductive care sites. Interventions tended to be brief, delivered by nonphysicians, and focused on empowerment, empathetic listening, discussion of the cycle of violence and safety, and referral to community-based resources. Thirteen studies demonstrated at least one intervention-related benefit. Six of 11 articles measuring IPV persistence found reductions in future violence; two of five measuring safety-promoting behaviors found increases; and six of ten measuring IPV/community resource referrals found enhanced use. Some studies also documented health improvements.

CONCLUSIONS

The majority of studies demonstrated patient-level benefit subsequent to primary care IPV interventions, with IPV/community referrals the most common positively affected outcome.

Mapping and exploring health systems' response to intimate partner violence in Spain

BACKGROUND

For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system.

METHODS

Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain's 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain.

RESULTS

In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere.

CONCLUSIONS

Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.

Possibilities and hindrances for prevention of intimate partner violence: perceptions among professionals and decision makers in a Swedish medium-sized town

BACKGROUND

Intimate partner violence (IPV) is a major public health problem, but few evidence-based prevention programs have yet been implemented.

PURPOSE

This study explored the perceptions and beliefs of local-level decision makers, social and health-care professionals, and representatives from the police force regarding the possibilities and hindrances for prevention of IPV.

METHOD

An explorative qualitative approach was used, and participants were strategically selected for focus group discussions. The participants, 19 men and 23 women, were professionals or decision makers within health-care services, social welfare, municipal administration, the police force, local industry, and local politicians in a Swedish town of 54,000 inhabitants. The focus group discussions were audio recorded, transcribed verbatim, and thematically analyzed. A manifest content analysis was performed on the text.

RESULTS

Preschools, schools, sports associations, workplaces, and the mass media were suggested as possible arenas for prevention measures. The proposed activities included norm building and improved social support structures. Hindrances were conceptualized as societal beliefs and attitudes, shame, silence, gender inequality, the counteracting influence of the media, and lack of resources. The participants demonstrated closeness and distance to IPV, expressed as acceptance or referral of responsibility to others regarding where and by whom prevention measures should be executed.

CONCLUSION

This study gave new insights in the prevailing perceptions of professionals and decision makers of a medium-sized Swedish town, which can be a useful knowledge in future preventive work and contribute to bridge the gap between research and practice.

How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol

BACKGROUND

Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues-such as IPV management-get integrated into health systems, and that focuses on healthcare teams' learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services.

METHODS

This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management.

DISCUSSION

Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

Influence of interpersonal violence on maternal anxiety, depression, stress and parenting morale in the early postpartum: a community based pregnancy cohort study

BACKGROUND

Research has shown that exposure to interpersonal violence is associated with poorer mental health outcomes. Understanding the impact of interpersonal violence on mental health in the early postpartum period has important implications for parenting, child development, and delivery of health services. The objective of the present study was to determine the impact of interpersonal violence on depression, anxiety, stress, and parenting morale in the early postpartum.

METHODS

Women participating in a community-based prospective cohort study (n = 1319) completed questionnaires prior to 25 weeks gestation, between 34-36 weeks gestation, and at 4 months postpartum. Women were asked about current and past abuse at the late pregnancy data collection time point. Postpartum depression, anxiety, stress, and parenting morale were assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale, the Spielberger State Anxiety Index, the Cohen Perceived Stress Scale, and the Parenting Morale Index, respectively. The relationship between interpersonal violence and postpartum psychosocial health status was examined using Chi-square analysis (p < 0.05) and multivariable logistic regression.

RESULTS

Approximately 30% of women reported one or more experience of interpersonal violence. Sixteen percent of women reported exposure to child maltreatment, 12% reported intimate partner violence, and 12% reported other abuse. Multivariable logistic regression analysis found that a history of child maltreatment had an independent effect on depression in the postpartum, while both child maltreatment and intimate partner violence were associated with low parenting morale. Interpersonal violence did not have an independent effect on anxiety or stress in the postpartum.

CONCLUSION

The most robust relationships were seen for the influence of child maltreatment on postpartum depression and low parenting morale. By identifying women at risk for depression and low parenting morale, screening and treatment in the prenatal period could have far-reaching effects on postpartum mental health thus benefiting new mothers and their families in the long term.

Screening of women for intimate partner violence: a pilot intervention at an outpatient department in Tanzania

Intimate partner violence (IPV) is a public health problem in Tanzania with limited health care interventions.

OBJECTIVES

To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges.

METHODS

Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during March-April 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data.

RESULTS

Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women hospital' only indicated a concern that abused men would be neglected.

CONCLUSIONS

Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.

An interpersonally based intervention for low-income pregnant women with intimate partner violence: a pilot study

This study assessed the initial feasibility, acceptability, and efficacy of an intervention aimed at reducing depression and posttraumatic stress disorder (PTSD) in a sample of low-income pregnant women with recent intimate partner violence (IPV). Fifty-four women were randomly assigned to the intervention or control group. The intervention consisted of four sessions during pregnancy and one "booster" session within 2 weeks of delivery. Based on principles of Interpersonal Psychotherapy, the intervention was designed to help participants improve their interpersonal relationships, including their social support networks, and master their role transition to motherhood. Assessments were administered at four time points (intake, 5-6 weeks post-intake, 2 weeks postpartum, 3 months postpartum) to assess for depression, PTSD, and IPV. The intervention did not significantly reduce the likelihood of a major depressive episode, PTSD, or IPV during pregnancy or up to 3-month postpartum. However, we found moderate effects for the intervention in reducing symptoms of PTSD and depression during pregnancy and a large effect for PTSD symptoms from pregnancy up to 3 months postpartum. This study suggests some initial support for our intervention. Larger randomized trials are needed to further examine the intervention both during and after pregnancy.