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Lee NS, Keddem S, Sorrentino AE, Jenkins KA, Long JA. Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex. JAMA Netw Open 2024; 7:e2356600. [PMID: 38373000 PMCID: PMC10877456 DOI: 10.1001/jamanetworkopen.2023.56600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Importance Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.
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Affiliation(s)
- Natalie S. Lee
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus
| | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Anneliese E. Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Kevin Ahmaad Jenkins
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Judith A. Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Sorrentino AE, Iverson KM, Tuepker A, True G, Cusack M, Newell S, Dichter ME. Mental health care in the context of intimate partner violence: Survivor perspectives. Psychol Serv 2020; 18:512-522. [PMID: 32237873 DOI: 10.1037/ser0000427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Experience of violence or abuse from an intimate partner (intimate partner violence, IPV) can result in a variety of psychological and mental health impacts for which survivors may seek psychotherapy or other mental health services. Individuals experiencing IPV may have specific needs and preferences related to mental health care, yet the question of how to best provide client-centered mental health care in the context of IPV has received little attention in the literature. In this article, we report on findings from qualitative interviews with 50 women reporting past-year IPV who received care through the Veterans Health Administration regarding experiences with and recommendations for mental health services. Participants described client-centered mental health care in the context of recent or ongoing IPV as being characterized by flexibility and responsiveness around discussion of IPV; respect for the complexity of clients' lives and support for self-determination; and promoting safety and access to internal and external resources for healthy coping. We discuss findings in terms of their implications for the mental health field, highlighting the need for flexibility in application of evidence-based treatments, improved coordination between therapeutic and advocacy services, and training to enhance competencies around understanding and responding to IPV. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | - Katherine M Iverson
- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
| | - Gala True
- South Central Mental Illness, Research, Education, and Clinical Center, Southeast Louisiana Veterans Health Care System
| | - Meagan Cusack
- VA Center for Health Equity Research and Promotion, Crescenz VA Medical Center
| | - Summer Newell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
| | - Melissa E Dichter
- VA Center for Health Equity Research and Promotion, Crescenz VA Medical Center
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Dichter ME, Sorrentino AE, Haywood TN, Tuepker A, Newell S, Cusack M, True G. Women's Participation in Research on Intimate Partner Violence: Findings on Recruitment, Retention, and Participants' Experiences. Womens Health Issues 2019; 29:440-446. [PMID: 31072755 PMCID: PMC10077872 DOI: 10.1016/j.whi.2019.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/13/2019] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Research on intimate partner violence (IPV) faces unique challenges to recruitment and retention. Little is known about successful strategies for recruiting and retaining in research women who have experienced IPV, and their experiences of research participation. PURPOSE This article presents findings on recruitment, retention, and research participation experiences from a longitudinal observational study of IPV among women receiving care through the Veterans Health Administration. METHODS Administrative tracking data were analyzed to identify strengths, challenges, and outcomes of multiple recruitment strategies for an observational study of women patients who had experienced past-year IPV. Qualitative interviews with a purposively selected subset of the larger sample were used to identify motivations for and experiences of study participation. RESULTS Of the total sample (N = 169), 92.3% were recruited via direct outreach by the research team (63.3% via letter, 29.0% in person), compared with provider or patient self-referral (3.6% and 4.1%, respectively); 88% returned for a follow-up assessment. In qualitative interviews (n = 50), participants expressed a desire to help others as a primary motivation for study participation. Although some participants experienced emotional strain during or after study visits, they also expressed perceiving value in sharing their experiences, and several participants found the experience personally beneficial. Participants expressed that disclosure was facilitated by interviewers' empathic and neutral stance, as well as the relative anonymity and time-limited nature of the research relationship. CONCLUSIONS Direct outreach to women Veterans Health Administration patients to participate in research interviews about IPV experience was feasible and effective, and proved more fruitful for recruitment than reliance on provider or patient self-referral. Women who have experienced IPV may welcome opportunities to contribute to improvements in care through participation in interviews.
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Chhabra M, Sorrentino AE, Cusack M, Dichter ME, Montgomery AE, True G. Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health. J Gen Intern Med 2019; 34:1213-1219. [PMID: 30993632 PMCID: PMC6614210 DOI: 10.1007/s11606-019-04895-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/19/2018] [Accepted: 01/03/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services. OBJECTIVE This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making. DESIGN We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016. APPROACH Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach. KEY RESULTS Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening. CONCLUSIONS Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.
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Affiliation(s)
- Manik Chhabra
- U.S. Department of Veterans Affairs, Department of Medicine at the Cpl. Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Anneliese E Sorrentino
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia, PA, USA
| | - Meagan Cusack
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia, PA, USA
| | - Melissa E Dichter
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia, PA, USA.,University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Ann Elizabeth Montgomery
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Philadelphia, PA, USA. .,School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA. .,Health Services Research & Development, Mail Stop 151(A) - Pickwick Center, Birmingham VA Medical Center, 700 S 19th Street, Birmingham, AL, 35233, USA.
| | - Gala True
- U.S. Department of Veterans Affairs, South Central Mental Illness, Research, Education and Clinical Center, New Orleans, LA, USA.,School of Medicine, Louisiana State University, New Orleans, LA, USA
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Brignone E, Sorrentino AE, Roberts CB, Dichter ME. Suicidal ideation and behaviors among women veterans with recent exposure to intimate partner violence. Gen Hosp Psychiatry 2018; 55:60-64. [PMID: 30412860 DOI: 10.1016/j.genhosppsych.2018.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Women veterans have disproportionately high risk for both suicide and intimate partner violence compared to women non-veterans. The objective of this study was to assess the relationship between intimate partner violence (IPV) and suicidal ideation and suicidal or self-harm behaviors among women veterans. METHOD Veterans Health Administration (VHA) electronic medical records were extracted for 8427 women veterans who completed screening for past-year IPV between April 2014 and 2016. Risk for suicidal ideation and self-harm behaviors were estimated as function of screening results using logistic regression. RESULTS Overall, 8.4% screened positive for IPV. Suicidal ideation or self-harm behaviors were recorded for 3.2%. Positive IPV screen was associated with double the odds for suicidal ideation (AOR = 2.04; 95% CI = 1.47-2.86) and self-harm behaviors (AOR = 2.05, 95% CI = 1.10-3.83). Risks did not significantly differ by IPV type. Suicide-related ICD codes were most often recorded prior to IPV screening. CONCLUSIONS There is a strong association between positive IPV screen and suicidal ideation and self-harm behaviors among VHA-engaged women veterans. Documentation of either event is an important marker for the other. Integration of suicide prevention with IPV services may enhance identification of women at risk and speed service uptake. Suicidal ideation and behaviors should be assessed among women with positive IPV screens, and identification of suicide risk should trigger IPV assessment.
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Affiliation(s)
- Emily Brignone
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States.
| | - Anneliese E Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States; Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Dichter ME, Sorrentino AE, Haywood TN, Bellamy SL, Medvedeva E, Roberts CB, Iverson KM. Women's Healthcare Utilization Following Routine Screening for Past-Year Intimate Partner Violence in the Veterans Health Administration. J Gen Intern Med 2018; 33:936-941. [PMID: 29423623 PMCID: PMC5975147 DOI: 10.1007/s11606-018-4321-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/19/2017] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Experience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system. OBJECTIVE The objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV-) and to examine the timing and types of healthcare services accessed among women screening IPV+. DESIGN A retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016. MAIN MEASURES Demographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes). KEY RESULTS In the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV-. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV-. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening. CONCLUSIONS Women who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of emergency department utilization and inpatient stays among women screening IPV+ may indicate adverse health outcomes related to IPV experience.
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Affiliation(s)
- Melissa E Dichter
- Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs, Philadelphia, PA, USA. .,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Anneliese E Sorrentino
- Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs, Philadelphia, PA, USA
| | - Terri N Haywood
- Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs, Philadelphia, PA, USA
| | - Scarlett L Bellamy
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs, Philadelphia, PA, USA
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs, Philadelphia, PA, USA
| | - Katherine M Iverson
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
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Montgomery AE, Sorrentino AE, Cusack MC, Bellamy SL, Medvedeva E, Roberts CB, Dichter ME. Recent Intimate Partner Violence and Housing Instability Among Women Veterans. Am J Prev Med 2018; 54:584-590. [PMID: 29433952 DOI: 10.1016/j.amepre.2018.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/18/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Women Veterans are at increased risk of both housing instability and intimate partner violence compared with their non-Veteran counterparts. The objectives of the present study were (1) to assess the relationship between women Veterans' experience of intimate partner violence and various indicators of housing instability, and (2) to assess what correlates help to explain experiences of housing instability among women Veterans who experienced past-year intimate partner violence. METHODS Data were collected from U.S. Department of Veterans Affairs electronic medical records for 8,427 women Veterans who were screened for past-year intimate partner violence between April 2014 and April 2016 at 13 Veterans Affairs' facilities. Logistic regressions performed during 2017 assessed the relationship between past-year intimate partner violence and housing instability. RESULTS A total of 8.4% of the sample screened positive for intimate partner violence and 11.3% for housing instability. Controlling for age and race, a positive intimate partner violence screen increased odds of housing instability by a factor of 3. Women Veterans with past-year intimate partner violence were more likely to have an indicator of housing instability if they identified as African American, had screened positive for military sexual trauma, or had a substance use disorder; receiving compensation for a disability incurred during military service and being married were protective. CONCLUSIONS For women Veterans, intimate partner violence interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with intimate partner violence programs to address common barriers to resources.
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Affiliation(s)
- Ann Elizabeth Montgomery
- U.S. Department of Veterans Affairs (VA), National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania; Birmingham VA Medical Center, Birmingham, Alabama; Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama.
| | | | - Meagan C Cusack
- VA, Center for Health Equity Research & Promotion, Philadelphia, Pennsylvania
| | - Scarlett L Bellamy
- VA, Center for Health Equity Research & Promotion, Philadelphia, Pennsylvania; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Elina Medvedeva
- VA, Center for Health Equity Research & Promotion, Philadelphia, Pennsylvania
| | | | - Melissa E Dichter
- VA, Center for Health Equity Research & Promotion, Philadelphia, Pennsylvania; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Iverson KM, Sorrentino AE, Bellamy SL, Grillo AR, Haywood TN, Medvedeva E, Roberts CB, Dichter ME. Adoption, penetration, and effectiveness of a secondary risk screener for intimate partner violence: Evidence to inform screening practices in integrated care settings. Gen Hosp Psychiatry 2018; 51:79-84. [PMID: 29353128 DOI: 10.1016/j.genhosppsych.2018.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Veterans Health Administration (VHA) has implemented screening for past-year intimate partner violence (IPV) in some healthcare facilities along with secondary screening of risk for severe violence among those screening positive in order to facilitate follow-up care for high-risk patients. We evaluated the adoption, penetration, and effectiveness of secondary screening as a tool to facilitate timely follow-up services. METHODS Retrospective review of medical records (screening and healthcare use) of 774 women screening positive for past-year IPV (IPV+) at 11 facilities nationwide from April 2014-April 2016. Chi-square and t-tests examined factors related to secondary screening. RESULTS Three of eleven (27.3%) facilities that implemented primary IPV screening adopted secondary screening. At adopting sites, 56.4% eligible (i.e., IPV+) women received secondary screening. Among 185 IPV+ women who completed secondary screening, 33.0% screened positive for severe IPV. Screening positive during secondary screening was associated with higher rate of psychosocial care within 60 days (73.8% vs. 54.0% of IPV+ patients screening negative; p < .05), posttraumatic stress disorder diagnosis (31.1% vs. 15.3%; p < .05), and being physically threatened or harmed (>50% vs. <15%; p < .001). CONCLUSIONS Secondary risk assessment following IPV screening may expedite access to psychosocial follow-up care in integrated healthcare settings. However, program uptake needs to be enhanced.
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Affiliation(s)
- Katherine M Iverson
- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Anneliese E Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Scarlett L Bellamy
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, United States
| | - Alessandra R Grillo
- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - Terri N Haywood
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States; Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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