Devora Schapiro
1/22/20
Provider Barriers to Understanding, Screening, and Helping Victims of Intimate Partner Violence
Intimate partner violence (IPV) on average affects 10 million people a year in the United States. [1] has been described as a public health “epidemic”.[2] Unfortunately due to the prevalence of IPV in this country nearly every type of healthcare provider will have a patient that is a victim.[1] This puts health care providers in a unique position to recognize and help victims of IPV.
Why is IPV still so prevalent given the amount of contact victims have with healthcare providers? Healthcare providers are not doing enough to recognize and help victims. The CDC reports that 1 in 4 women and 1 in 10 men have experienced and reported some form of IPV in their lifetime. [3] There are risk factors that healthcare providers should be on the lookout for. Several of these include alcohol consumption, psychiatric illness, history of violence, as well as frequent injuries and visits to the emergency room.[4, 5]
In a retrospective observational study published in 2006, compared the medical records of 788 victims of IPV (as found in a prosecutor’s intimate partner violence database), who visited the emergency department a total 4,456 times. The results are horrifying. Only 1,349 of those times was IPV screening documented. Of those screenings only 259 of those resulted in positive screens. The researchers hypothesized that most of the 259 were only identified because of repetitive visits to the emergency department.[6] Clearly something is not working because these victims of IPV are being failed again and again by the system.
A study done spanning 2014-2015 aimed to understand if certain independent risk factors (i.e. presence of children, age of the victim, pregnancy) led to an increased risk of IPV homicide after collecting data from women that disclosed IPV on visits to the emergency room. The study proclaimed that based on their results they can now more easily identify women who are at risk of death from IPV, [7] yet 44% of women who were later victims of IPV homicides were seen in the ED at least 2 years before their death.[2] From this it is clear not enough is being done to identify the victims of IPV who are at risk for homicide after disclosing their victim status.
IPV is a public health issue, not only because it affects so many people, but because it has many sequalae. Several studies have found that victims of IPV are at an increased risk of having poor current health, developing mental health issues and substance abuse issues, as well as chronic diseases such as cardiovascular disease, stroke, IBS, asthma, seizures, and reproductive health disorders.[2, 8]
The current recommendation for screening for IPV according to USPSTF is only for women of childbearing age. [9] One study found that less than 13% of all health care providers screen for IPV.[2] Additionally, another study found only 13% of IPV victims presenting to the ED with an IPV injury are screened for IPV.[10] According to one study, in the ED screening for IPV is mainly done by nursing staff. This study suggests that the clinician should provide their own screening especially to those who have injuries to head, neck, face, substance use disorders, or frequent ED visits because that indicates high risk for IPV. They suggest that the one of the issues with screening in the ED is how busy it is, and how difficult it is to have a proper environment for the screening.[11]
Current screening tools for IPV aim to be patient centered. These include the HITS (hurt, insult, threaten, scream), Woman abuse screening tool, Partner violence screen, and abuse assessment screen. Of a systematic review of these four tools, it was found that the abuse assessment screen was the most sensitive and specific (93-94% sensitive, 55-99% specific), but no one assessment tool is perfect and many health care providers do not screen for IPV at all. [12] Many healthcare providers have perceived barriers to screening. These barriers include lack of education about screening for IPV, not having enough time to screen, being uncertain about diagnosing IPV, lack of knowledge of how to intervene or help victims of IPV. [2]
From the evidence presented above, it is obvious that there is something missing in healthcare regarding identifying and treating victims of intimate partner violence. In order to change this, I propose we have better training and education in every healthcare profession school. For example, in physician assistant programs part of the accreditation requirement should include education on statistics, risk factors, warning signs and public health outcomes of victims of IPV. Additionally, there should be a requirement for students to practice their screening skills with OSCEs and simulation training. The research has shown that one of the barriers to screening for IPV is education about IPV. So, in addition to increasing education about IPV while healthcare professionals are in school, I propose having mandatory CMEs in IPV. For example, PAs are required to log 100 CME credits every two years, the requirement could be 4 CME credits that cover IPV. This would address education concerns as data and recommendations change. This solution addresses the barrier of education about IPV well. Additionally, the constant reminders about it through education, will help health care providers always have IPV in the back of their minds. However, this proposal also has some weaknesses, it will be difficult to change accreditation and CME requirements on a widespread level like this. It would take the approval of many committees and organizations to make this change. Additionally, adding extra requirements to the curriculum of health professional schools could disrupt the whole curriculum if not done efficiently. This could increase time spent in school, and financial requirement of health students putting an unfair burden on them.
In order to increase the number of providers who screen for IPV, we should make it simple and easy to transition into ways they already practice. A section of the social history on the electronic medical record (EMR) should include screening questions for IPV, that will make it easier to slip in the questions as the provider is going through the EMR, as well make sure it is kept on their radar. This proposal has many strengths. It should be quite easy to implement, as many practices and hospitals already use EMRs, adding a few questions to the EMR should not be a lot of effort on the part of the engineers, and asking a few additional questions should not be a lot of effort on the part of clinicians. However, this does not address the personal barriers that providers have about screening patients, it just makes it easier to efficiently ask, and addresses the barrier of time. This does not help providers understand IPV or know how to help their patients when they have a positive screen.
In places like the emergency room where it is often crowded and busy, a private area for screening patients who are suspected of being victims of IPV should be implemented. If patients are being questioned about IPV in front of the perpetrator they are not likely to disclose accurate information. Great effort should be made to ask patients privately, so they are more likely to disclose. This proposal aims to address missed opportunities to screen in the ED, as well as attempting to obtain positive screens. It does that well, however there are some weaknesses as well. Adding a new private area to all emergency departments is expensive. Additionally, moving patients to a private area to screen lowers timing efficiency in the ED.
Healthcare providers have a responsibility to help patients to the best of their ability. Once victims are identified it is important to make sure they get the proper help. In order to do this referral networks to social workers and therapists should be strengthened. There are several ways this can be accomplished. Firstly, in during school interprofessional education seminars can be implemented. This would allow students from different professional programs to meet each other, understand each other’s job descriptions, and start forming networks for practice later. Additionally, interprofessional education with practicing professionals can help widen referral networks. Understanding what role social workers and therapists have in helping victims of IPV is great first step in referring the patients who need them. However, this may be difficult to implement in every health profession school, due to timing issues in the curriculum. Adding additional requirements would add weight to an already heavy curriculum. Additionally, having interprofessional education with working professionals can get expensive.
From a public health standpoint, additional screening tools can be developed. These tools should have their effectiveness studied in many different areas of practice to see what works best where. For example, what works in the emergency department may be different than what works in gynecology offices. These studies would require widespread participation from many providers, which would also help providers screen more for victims IPV while these tools are in research mode. This aims to address the problem that the screening tools that we have currently are not good enough. In the past it has been difficult to develop efficient screening tools, and not only would additional studies on screening tools be expensive, the research requires increased healthcare provider screening and if healthcare providers are not compliant very little knowledge can be gained.
I believe adhering to these proposals will increase provider recognition of IPV and improve victim outcomes.
Sources:
1. Huecker MR, S.W., Domestic Violence 2019.
2. Collett, D. and T. Bennett, Putting intimate partner violence on your radar. JAAPA, 2015. 28(10): p. 24-8.
3. CDC. Preventing Intimate Partner Violence 2019 [cited 2020; Available from: https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html.
4. Daniel Dicola, E.S., Intimate Partner Violence American Academy of Family Physicians 2016. 94.
5. Davidov, D.M., H. Larrabee, and S.M. Davis, United States emergency department visits coded for intimate partner violence. J Emerg Med, 2015. 48(1): p. 94-100.
6. Kothari, C.L. and K.V. Rhodes, Missed opportunities: emergency department visits by police-identified victims of intimate partner violence. Ann Emerg Med, 2006. 47(2): p. 190-9.
7. Brignone, L. and A.M. Gomez, Double jeopardy: Predictors of elevated lethality risk among intimate partner violence victims seen in emergency departments. Prev Med, 2017. 103: p. 20-25.
8. Coker, A., Davis, Keith, Arias, Ileana, Desai, Sujata, Sanderson, Maureen, Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventative Medicine, 2002. 23(4): p. 260-268.
9. USPSTF. Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Screening 2013 January 2013 [cited 2020 January 13]; Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening.
10. Jill Walen, M.M.G., Screening for Intimate Partner Violence by Healthcare Providers: Barriers and Intervention American Journal of Preventative Medicine 2000.
11. Choo, E.K. and D.E. Houry, Managing intimate partner violence in the emergency department. Ann Emerg Med, 2015. 65(4): p. 447-451 e1.
12. Rabin, R.F., et al., Intimate partner violence screening tools: a systematic review. Am J Prev Med, 2009. 36(5): p. 439-445 e4.
