Addressing Intimate Partner Violence in Primary Care Practice

Leigh Kimberg, MD

Disclosures
In This Article

Implementing Screening Policy and Programs: Barriers and Solutions

Many barriers exist to implementing intimate partner violence screening programs. Provider barriers and patient barriers are powerful influences on the success of screening programs. Provider barriers have been well described and include: feeling that discussing intimate partner violence is "too close for comfort"[67] either due to identifying with a cultural group or having a personal history of exposure to abuse and interpersonal violence,[67] personal discomfort with discussing intimate partner violence,[64,65,67] a belief that abuse is "too personal" to ask about or that the patient will be offended by screening,[67,68] lack of education and training,[64,67,68] lack of time to screen and respond,[64,65,67] cultural differences between patient and providers,[64,65,67] frustration due to the belief that screening and intervention in the healthcare setting is futile,[66,67,105] belief and/or experience that patients will not disclose intimate partner violence,[64,65] belief in a strictly "medical" model of care in which the role of the provider does not include addressing intimate partner violence,[58,105,109] fear of repercussions of mandatory reporting laws,[65,110] and more.

Patient barriers about discussing intimate partner violence with providers have been described as well and include: fear of perpetrator's retaliation,[62,69,111] the perpetrator directly preventing access to care,[62] low self-esteem and a feeling of shame,[62,69,111] sense of family responsibilities and fear of loss of custody,[69] socioeconomic barriers to accessing care,[69] the healthcare provider appearing too busy or treating the patient negatively,[60,62,69,111] fear of consequences of mandatory reporting or police involvement.[69] Importantly, though, as previously discussed, most patients studied have said that they would discuss intimate partner violence if asked in a caring, confidential manner.

Institutional barriers, though less immediately apparent, are highly significant in hindering the development and expansion of intimate partner violence screening and treatment programs. Institutional barriers to implementing screening programs abound: lack of training of healthcare personnel; multiple research issues, including a remarkably large number of crucial unanswered questions; lack of uniform or standard definitions used in the field of intimate partner violence research; lack of funding for research on violence, especially violence against women; lack of societal resources for treatment and prevention of intimate partner violence for both victims and perpetrators; numerous legal issues, including mandatory healthcare reporting laws that do not require patient consent, insurance discrimination against victims and survivors of intimate partner violence, lack of privacy protections of the medical records of victims/survivors of intimate partner violence, lack of legal requirements for education about violence for licensure of medical personnel, and lack of legal incentives for development of healthcare-based programs; lack of sufficient diagnostic and procedural codes for violence; lack of reimbursement for intimate partner violence-related services; lack of financial and other support for development of violence screening and treatment programs. Enhancement of screening and treatment by providers and healthcare systems may require a number of different, concurrent approaches that directly address provider, patient, and institutional barriers.

Training must be a part of the approach to enhancing screening programs. Sustained and repeated training that starts in professional schools (medical, nursing, social service) and continues through postgraduate residency training and CME courses are necessary to effect a significant cultural change in medical and mental health intimate partner violence screening practice. Comprehensive training guidelines have been published[112,113] and excellent resources for training exist.[113,114,115,116,117,118] Ideally, survivors of intimate partner violence or at least their stories may be incorporated into all training efforts. Training must be sensitive to the fact that many healthcare providers have been victimized also.[119] Often, local shelters and community-based advocacy organizations are excellent sources of information and training. Involving a shelter or community-based organization in training may establish collaboration with an ongoing source of support and assistance for both one's practice and one's patients.

Research on the impact of training about intimate partner violence on provider behavior has highlighted that training, although acceptable, does not necessarily create large changes in provider behavior.[120,121,122] CME methods that employ interactive techniques, such as systematic practice-based interventions and outreach visits, show more promise as tools of change.[123]

It is essential that training be part of a comprehensive institutionalized response. The experience of an emergency room in Pennsylvania underscores this lesson. In this emergency room, training and a protocol for screening for and assisting with intimate partner violence were introduced without other methods of institutionalizing the program. Great gains were made in intimate partner detection in the year the protocol was introduced.[89] Ten years later, without significant changes in the population served, the detection rate had dropped below pre-protocol levels.[57] Training must be ongoing, independent of "champions" who may leave, and institutionalized. Even if it satisfies these criteria, training by itself is not enough.

There are other low-cost, relatively simple institutional changes that, in expert and model program experience[124] and in some studies, have an additive effect in increasing screening rates. Chart prompts have been found during program development to be relatively easy to institute and, in my experience and that of others,[81] can increase screening rates. Routine questions or standardized forms included in provider or patient health screening forms in the medical record have been found to increase documented screening rates.[103,104] Protocols can serve as training documents and resources for providers and staff. There are protocols already developed that may be easily modified for use.[30] The use of a protocol has also been shown to increase documented screening rates.[89] The introduction of a protocol with training for staff, a standardized screening form, and an on-site bilingual advocate to provide counseling was shown to increase both screening and identification rates.[59] In one emergency department, the administration tested a disciplinary but counseling-based intervention that was triggered by failure of nurses to meet screening rate goals set by the administration. This administrative policy did improve the documented screening rates of the nurses. The quality of screening done was not assessed.[125]

Including screening for intimate partner violence in one's quality improvement program may help to sustain a successful program. The main goal of a successful screening program is the creation of a safe, supportive climate for victims of intimate partner violence to access help when they are ready rather than one in which disclosure is demanded or forced. Yet, it is helpful to monitor both screening rates and approximate prevalence. If one detects a prevalence far lower than that found in a study of a similar population, one can examine the potential barriers to patients revealing intimate partner violence in one's practice. Are you using only a written screening tool? Are you asking questions in a culturally appropriate manner? Are there mandatory reporting laws that are inhibiting patients from revealing intimate partner violence? Do patients feel that confidentiality is not guaranteed? One can then experiment with different screening techniques to improve detection and/or access to services. Ideally, providers and practices can invite victims, survivors, advocates, and others who have established screening programs to evaluate one's program.

Other, more expensive interventions may also enhance screening rates but have not been extensively evaluated. For example, establishing an on-site counseling program or resource for patients and staff, assigning a team of providers/staff the responsibility of developing and maintaining a screening program, and developing community outreach and education programs may all enhance screening and treatment programs. The WomanKind program in Minnesota, a comprehensive program of on-site counseling and advocacy, has been evaluated recently and was shown to increase identification and referral of victims of intimate partner violence.[126,127] The AWAKE program in Children's Hospital in Boston has pioneered placing social work specialists in intimate partner violence in a pediatric clinic.[124] On-site "champions" for intimate partner violence screening are invaluable. Direct outreach and education of patient populations and communities ideally should be coordinated with healthcare responses to intimate partner violence.

Enabling patients to access assistance and services without necessarily disclosing intimate partner violence is a key approach the healthcare system can adopt in conjunction with other efforts. Providers and practices can create a climate that invites patients to feel more comfortable revealing intimate partner violence and shares resources and information with patients who do not feel comfortable revealing intimate partner violence. Posters placed in examination rooms, buttons for providers that address violence, and safety cards placed in examination rooms and patient (and staff) bathrooms may reach out to a victim of intimate partner violence regardless of whether she is ready to disclose intimate partner violence. Posters that encourage perpetrators, who often may be experiencing high levels of stress,[128] to access help are also available.[129]

On a larger scale, the financial reimbursement for screening programs and the interventions that follow screening must be put into place in the United States to overcome barriers to screening. Managed care plans and the insurance industry working with domestic violence experts and advocacy groups are starting to explore these issues.[130,131,132] As more data are available on potential cost savings associated with screening and treating the effects of intimate partner violence, it is hoped that these efforts will accelerate.

Some exciting new developments offer hope and promise that some of the barriers to implementing screening programs will be overcome in the next decade. Three such developments are highlighted below. In order to propel the research agenda in the field of intimate partner violence, the CDC has published guidelines for standard research definitions.[133] Two branches of the CDC, the National Center for Injury Prevention and Control and the National Center for Chronic Disease Prevention and Health Promotion, have formed the Prevention Working Group on Violence and Reproductive Health. This novel and fruitful collaboration has convened a major conference on intimate partner violence and reproductive health,[134] with a large number of funding partners and cosponsors, and is working on a national research agenda in collaboration with intimate partner violence advocates, providers, and researchers. This collaborative effort has already resulted in a number of publications.

The passage of the Violence Against Women Act of 2000 (VAWA) (by 371-1 votes in the House of Representatives and by 95-0 in the Senate) was a triumph that signals rising awareness of the horrific impact of violence against women and support for programs to reduce violence against women. This legislation authorizes a total of $3.3 billion over the next 5 years to fund essential programs and services to assist women who are victims of violence. VAWA appropriates funds for direct services to victims of intimate partner violence and sexual assault, training for police officers, prosecutors, judges, and child protective service workers, programs that address violence against women on college campuses, teen dating violence, intimate partner violence in the workplace, support for children who witness intimate partner violence, and protections for battered immigrant women. This legislation will positively affect the ability of the healthcare system to provide intimate partner violence screening and treatment by increasing the capacity of society to respond to victims and survivors of intimate partner violence and enhancing collaborations between healthcare and other branches of societal assistance.

Finally, The National Advisory Council on Violence Against Women, cochaired by Health and Human Services Secretary Donna Shalala and Attorney General Janet Reno and advised by experts, has recently released the majority of a report on ending violence against women; the findings were presented at the National Conference on Violence and Reproductive Health. The "National Agenda for Ending Violence Against Women" advises multiple sectors of society on how to participate in ending violence against women.[131] The second key area on the agenda of this national plan to end violence against women calls for "enhanc(ing) the health and mental healthcare systems' response to violence against women." The healthcare agenda outlines areas in which the healthcare response to intimate partner violence and sexual assault could be improved.

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