How Health Care Providers Address Intimate Partner Violence
How Health Care Providers Address Intimate Partner Violence
In this study of 142 low-income women who have experienced IPV, half of the participants reported disclosing abuse to an HCP. Of those who disclosed IPV to an HCP, 65% did so in response to being asked; only 31% volunteered their IPV status. Among those who did not disclose to an HCP, 63% stated that they would have disclosed if they had been asked. Eighty-five percent of the women who disclosed IPV told a primary care provider. Among the women that disclosed IPV to an HCP, 71% felt that their provider wanted them to leave the relationship, with 37.5% reporting being specifically directed to leave. Among the women who disclosed IPV to an HCP, 69% were not provided safety advice. Finally, among the women who disclosed IPV to an HCP, 65% to 85% felt comfortable and believed their HCP to be open or knowledgeable regarding IPV. In this study, women aged 36 to 45 years are 4 times more likely to be screened for IPV.
Most of our participants who told an HCP about IPV reported having disclosed their abuse to a primary care provider. This finding demonstrates the prominent role such providers play for these patients and supports current recommendations for primary care providers to screen for and address IPV. Importantly, women seeking orders of protection sought care at the emergency department at twice the rate that they utilized primary health care, and 40% reported delayed medical care in the past year. Hence, HCPs may see a patient only once, further reinforcing asking all patients about IPV, even at the first visit.
Another important finding in our study is that only half of our participants had disclosed IPV to a HCP; almost two thirds of those disclosed IPV only when they were asked, and most of those who did not disclose IPV reported that they would have disclosed it if they had been asked. These findings support the practice of routine inquiry of IPV in all patients, as has recently been recommended by an IOM report, a recommendation accepted by the secretary of the DHHS. Women who have disclosed their IPV experience to an HCP have been found to be more likely to report receiving an IPV intervention, which is associated with leaving the abusive relationship and improved health outcomes. Not inquiring of all patients ensures that IPV will be underdetected and therefore undertreated. To fulfill the DHHS directives, HCPs will benefit from using evidence-based guidelines to respond to women who disclose IPV on routine inquiry.
Among our participants, 69% reported that they had not received safety advice regarding IPV, whereas 71% reported feeling that their HCP wanted them to leave the abusive relationship. If providers feel helpless to address the needs of women experiencing IPV, they may focus on counseling the woman to leave the abusive relationship without adequately providing information about other strategies and, if the woman wants to leave, ensuring safety procedures are in place. Risk of femicide is increased significantly during the year after an abused partner leaves the abuser, yet only 50% of survivors of attempted femicide reported being aware of their extreme risk, hence increasing susceptibility to possibly unsafe suggestions or a lack of adequate safety planning. Furthermore, some abused women reported that fearing providers will require them to leave an abusive relationship to receive help was a barrier to seeking such help, supporting the importance of our results.
A positive finding in this study is the degree of comfort with and confidence in their HCPs, most of whom were primary care providers, that abused women reported and the extent to which the women looked to the HCPs for help in managing this complex situation. However, there is discordance between this confidence and the finding that HCPs rarely provided safety planning and a nonjudgmental approach to the question of staying or leaving the abusive relationship. In addition, supporting patients' autonomy to make their own choices is associated with other positive outcomes such as improvements in satisfaction, well-being, and change associated with intrinsic rather than extrinsic motivation.
Our finding that participants perceived their HCP to be advocating leaving the abusive relationship raises the question of whether someone who becomes aware of a dangerous (physically, emotionally, or both) situation would not reasonably want the person in danger to leave it. It is also possible that those participants who were not directly advised to leave may have assumed their provider wanted them to do so because it is one reasonable response to an abusive relationship. The fundamental question is whether someone can be supportive of a patient making her own decision and still want her to change her situation. Research on motivation regarding substance abuse and adherence to medical recommendations helps to address these questions. Empathy, information, and support can be provided to increase patient autonomy and perceived competence, consequently improving health outcomes. Qualitative research among the IPV survivor population supports the notion that respectful information-sharing and support by HCPs will help break the cycle of control, degradation, and physical violence that constitutes IPV.
In July 2011 the IOM recommended universal IPV screening, noting the prevalence of IPV and the need to address current and future health risks. Nevertheless, there has been a lack of consensus regarding the utility of screening women for IPV. It is possible that one reason for the lack of clear efficacy of some screening interventions relates to the difficulty HCPs have with the complex and numerous tasks that have been suggested when the patient screens positively, such as assessing mechanisms of injury and child safety. Clinical practice, policy, and research implications of this study would be to focus on establishing fewer HCP responses to a determination of ongoing IPV. In this study, participants reported that HCPs conveyed support, as has been suggested by IPV survivors, but did less well with safety-related suggestions. Hence, focusing educational efforts on getting HCPs to provide a referral to a trained IPV provider at a local shelter or a national toll-free hotline (1-800-799-SAFE (7233) may be the appropriate strategy for primary care providers with multiple important tasks. Research regarding such a strategy could be important as well.
Our results suggest that patients look to their HCP for guidance and information, giving HCPs an opportunity to respectfully educate women to seek safety planning and impact their ability to make positive change. The cumulative evidence suggests that, after such referrals, HCPs should support patients' choices and decrease the focus on leaving the abusive relationship until resources are present to help avoid potentially serious harm.
A strength of this study is that women were recruited from different sites. Although other articles have focused on patient responses to HCPs in primary or emergency medical settings, ours broadens the population studied and adds to the literature by including participants recruited from 2 sites where biomedical care was not being obtained. Some differences by site were noted (Table 2) with regard to ethnicity and age. The family court sample was seeking an order of protection and was more likely to be younger and nonwhite, whereas the psychiatric practice clinic sample was likelier to be older and white. The primary health care population was less likely to have some college education, had a lower income, and was more likely to have an alcohol problem. These findings support our belief that we have assembled a diverse population. A larger sample may be needed to determine associated differences in IPV communication beyond the finding of women in the middle age group range being more likely to be asked about IPV by an HCP.
Our results should be considered with caution. This study is based on patient report. Other studies have utilized audiotape, videotape, or chart review to document actual HCP behaviors. This study focuses more on diverse patients' perceptions of and response to community HCPs' behaviors. Another limitation of this study is the lack of a qualitative thematic analysis of participant comments. Because such an analysis was not the purpose of this study, the depth and breadth of responses needed for such an analysis were not obtained.
Future studies could aim to test specific hypotheses regarding interactions between patient characteristics, HCP behaviors, and patient attitudes toward their HCPs. For example, do patient race, education, and income affect the likelihood that HCPs will ask about IPV? Would HCPs asking about IPV increase patient comfort and confidence and could that lead to an increase in needed health services use? If HCPs were trained to support patient autonomy regarding their decisions to stay or leave the abusive relationship, would this improve patient motivation to increase controllable safety behaviors? These important questions have yet to be addressed.
Discussion
In this study of 142 low-income women who have experienced IPV, half of the participants reported disclosing abuse to an HCP. Of those who disclosed IPV to an HCP, 65% did so in response to being asked; only 31% volunteered their IPV status. Among those who did not disclose to an HCP, 63% stated that they would have disclosed if they had been asked. Eighty-five percent of the women who disclosed IPV told a primary care provider. Among the women that disclosed IPV to an HCP, 71% felt that their provider wanted them to leave the relationship, with 37.5% reporting being specifically directed to leave. Among the women who disclosed IPV to an HCP, 69% were not provided safety advice. Finally, among the women who disclosed IPV to an HCP, 65% to 85% felt comfortable and believed their HCP to be open or knowledgeable regarding IPV. In this study, women aged 36 to 45 years are 4 times more likely to be screened for IPV.
Most of our participants who told an HCP about IPV reported having disclosed their abuse to a primary care provider. This finding demonstrates the prominent role such providers play for these patients and supports current recommendations for primary care providers to screen for and address IPV. Importantly, women seeking orders of protection sought care at the emergency department at twice the rate that they utilized primary health care, and 40% reported delayed medical care in the past year. Hence, HCPs may see a patient only once, further reinforcing asking all patients about IPV, even at the first visit.
Another important finding in our study is that only half of our participants had disclosed IPV to a HCP; almost two thirds of those disclosed IPV only when they were asked, and most of those who did not disclose IPV reported that they would have disclosed it if they had been asked. These findings support the practice of routine inquiry of IPV in all patients, as has recently been recommended by an IOM report, a recommendation accepted by the secretary of the DHHS. Women who have disclosed their IPV experience to an HCP have been found to be more likely to report receiving an IPV intervention, which is associated with leaving the abusive relationship and improved health outcomes. Not inquiring of all patients ensures that IPV will be underdetected and therefore undertreated. To fulfill the DHHS directives, HCPs will benefit from using evidence-based guidelines to respond to women who disclose IPV on routine inquiry.
Among our participants, 69% reported that they had not received safety advice regarding IPV, whereas 71% reported feeling that their HCP wanted them to leave the abusive relationship. If providers feel helpless to address the needs of women experiencing IPV, they may focus on counseling the woman to leave the abusive relationship without adequately providing information about other strategies and, if the woman wants to leave, ensuring safety procedures are in place. Risk of femicide is increased significantly during the year after an abused partner leaves the abuser, yet only 50% of survivors of attempted femicide reported being aware of their extreme risk, hence increasing susceptibility to possibly unsafe suggestions or a lack of adequate safety planning. Furthermore, some abused women reported that fearing providers will require them to leave an abusive relationship to receive help was a barrier to seeking such help, supporting the importance of our results.
A positive finding in this study is the degree of comfort with and confidence in their HCPs, most of whom were primary care providers, that abused women reported and the extent to which the women looked to the HCPs for help in managing this complex situation. However, there is discordance between this confidence and the finding that HCPs rarely provided safety planning and a nonjudgmental approach to the question of staying or leaving the abusive relationship. In addition, supporting patients' autonomy to make their own choices is associated with other positive outcomes such as improvements in satisfaction, well-being, and change associated with intrinsic rather than extrinsic motivation.
Our finding that participants perceived their HCP to be advocating leaving the abusive relationship raises the question of whether someone who becomes aware of a dangerous (physically, emotionally, or both) situation would not reasonably want the person in danger to leave it. It is also possible that those participants who were not directly advised to leave may have assumed their provider wanted them to do so because it is one reasonable response to an abusive relationship. The fundamental question is whether someone can be supportive of a patient making her own decision and still want her to change her situation. Research on motivation regarding substance abuse and adherence to medical recommendations helps to address these questions. Empathy, information, and support can be provided to increase patient autonomy and perceived competence, consequently improving health outcomes. Qualitative research among the IPV survivor population supports the notion that respectful information-sharing and support by HCPs will help break the cycle of control, degradation, and physical violence that constitutes IPV.
In July 2011 the IOM recommended universal IPV screening, noting the prevalence of IPV and the need to address current and future health risks. Nevertheless, there has been a lack of consensus regarding the utility of screening women for IPV. It is possible that one reason for the lack of clear efficacy of some screening interventions relates to the difficulty HCPs have with the complex and numerous tasks that have been suggested when the patient screens positively, such as assessing mechanisms of injury and child safety. Clinical practice, policy, and research implications of this study would be to focus on establishing fewer HCP responses to a determination of ongoing IPV. In this study, participants reported that HCPs conveyed support, as has been suggested by IPV survivors, but did less well with safety-related suggestions. Hence, focusing educational efforts on getting HCPs to provide a referral to a trained IPV provider at a local shelter or a national toll-free hotline (1-800-799-SAFE (7233) may be the appropriate strategy for primary care providers with multiple important tasks. Research regarding such a strategy could be important as well.
Our results suggest that patients look to their HCP for guidance and information, giving HCPs an opportunity to respectfully educate women to seek safety planning and impact their ability to make positive change. The cumulative evidence suggests that, after such referrals, HCPs should support patients' choices and decrease the focus on leaving the abusive relationship until resources are present to help avoid potentially serious harm.
A strength of this study is that women were recruited from different sites. Although other articles have focused on patient responses to HCPs in primary or emergency medical settings, ours broadens the population studied and adds to the literature by including participants recruited from 2 sites where biomedical care was not being obtained. Some differences by site were noted (Table 2) with regard to ethnicity and age. The family court sample was seeking an order of protection and was more likely to be younger and nonwhite, whereas the psychiatric practice clinic sample was likelier to be older and white. The primary health care population was less likely to have some college education, had a lower income, and was more likely to have an alcohol problem. These findings support our belief that we have assembled a diverse population. A larger sample may be needed to determine associated differences in IPV communication beyond the finding of women in the middle age group range being more likely to be asked about IPV by an HCP.
Our results should be considered with caution. This study is based on patient report. Other studies have utilized audiotape, videotape, or chart review to document actual HCP behaviors. This study focuses more on diverse patients' perceptions of and response to community HCPs' behaviors. Another limitation of this study is the lack of a qualitative thematic analysis of participant comments. Because such an analysis was not the purpose of this study, the depth and breadth of responses needed for such an analysis were not obtained.
Future studies could aim to test specific hypotheses regarding interactions between patient characteristics, HCP behaviors, and patient attitudes toward their HCPs. For example, do patient race, education, and income affect the likelihood that HCPs will ask about IPV? Would HCPs asking about IPV increase patient comfort and confidence and could that lead to an increase in needed health services use? If HCPs were trained to support patient autonomy regarding their decisions to stay or leave the abusive relationship, would this improve patient motivation to increase controllable safety behaviors? These important questions have yet to be addressed.
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