Screening for Intimate Partner Violence in Health Care Settings


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"Screening for Intimate Partner Violence in Health Care Settings" Presentation with the Waterloo Region Crime Prevention Council by Dr. Robin Mason.

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  • The research reports on prevalence and incidence of IPV are fraught with all kinds of methodological issues with the result that almost every study suggests its data likely represents an underestimation of the actual figures. The Global Report on Violence devotes a chapter to Violence by Intimate Partners and in it notes that over a number of population based studies the lifetime incidence of physical violence by an intimate partner ranges between 10 - 69%. Homicide is the second leading cause of traumatic death for women of reproductive age. From 1991 to 1999, for every 100,000 live births in the U.S., at least two women died as a result of homicide during pregnancy or within one year of pregnancy. Those are among the findings of a new study from the Centers for Disease Control and Prevention. The results were published in the March 2005 issue of the American Journal of Public Health . The study found that homicide is the second leading cause of reported injury deaths among pregnant and postpartum women in the United States, ranking behind motor vehicle accidents and ahead of unintentional injury, suicide and other causes. In their reports on data gathered in the General Social Survey 2004 version, Stats Canada reports that READ an estimated 653,000 women and 546,000 men encountered some form of violence by a current or former spouse. These figures are generally counted as underestimates due to the shame and embarrassment attached to disclosing. Rates highest amongst 15-24 year olds, relationships of less than three years, those who had separated, and in common law unions. Women are at increased risk when partners are unemployed and when there are substance abuse issues. More severe consequences for women. Even minor abuse can intensify. And we know that it is at the time of leaving or trying to leave the relationship that women are at most danger of being murdered. 21 women and 1 child have been killed in Toronto in the past year. (18 women were killed while trying to leave their partners - not sure over what time period). Sexual assault is also widely prevalent in domestic settings. Thirty-three percent to 50% of women who are physically assaulted by their partners are also sexually assaulted (1992, Kilpatrick et al).
  • Less injurious forms of violence.
  • Individual : The first level identifies biological and personal history factors that increase the likelihood of becoming a victim or perpetrator of violence. Some of these factors are young age, low income, lack of academic achievement or opportunity, witnessing or experiencing violence as a child, substance use problems and social isolation Relationship : The second level includes factors that increase risk because of relationships with peers, intimate partners, and family members. A person's closest social circle-peers, partners and family members-influences their behavior and contributes to their range of experience. Also included are presence or absence of: marital conflict, poor family functioning, male dominance, and the presence or absence of children Community : The third level explores the settings, such as schools, workplaces, and neighborhoods, in which social relationships occur and seeks to identify the characteristics of these settings that are associated with becoming victims or perpetrators of violence. Societal : The fourth level looks at the broad societal factors that help create a climate in which violence is encouraged or inhibited. These factors include social and cultural norms. Other large societal factors include the health, economic, educational and social policies that help to maintain economic or social inequalities between groups in society. Societal-level factors include legislation on weapons and women and children’s rights Dahlberg LL, Krug EG. Violence-a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002:1-56. Several factors have been found to be consistently associated with the physical assault of intimate partners, and as a result they are widely believed to play some causal role. At the societal level, these include poverty (Bachman & Saltzman, 1995; Hotaling & Sugarman, 1986; Aldorando & Sugarman, 1996) and social norms that reflect male dominance (Levinson, 1989). At the individual level, it has been demonstrated that those who physically assault their female intimates are more likely to have witnessed interparental violence (Hotaling & Sugarman, 1986), experienced child abuse (Wekerle & Wolfe, 1998; Alexander, Moore & Alexander, 1991; Simonelli et al., 2002), have been raised in families with patriarchal values (Fagot, Loerber & Reid, 1998; Gwartney-Gibbs, Stockard & Bohmer, 1987; Riggs & O’Leary, 1989), subscribe to patriarchal values themselves (Yllo & Straus, 1990), and use alcohol or drugs more than their non-abusive counterparts (Hotaling & Sugarman, 1986; Tolman & Bennett, 1990; Kantor & Straus, 1989).
  • Expectant mothers are more likely to die from murder or suicide than several of the most common pregnancy-related medical problems, U.S. researchers have found. Roughly half of those women who died violently had had some sort of conflict with their current or former partners leading up to the death, causing experts to call for more thorough screening and follow up for domestic problems during pregnancy check-ups. The study shows that about three out of every 100,000 women who are pregnant or have a child less than one year old are murdered, and two out of every 100,000 kill themselves.   Those numbers remained fairly constant from 2003 to 2007, the years that the researchers examined.   They pulled their data from the Centers for Disease Control and Prevention's National Violent Death Reporting System, which includes 17 states.   Murder and suicide were more common causes of death than medical conditions related to the pregnancy, according to a different set of data.   For instance, fewer than two out of every 100,000 women died from either pregnancy-related bleeding, improper development of the placenta, or preeclampsia, a complication of high blood pressure that can occur during pregnancy.
  • Choking or shaking can produce retinal hemorrhages that are often missed
  • August 10, 2011 A Study conducted in New South Wales, Sydney, Australia, analyzed data from the Australian National Mental Health and Well-being Survey of 2007, which included 4451 women aged 16 to 85 years. They used diagnostic criteria from the WHO’s World Mental Health Survey to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD). They found that over their lifetimes, 27.4% experienced at least 1 type of GBV, (sexual assault, 14.7%; stalking, 10.0%; rape, 8.1%; and IPV, 7.8%.) Women who had been exposed to 1 form of GBV reported a high rate of lifetime mood disorder (30.7%), lifetime anxiety disorder (38.5%), lifetime substance use disorder (23.0%), lifetime PTSD (15.2%), and any lifetime mental disorder (57.3%).
  • Because DV is dynamic, screening during successive patient encounters will yield different answers. An answer of "no" to a DV screening question today does not mean it will be "no" in the future. In 4 studies women say they want or would not object to being asked about DV Physician comfort and dialogue with patients are important prerequisites to effective implementation of screening. In general, it is more appropriate to screen women for abuse after a rapport has been established with the interviewer.21 Screening as part of a women's sexual history, or along with anticipatory guidance questions, would also seem appropriate. Simple and direct clinical inquiry that avoids ambiguity is best. This can be done orally or through the use of questionnaires. It is vital to ensure privacy during administration and completion of questionnaires. The environment in which DV screening occurs is key to its success. Because women in abusive relationships live in a chaotic, violent world, it is important for the screening environment to feel private and safe.15,23,24 Normalizing statements such as "Because violence is so common in women's lives, I ask all women about possible violence in their lives"1,15,21 can help make the exchange easier for both the physician and patient. The physician needs to be aware of his/her body language and other nonverbal responses to the information shared. It is crucial to convey that the practitioner is listening and acknowledges the patient's courage in sharing this information.21 In qualitative studies, women from various cultural groups report that they seek respectful, supportive, nonjudgmental, and attentive medical providers to facilitate discussions of abuse.13,25,26 Potential opportunities to intervene in cases of domestic violence (DV) are often missed, because clinicians are reluctant to bring up the issue with women they suspect may have been abused. Also, fear and shame make abused women unlikely to volunteer such information unless specifically asked.
  • Main Outcome Measures Women disclosing past-year IPV were interviewed at baseline and every 6 months until 18 months regarding IPV reexposure and quality of life (primary outcomes), as well as several health outcomes and potential harms of screening. Results Participant loss to follow-up was high: 43% (148/347) of screened women and 41% (148/360) of nonscreened women. At 18 months (n = 411), observed recurrence of IPV among screened vs nonscreened women was 46% vs 53% (modeled odds ratio, 0.82; 95% confidence interval, 0.32-2.12). Screened vs nonscreened women exhibited about a 0.2-SD greater improvement in quality-of-life scores (modeled score difference at 18 months, 3.74; 95% confidence interval, 0.47-7.00). When multiple imputation was used to account for sample loss, differences between groups were reduced and quality-of-life differences were no longer significant. Screened women reported no harms of screening. Conclusions Although sample attrition urges cautious interpretation, the results of this trial do not provide sufficient evidence to support IPV screening in health care settings. Evaluation of services for women after identification of IPV remains a priority. The effectiveness of screening for partner violence remains uncertain. These investigators identified consenting women older than 18 years (mean age = 38.7 years) who were seeking clinical services at 10 community-based primary health care clinics who spoke and understood English or Spanish (N = 2708). Patients randomly received assignment (allocation concealed) to 1 of 3 study groups: (1) Women were screened by an audio-computer-assisted self-interview using a standard 3-question partner violence screening tool. Women who screened positive (affirmative response to one or more questions) viewed a brief video of a partner violence advocate encouraging the viewer to seek help. These women also received contact information for local partner violence advocacy programs and women's shelters, as well as a list of general resources on health services, legal aid, substance abuse treatment, and parenting support. Women who screened negative received only the list of general resources. (2) All women received the partner violence resources and general resource list without screening. And (3) women were not screened and did not receive the partner violence resource list, but were given the general resources list. Quality of life was assessed using standardized valid scoring tools. Individuals assessing outcomes remained masked to treatment group assignment. Complete follow-up occurred for 87.2% of women at 1 year. Using intention-to-treat analysis, no significant group differences were detected in quality-of-life indicators, number of days lost from work or housekeeping, hospitalizations, emergency department or clinic visits, use of partner violence resources, or recurrence of partner violence. The study was 85% powered to detect a predetermined clinically significant difference in effect size among the 3 study groups.
  • Each of the Tools we are about to review have been evaluated in just a few settings. (3-6) Evaluation is difficult as there is no gold standard against which to compare these. PLUS disclosure is a voluntary act so no matter how sensitive your tool is, women may choose not to disclose…
  • WAST-SF consists of the first two questions only; positive if “a lot of tension” and/or “great difficulty” WAST scoring: cutoff for what constitutes a positive score not available Tested in white, African- American and Latina women Spanish version tested17
  • Screening for Intimate Partner Violence in Health Care Settings

    1. 1. Screening for Woman Abuse “ can’t change society by changing only half of it” (Farida Shaheed, the UN expert on culture Robin Mason, PhD Women’s College Research Institute, Women’s College Hospital Assistant Professor Dalla Lana School of Public Health & Department of Psychiatry, University of Toronto 1
    2. 2. Definitions and Terms: WHO Intimate partner violence includes acts of physical aggression, psychological abuse, forced intercourse and other forms of sexual coercion, and various 2
    3. 3. Prevalence in Canada• 7% of women experienced physical and/or sexual abuse by current or former partner in previous 5 years;• 18% of women experienced emotional and/or financial abuse by current or former partner in previous 5 years;• Where there was emotional abuse, 25% of women & 19% of men also experienced physical violence (Stats Canada, 2005)• Nearly 1 in 3 women will experience IPV at some point during her life (VAWS 1993)• Under reporting is likely, particularly for same sex partner abuse
    4. 4. Women Experience More andMore Severe Violence 5 x more likely to have been injured and to require medical attention – 5 x more likely to fear for their life – 5 x more likely to have been choked – 3 x more likely to require time off from work – 65% report being assaulted > once – 39% assaulted 2 -10 times – 26% victimized > 10 times General Social Survey, 2004 4
    5. 5. Gendered Experience of DVMen are more likely to experience: • being slapped • hit • kicked • bitten • having something thrown at them (GSS 2004)• 7% reported physically hurting their partner in the pastyear, 16% ever hurting their partner• 93% of individuals asked believe their physicians couldbe helpful (Burge et al 2005)
    6. 6. Homicide FemicideSuicide • Domestic Violence Death Review Committee (DVDRC) 2003-2007: 196 fatal incidents (120 women, 20 children, 55 men) • Between 2003-2007: 84% of cases reviewed had 7 or more risk factors • In 8 out of 9 cases, the murder was both predictable and preventable* (DVDRC 2005). • 20 Women and 3 Children murdered by current or former intimate partners in 2010 in Ontario • In a US study, 69% of intimate femicide victims were abused prior to their deaths; 41% of these were seen in a health care setting in the year prior to their death (Sharps et al, 2001) 6
    7. 7. Domestic Violence DeathReview Committee Risk Factors 1. Actual or pending separation (79%) 2. History of domestic violence (75%) 3. Perpetrator depressed (63%) Not clinically diagnosed 4. Perpetrator’s obsessive behaviour (63%) 5. Escalation of violence (50%) 6. Prior threats to kill victim (45%) 7. Prior threats to commit suicide (44%) 8. Prior attempts to isolate victim (44%) 9. Access to/possession of firearms (42%) 10 Excessive alcohol or drug use (40%) In 8 out of 9 cases, the murder was both predictable and preventable (DVDRC 2005) 7
    8. 8. A System’s View Health Care Sector Shelters & Housing Social Services Policy Sector Justice Sector Education Community Family 8
    9. 9. Ecological Model Risk and Protective Factors Community Society Relationship Individual WHO, 2002
    10. 10. Power and Control Model 10
    11. 11. DV ImpactsHealth and Well-beingAll forms of violence against women potentially reinforce a range of other known determinants of overall health problems, including poor mental health status, gender inequity, social isolation and economic disadvantage.Women experiencing violence may also respond to the trauma of violence in ways that damage their own health: substance use, depression, anxiety and social withdrawal.A Right to Respect, Victoria’s Plan to Prevent Violence Against Women 2010–2020 11
    12. 12. Clinical Presentations Associated with DV Visible Recurrent injury to: • head, face , torso, dental damage • injury during pregnancy • bruising: pattern bruises, symmetrical bruises, bruises in varying stages of healing • internal bleeding • perforated eardrums • broken bones • burns (stoves, appliances, acids) (Anne Flitcraft , Textbook of Women’s Health, Lippincott Raven 1998)
    13. 13. Clinical Presentations Associated with DV Injury Sequelae: • headaches • hearing difficulty • joint pains (due to twisting injury) • dyspareunia or UTI’s (due to sexual assault) • dysphagia (due to strangulation) • recurrent sinus infections (due to face/jaw injuries)
    14. 14. Clinical Presentations Associated with DVSymptoms of Stress:• functional gastrointestinal symptoms• chronic pain syndromes• atypical chest pain• hyperventilation• sleep, mood, appetite disorders
    15. 15. MENTAL HEALTH SEQUELAE• Depression • Substance misuse• Suicidal ideation • Pronounced fear responses• Dissociation • Hypervigilance• Eating Disorders • Chronic stress• Adjustment Disorder • Uncontrolled anger responses• OCD • Sleep disturbance• Low self esteem • Flashbacks• Self-harming behaviours • Phobias• Difficulty maintaining healthy • Memory loss relationships • Loss of concentration and• Dysfunctional parenting productivity• Acute anxiety • Self-degradation• Frequent crying • Uncommunicativeness• Sexual dysfunction • Evasion• Boundary issues • Passivity
    16. 16. Other “Red Flags” • Limited ability to keep medical appointments • Inability to take / use medications including contraception • Patient may appear unreliable, “non-compliant” or ignorant • Partner (perpetrator) may appear “overprotective” and not allow patient to be seen alone
    17. 17. Should We Ask About DV?• 44% of victims told someone; 37% told their healthcare provider (Family Violence Prevention Fund)• Women say they want (or would not object) to being asked about DV by healthcare providers• Victims and perpetrators believe healthcare providers should ask about family conflict• 7% of men in relationships report physically hurting their partner (past year), 16% (lifetime)
    18. 18. Sandra Bell-Lundy, 2008 18
    19. 19. Let’s Talk About Screening • Two position papers state there is insufficient evidence to recommend for or against routine screening – Canadian Task Force on Preventive Health Care (CMAJ 2003) – US Preventive Services Task Force (2004) Updated 2012 conclusion: Screening could reduce IPV and improve health but the trials have had limitations • Canadian RCT showed neither benefit nor ‘harm’ from routine screening* (Macmillan et al 2009) • USA RCT at one year follow up: no improvements in health outcomes or quality of life (Klevenset al 2012) 19
    20. 20. Screening Tools:A SystematicReview (Rabin et al, 2009) • Search of English-language publications describing the psychometric testing of screening tool in a health care setting. • The most studied tools were HITS, WAST, PVS, AAS. • Conclusion: No single screening tool had well-established psychometric properties. Little evaluation conducted. 20
    21. 21. Hurts, Insults, Threatens, Screams(HITS) (Copyright Sherin 2003. There is a $25 fee to use) • Developed for Family Practice Settings • Validated in other settings How often does your partner: (1) Hurt you physically? (2) Insult you or talk down to you? (3) Threaten you with harm? (4) Scream or curse at you? Likert Scale: 1= Never 5= Frequently; >10 is significant 21
    22. 22. Woman Abuse Screening Tool(WAST) (Brown et al., 1996) • Originally developed for Family Practice Settings • Validated in Emergency Departments • Short Form (WAST SF) consists of the first 2 questions • No scoring provided 22
    23. 23. WAST cont’d Copyright 1996 1. In general, how would you describe your relationship? A lot of tension, Some tension, No tension? 2. Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty? 3. Do arguments ever result in you feeling down or bad about yourself? Often, Sometimes, Never 4. Do arguments ever result in hitting, kicking, or pushing? 5. Do you ever feel frightened by what your partner says or does? 6. Has your partner ever abused you physically? 7. Has your partner ever abused you emotionally? 8. Has your partner ever abused you sexually? 23
    24. 24. Partner Violence Screen (PVS)(Feldhaus et al.,1997) Developed for Emergency Settings: 1. Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is making you feel unsafe now? Positive response to any one question = + Abuse 24
    25. 25. Abuse Assessment Screen(AAS) (Weiss et al.,2003) 1. Have you ever been emotionally or physically abused by your partner or someone important to you? 2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom? How many times? 3. Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom? How many times/where? 4. In the last year, has anyone forced you to have sexual activities? If so, by whom? How many times? 5. Are you afraid of your partner or anyone listed above? Positive response to any one question = + Abuse 25
    26. 26. Routine Universal ComprehensiveScreening (RUCS) Protocol • Ask every female over age 12 about all forms of abuse • Address safety directly • Refer to other professionals or services • Consider abuse during every assessment • Document • Educate patients about abuse and available services 26
    27. 27. Principles for Screening: ABCD-ER(RUCS) • Attitude and Approachability of provider • Belief in woman’s account • Confidentiality • Documentation • Education about health effects • Respect her choices; Recognize her pace 27
    28. 28. Women Tell Us How To Ask“Ive been through a rough ordeal. Treat me like a human being."“The doctor could have said this is not right. If you want to talk to me, I can sit you down and let you talk... theres a bit more I can help you with...”“Give me a chance; you asked me what happened - you opened the door. Dont open the door and then shut it.” 28
    29. 29. Women Tell Us How To Ask “Ask my boyfriend to leave so I can open up to you.” [Ensure privacy when discussing abuse. Do not use a family member to interpret – call in a professional interpreter] “[Don’t] be pushy on what you tell somebody to do (they did that a lot). I think they need a different tactic, perhaps, ‘we have some literature if you would like read this.’” “It is never so much about the words you use but the motives behind them. If the questions are asked to support a client or patient towards their goals and help them be safer -- then that comes across.” 29
    30. 30. To Learn More AND COLLECT CME CREDITSVisit the interactive web-based 30