What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Getting Routine Intimate Partner Violence Screening Right: Implementation Strategies Used in Veterans Health Administration (VHA) Primary Care.

BACKGROUND: Evidence supports the clinical effectiveness of intimate partner violence (IPV) screening programs, but less is known about implementing and sustaining them. This qualitative study identified implementation strategies used to integrate IPV screening programs within Veterans Health Administration (VHA) women's health primary care. METHODS: Thirty-two administrators and clinician key informants from 11 VHA facilities participated in semistructured interviews. Implementation strategies were identified using established definitions from implementation science literature, through multistep content analysis, involving site comparisons by implementation status. RESULTS: We identified 8 implementation strategies. Three were present across all sites: (1) conduct ongoing IPV trainings, (2) conduct educational meetings and outreach visits, and (3) develop and distribute educational materials. Five strategies were unique to early adopting sites: (4) identify and prepare champions, (5) change record systems to remind clinicians, (6) create a learning collaborative through advisory boards or workgroups, (7) audit and provide feedback with relay of clinical data to providers, and (8) access new funding. DISCUSSION: Strategies align with and extend literature addressing barriers to screening. Evidence shows that effective IPV screening implementation in primary care requires a bundle of well-defined, carefully selected strategies. CONCLUSIONS: Implementation strategies used collectively can enable integration of IPV screening programs in primary care.

Self-Efficacy for Adoption and Maintenance of Exercise Among Fibromyalgia Patients: A Pilot Study.

Objective. While multimodal treatment approaches for fibromyalgia (FM), incorporating exercise, have been found most effective, information about factors associated with exercise adoption and maintenance is lacking. Design, Setting, and Methods. Women veterans with FM (N = 19) completed an anonymous Internet survey measuring FM impact (FI), adoption of exercise behavior, and self-efficacy for exercise. Using classifications of behavior specified by the transtheoretical model, the self-efficacy of participants classified in the action or maintenance (AM) stages was compared with those in earlier stages (precontemplation through preparation) of exercise readiness. Multivariate analysis of variance analyses examined differences in FI domains by stage of change. Analysis of covariance examined whether exercise self-efficacy differed by stage of change while controlling for FI. Results. Higher levels of self-efficacy were detected among participants in the AM stages. Participants in the AM stages also reported higher levels of FI symptoms. After controlling for FI, self-efficacy did not differ significantly between the 2 groups; however the effect size was large (η2 = .11). Conclusions. Findings of this pilot study suggest a role for self-efficacy in exercise adoption and maintenance, even in the setting of higher FM symptoms. Replication of this study with a larger sample size is warranted.

Association of Depression and Post-Traumatic Stress Disorder with Receipt of Minimally Invasive Hysterectomy for Uterine Fibroids: Findings from the U.S. Department of Veterans Affairs.

BACKGROUND: When hysterectomy is used to treat uterine fibroids, a minimally invasive versus open abdominal approach is preferred. Depression and post-traumatic stress disorder (PTSD) may be associated with surgical mode. We sought to examine whether depression and PTSD are associated with minimally invasive hysterectomy (MIH). METHODS: This was a cross-sectional study of veterans with uterine fibroids undergoing hysterectomy in the Department of Veterans Affairs between 2012 and 2014. Diagnoses and procedures were identified by International Classification of Disease, Ninth Revision, codes. MIH was defined as laparoscopic, vaginal, or robotic-assisted versus open abdominal. A dichotomous variable indicated presence of depression or PTSD. Clinical variables, including uterine size, were abstracted from the medical record. We employed generalized linear models to estimate adjusted percentages and 95% confidence intervals (CIs) of MIH by presence of depression or PTSD and sequentially adjusted for sociodemographic variables and health indicators (model 1), and then gynecologic and reproductive history variables, including uterine size (model 2). RESULTS: We included 770 veterans in our analytic sample. Veterans with depression or PTSD were more likely than those without such diagnoses to have a MIH (49% vs. 42%). Differences were attenuated in model 1 (47% [95% CI, 37%-57%] vs. 43% [95% CI, 34%-52%]) and no longer detectable in model 2 (45% [95% CI, 36%-54%] vs. 44% [95% CI, 36%-52%]). CONCLUSIONS: Veterans with depression or PTSD were more likely that those without to have a MIH, possibly owing to smaller uterine size, suggesting that they may be undergoing hysterectomy earlier in the disease process. Further research is needed to understand whether this reflects high-quality, patient-centered care.

Assessing the Veterans Health Administration's response to intimate partner violence among women: protocol for a randomized hybrid type 2 implementation-effectiveness trial.

BACKGROUND: Intimate partner violence (IPV) against women in the United States (US) remains a complex public health crisis. Women who experience IPV are among the most vulnerable patients seen in primary care. Screening increases the detection of IPV and, when paired with appropriate response interventions, can mitigate the health effects of IPV. The Department of Veterans Affairs (VA) has encouraged evidence-based IPV screening programs since 2014, yet adoption is modest and questions remain regarding the optimal ways to implement these practices, which are not yet available within the majority of VA primary care clinics. METHODS/DESIGN: This paper describes the planned evaluation of VA's nationwide implementation of IPV screening programs in primary care clinics through a randomized implementation-effectiveness hybrid type 2 trial. With the support of our VA operational partners, we propose a stepped wedge design to compare the impact of two implementation strategies of differing intensities (toolkit + implementation as usual vs. toolkit + implementation facilitation) and investigate the clinical effectiveness of IPV screening programs. Using balanced randomization, 16-20 VA Medical Centers will be assigned to receive implementation facilitation in one of three waves, with implementation support lasting 6 months. Implementation facilitation in this effort consists of the coordinated efforts of the two types of facilitators, external and internal. Implementation facilitation is compared to dissemination of a toolkit plus implementation as usual. We propose a mixed methods approach to collect quantitative (clinical records data) and qualitative (key informant interviews) implementation outcomes, as well as quantitative (clinical records data) clinical effectiveness outcomes. We will supplement these data collection methods with provider surveys to assess discrete implementation strategies used before, during, and following implementation facilitation. The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will guide the qualitative data collection and analysis. Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. DISCUSSION: This research will advance national VHA efforts by identifying the practices and strategies useful for enhancing the implementation of IPV screening programs, thereby ultimately improving services for and health of women seen in primary care. TRIAL REGISTRATION: NCT04106193. Registered on 23 September 2019.

Intimate Partner Violence Screening Programs in the Veterans Health Administration: Informing Scale-up of Successful Practices.

OBJECTIVES: Screening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA). DESIGN: Descriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women's health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners. PARTICIPANTS: Thirty-two administrators and clinician key informants (e.g., Women's Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide. MAIN MEASURES: Participants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites. KEY RESULTS: Five successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified. CONCLUSIONS: Findings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women's health.

Accuracy and Acceptability of a Screening Tool for Identifying Intimate Partner Violence Perpetration among Women Veterans: A Pre-Implementation Evaluation.

OBJECTIVES: Veterans are at heightened risk for perpetrating intimate partner violence (IPV), yet there is limited evidence to inform practice and policy for the detection of IPV perpetration. The present study evaluated the accuracy and acceptability of a potential IPV perpetration screening tool for use with women veterans. DESIGN: A national sample of women veterans completed a 2016 web-based survey that included a modified 5-item Extended-Hurt/Insult/Threaten/Scream (Modified E-HITS) and the Revised Conflict Tactics Scales (CTS-2). Items also assessed women's perceptions of the acceptability and appropriateness of the modified E-HITS questions for use in healthcare settings. Accuracy statistics, including sensitivity and specificity, were calculated using the CTS-2 as the reference standard. MAIN OUTCOME MEASURES: Primary measures included the Modified E-HITS (index test), CTS-2 (reference standard), and items assessing acceptability. RESULTS: This study included 187 women, of whom 31 women veterans (16.6%) reported past-6-month IPV perpetration on the CTS-2. The Modified E-HITS demonstrated good overall accuracy (area under the curve, 0.86; 95% confidence interval, 0.78-0.94). In addition, the majority of women perceived the questions to be acceptable and appropriate. CONCLUSIONS: Findings demonstrate that the Modified E-HITS is promising as a low-burden tool for detecting of IPV perpetration among women veterans. This tool may help the Veterans Health Administration and other health care providers detect IPV perpetration and offer appropriate referrals for comprehensive assessment and services.

Human Papillomavirus Testing by Veterans Administration Women's Health Providers: Are They Adhering to Guidelines?

BACKGROUND: Evidence-based guidelines have been created by professional societies, including the United States Preventive Services Task Force (USPSTF) and American Society for Colposcopy and Cervical Pathology (ASCCP), for use of human papillomavirus (HPV) cotesting in cervical cancer screening. We investigated whether Veterans Health Administration (VA) providers at one VA medical center follow these guidelines. MATERIALS AND METHODS: Retrospective chart review of women aged 21-65 who had an HPV test ordered with pap testing in fiscal year 2014 at one Veterans Administration (VA) medical center to evaluate concordance of HPV ordering with screening (USPSTF) and management (ASCCP) guidelines. We collected data on patient characteristics and gynecologic history and documented the reason, if given, for HPV testing. RESULTS: Of the 210 eligible HPV tests evaluated, 142 tests (68%) were determined to be guideline discordant. Of the 142 guideline-discordant tests, 90 had no documented reason for HPV testing in the chart. Site of care was not significant. CONCLUSIONS: This study demonstrates potential overuse of HPV testing among women's health providers at one VA medical center. This may indicate that VA providers lack an understanding of HPV cotesting guidelines. Further studies are needed to characterize VA provider adherence to HPV testing guidelines nationally. Implementation of educational interventions and decision aids may improve VA providers' adherence to guidelines.

Association Between Mental Health Burden and Coronary Artery Disease in U.S. Women Veterans Over 45: A National Cross-Sectional Study.

BACKGROUND: The women Veteran population accessing Veterans Health Administration (VA) care has grown rapidly. Women Veterans exhibit high rates of mental health conditions that increase coronary artery disease (CAD) risk; however, the relationship between specific conditions and increasing mental health burden to CAD in this population is unknown. MATERIALS AND METHODS: Using VA National Patient Care Data for 2009, we identified women Veterans over 45 (N = 157,195). Logistic regression models examined different mental health diagnoses and increasing mental health burden (number of diagnostic clusters) as predictors of CAD. RESULTS: CAD prevalence was 4.16%, and 36% of women Veterans were current smokers. Depression exhibited the strongest association with CAD (odds ratio [OR] 1.60, 95% confidence interval [CI] [1.50-1.71]), similar to that of current smoking (OR 1.68 [1.58-1.78]). Controlling for demographic variables, smoking, diabetes, and obesity, each additional mental health diagnosis increased the odds of CAD by 44%. CONCLUSIONS: Women Veterans over age 45 accessing VA care exhibited a high degree of mental health burden, which is associated with elevated odds of CAD; those with depression alone had 60% higher odds of CAD. For women Veterans using VA, mental health diagnoses may act as CAD risk factors that are potentially modifiable. Novel interventions in primary care and mental health are needed to address heart disease in this growing and aging population.

Program Directors' Perceptions of Resident Education in Women's Health: A National Survey.

BACKGROUND: Despite professional societies' emphasis on women's health in internal medicine (IM) resident curricula, national implementation has varied. This study describes IM program directors' perceptions of women's health topics that residents should master and the current state of women's health education in IM residency programs. MATERIALS AND METHODS: We recruited 408 program directors of IM residency programs to complete an electronic cross-sectional survey. Participants were surveyed about expected resident mastery of twelve women's health topics in the context of their program's current characteristics, core curricula, and training opportunities. RESULTS: One hundred twelve IM program directors completed the survey (response rate 27%). The percentage of program directors who perceived that residents should master each of the twelve women's health topics ranged from 48% to 98%, with the most program directors expecting mastery of osteoporosis (N = 110, 98%), sexually transmitted infection (N = 110, 98%), and gender-specific cancer (N = 109, 97%). These topics, however, were not currently included in the core curricula of 6%-12% of programs. Programs offered varied opportunities in women's health, including dedicated women's health electives (N = 76, 68%), concentrations or tracks (N = 8, 7%), and continuity clinics (N = 15, 13%). Most program directors were interested (N = 90, 80%) in expanding women's health opportunities in their programs. CONCLUSION: While women's health topics were perceived by program directors as a priority for IM resident mastery, certain priority topics and training opportunities were limited. Additional studies are needed to explore barriers to expansion of resident education in women's health and potential solutions.

Vasomotor Symptoms and Quality of Life Among Veteran and Non-Veteran Postmenopausal Women.

INTRODUCTION: Vasomotor symptoms (VMS), including hot flashes and night sweats, are common among postmenopausal women and are associated with reduced health related quality of life (HRQOL). PURPOSE OF THE STUDY: To determine whether Veterans are more likely to report VMS than non-Veterans, and whether the association of VMS with HRQOL varies by Veteran status. DESIGN AND METHODS: We used data from the Women's Health Initiative Observational Study, including self-reported baseline VMS presence and severity, and HRQOL at follow-up Year 3 (RAND Short Form 36-Item Health Survey). Employing generalized linear models we estimated whether Veteran status was associated with any VMS. We estimated the association between any VMS and HRQOL using linear regression, stratified by Veteran status. Interaction terms were added separately to determine whether the association varied by baseline depression, obesity, or smoking status. RESULTS: The final analyses included 77,153 postmenopausal women (2,004 Veterans). After adjustment, Veterans were no more likely than non-Veterans to report any VMS at baseline (relative risk [RR] 0.97, 95% confidence interval [CI] 0.90-1.04) or moderate to severe VMS (RR 1.03, 95% CI 0.89-1.18). Any VMS was associated with decreased HRQOL at Year 3, particularly among Veterans (mean difference range: Veterans -2.7 to -4.6, p-values < .001; non-Veterans -2.2 to -2.6, 95% CI -0.13 to -0.09, p values < .001). Baseline depression and obesity, but not smoking, amplified the negative association between VMS and HRQOL. IMPLICATIONS: Multicondition care models for postmenopausal Veteran and non-Veteran women are needed that incorporate management strategies for VMS, weight, and depression.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension.

The 4-item Hurt/Insult/Threaten/Scream (HITS) tool accurately detects past-year intimate partner violence (IPV) among female Veterans Health Administration (VHA) patients; however, it lacks a sexual IPV item. This study evaluated the accuracy of an extended HITS (E-HITS), which adds a sexual IPV item, in female VHA patients. A sample of 80 female U.S. veteran VHA patients in New England completed a mail survey (50.0% response rate) that included the 5-item E-HITS and the Revised Conflict Tactics Scales (CTS-2). Women were included if they were in an intimate relationship in the past year. The women averaged 49 years of age and 86.0% of the sample was White. Accuracy of the 4-item HITS was compared to the 5-item E-HITS, using the CTS-2 as the reference. There were 20 women (25.0%) who reported past-year IPV on the CTS-2. The receiver operator characteristic curves demonstrated that the HITS and E-HITS performed nearly identically at their optimal cutoff scores of 6 and 7, respectively. At these cutoff scores, the sensitivity of both tools was .75, 95% CI [.55, .95]. The specificities were similar; .83 for the HITS, 95% CI [.73, .92], and .82 for the E-HITS, 95% CI [.72, .90]. Including a sexual IPV item may be clinically beneficial; it also attains the same accuracy of case identification as the HITS.

Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration.

Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings.

Clinical utility of an intimate partner violence screening tool for female VHA patients.

OBJECTIVES: Female Veterans are at high risk for physical, sexual, and psychological forms of intimate partner violence (IPV) victimization. This study evaluated the accuracy of a brief IPV victimization screening tool for use with female Veterans Health Administration (VHA) patients. DESIGN: Participants completed a paper-and-pencil mail survey that included the four-item Hurt/Insult/Threaten/Scream (HITS) and the 39-item Revised Conflict Tactics Scales (CTS-2). Operating characteristics, including sensitivity and specificity, were calculated using the CTS-2 as the reference standard for past-year IPV. PARTICIPANTS: Female veterans from a roster of randomly selected female patients of the New England VA Healthcare System. Women must have reported being in an intimate relationship in the past year to be included. MAIN MEASURES: Primary measures included the HITS (index test) and the CTS-2 (reference standard). KEY RESULTS: This study included 160 women. The percentage of women who reported past-year IPV, as measured by any physical assault, sexual coercion, and/or severe psychological aggression on the CTS-2, was 28.8 %. The receiver-operator characteristic curve demonstrated that the HITS cutoff score of 6 maximizes the true positives while minimizing the false positives in this sample. The sensitivity of the optimal HITS cutoff score of 6 was 78 % (95 % CI 64 % to 88 %), specificity 80 % (95 % CI 71 % to 87 %), positive likelihood ratio 3.9 (95 % CI 2.61 to 5.76), negative likelihood ratio 0.27 (95 % CI 0.16 to 0.47), positive predictive value 0.61 (95 % CI 0.47, 0.73), and negative predictive value 0.90 (95 % CI 0.82, 0.95). CONCLUSIONS: For a low-burden screen, the HITS demonstrated good accuracy in detecting past-year IPV relative to the CTS-2 in a sample of female VHA patients with an optimal cutpoint of 6. The HITS may help VHA and other health-care providers detect past-year IPV and deliver appropriate care for female Veterans.

Posttraumatic stress disorder and intimate partner violence in a women's headache center.

BACKGROUND: Posttraumatic stress disorder has been linked to women's ill health, including headaches. Intimate partner violence, which may result in posttraumatic stress disorder, is often reported by women with headaches. Prior studies of intimate partner violence and headache have estimated lifetime but not 12-month prevalence. The researchers in this study examined the relationship between headache and posttraumatic stress disorder in a novel population, and estimated 12-month and lifetime prevalence rates of intimate partner violence. METHODS: Patients were recruited from a women's headache center (n = 92) during 2006-07 and completed the Migraine Disability Assessment measure of headache severity. Posttraumatic stress disorder was measured using a modified Breslau scale. Twelve-month and lifetime physical intimate partner violence were measured with the Partner Violence Screen and the STaT ("slapped, threatened and throw") measure. Multivariable regression determined factors independently associated with headache severity. RESULTS: Among all participants, 28.3% screened positive for posttraumatic stress disorder; 9.8% and 36.9% of women endorsed recent and lifetime intimate partner violence. Posttraumatic stress disorder was strongly associated with headache severity (ß = 34.12, p = 0.01). Patients reporting lifetime intimate partner violence exhibited a trend of nine additional days of disability due to headache over 90 days. CONCLUSIONS: Posttraumatic stress disorder and intimate partner violence occur among a sizable proportion of women referred for headache. The authors' findings reaffirm that clinicians treating women with headaches must be aware of the possibility of posttraumatic stress disorder and intimate partner violence in such patients.

Head and neck injuries in adult victims of intimate-partner violence.

OBJECTIVE: to quantify head and neck injuries in known adult victims of intimate-partner violence (IPV). DESIGN: retrospective chart review. SETTING: sexual assault and domestic violence program in a southeastern Ontario hospital. METHODS: all subjects over the age of 16 years consenting for evaluation by a domestic violence nurse from August 2004 until February 2009 were eligible for inclusion. Subjects for which no physical injury was documented were excluded. Data were extracted from body maps and surveys completed by a specially trained domestic violence nurse. Demographic data, mechanisms of injury, relationship to the assailant, and a history of IPV from the same assailant were collected from the survey. The type and anatomic location of the injury were collected from body maps. Injuries were categorized into six larger categories for analysis according to general anatomic area and multiplicity of areas involved. MAIN OUTCOME MEASURE: anatomic location of the injury. RESULTS: one hundred eight visits were eligible for inclusion in the study. Data on 657 injuries were recorded. The frequency of any head and neck injury was significantly greater than no head and neck injury (p < .001). In subjects experiencing multiple areas of injury, head and neck injuries were significantly more common than not (p < .001). In subjects experiencing only one area of injury, head and neck injuries were more common than lower extremity injuries alone (p = .003) and trunk injuries alone (p = .033) but not significantly more common than upper extremity injuries (p = .102). CONCLUSIONS: head and neck injuries are more common than not in known adult victims of IPV.

How and why community hospital clinicians document a positive screen for intimate partner violence: a cross-sectional study.

BACKGROUND: This two-part study examines primary care clinicians' chart documentation and attitudes when confronted by a positive waiting room screen for intimate partner violence (IPV). METHODS: Patients at community hospital-affiliated health centers completed a screening questionnaire in waiting rooms that primary care providers (PCPs) were subsequently given at the time of the visit. We first reviewed the medical records of patients who screened positive for IPV, evaluating the presence and quality of documentation. Next we administered a survey to PCPs that measured their knowledge, attitudes and practice regarding IPV. RESULTS: Seventy-two percent of charts contained some documentation of IPV, however only 10% contained both a referral and safety plan. PCPs were more likely to refer patients (p < .05) who screened positively for mood or anxiety disorders, disclosed that they feared for their safety or were economically disadvantaged. Those that feared for their safety or endorsed mood or anxiety disorders were more likely to have notation of a safety plan in their records. When surveyed, 81.6% of clinicians strongly agreed that it is their role to inquire about IPV, but only 68% expressed confidence in their ability to manage it. In contrast, 93% expressed confidence in managing depression. Sixty-seven percent identified time constraints as a barrier to care. Predictors of PCP confidence in treating patients who have experienced IPV (p < .05) included hours of recent training and clinical experience with IPV. CONCLUSION: Mandatory waiting room screening for IPV does not result in high levels of referral or safety planning by PCPs. Despite the implementation of a screening process, clinicians lack confidence and time to address IPV in their patient populations suggesting that alternative methods of training and supporting PCPs need to be developed.

Intimate partner violence and patient screening across medical specialties.

OBJECTIVES: The aims of this study were to compare rates of intimate partner violence (IPV) across different medical specialties and health care sites in one metropolitan area, describe demographic characteristics of women with abusive partners, characterize health care provider assessment of IPV, and describe patient characteristics associated with health care assessment for partner violence. METHODS: Women (N = 2,465) completed written surveys about partner violence and health care screening for violence in the waiting rooms of five types of health care settings (obstetrician/gynecologist office, emergency department, primary care office, pediatrics, and addiction recovery) across eight different hospitals in the greater Boston area. RESULTS: The overall survey response rate was 62%. The 12-month prevalence rate of IPV was 14%, with 37% disclosing lifetime prevalence. The highest rates of recent IPV were disclosed in the hospital-based addiction recovery unit (36%) and in emergency departments (17%). Adjusted demographic risk characteristics for IPV included age (younger than 24 years), low income, and unemployment. Health care providers were more likely to discuss IPV with low-income women than with middle- or high-income women but were no more likely to assess violence within the youngest age group. Among women who disclosed abuse to their health care provider, 50% reported receiving direct interventions or services as a result. CONCLUSIONS: Using the same instrument and protocol, different rates of IPV and detection of IPV were found across medical departments, with the highest rates in emergency departments and an addiction recovery program. It is especially important for assessment of IPV to include young women who present to medical departments.

Adverse health behaviors and the detection of partner violence by clinicians.

BACKGROUND: Intimate partner violence (IPV) is a major public health problem in the United States, and victims are commonly encountered in medical settings. Many barriers exist to clinician-initiated screening for IPV. However, smoking and problem drinking are conditions that clinicians commonly screen for and both have been strongly associated with IPV in prior studies. By estimating the predicted probability of 12-month and lifetime IPV for a given patient based on whether she presents with these conditions, our study gives clinicians information that can help them identify patients at risk for IPV. METHODS: A cross-sectional written patient survey was administered to 2386 female patients at 8 different health care settings in the Greater Boston (Mass) metropolitan area. The probabilities of 12-month and lifetime IPV were estimated based on the women's self-report of smoking and drinking behaviors. RESULTS: A woman who neither smoked nor engaged in problem drinking had a 10% probability of IPV in the preceding 12 months and a 39% chance of IPV in her lifetime. Smoking increased the probability to 14% and 49%, respectively. Problem drinking resulted in a doubling of the predicted probability of 12-month IPV to 21%, with a lifetime probability of 43%. When both conditions were present, the effects were additive, with a woman having a 27% probability of experiencing IPV in the preceding 12 months and 54% chance of IPV in her lifetime. CONCLUSIONS: The presence of smoking or problem drinking should raise clinicians' suspicion for IPV. This paradigm should not replace direct questioning about IPV but may aid in the detection of abuse in patient populations.