Middle-aged Women's Experiences of Intimate Partner Violence Screening and Disclosure: "It's a private matter. It's an embarrassing situation".

BACKGROUND: National guidelines indicate that healthcare providers should routinely screen women of reproductive age for experience of intimate partner violence. We know little about intimate partner violence (IPV) screening and disclosure experience among women older than reproductive age. OBJECTIVE: To examine the perspectives of middle-aged women who had experienced past-year IPV regarding IPV screening and disclosure in the healthcare setting. DESIGN: Individual semi-structured qualitative interviews were conducted in-person as part of a larger study examining IPV screening and response services through the Veterans Health Administration. PARTICIPANTS: Twenty-seven women aged 45-64 (mean age 53) who experienced past-year IPV and received care at one of two Veterans Affairs Medical Centers. APPROACH: Interviews were digitally recorded and transcribed. Data were sorted and analyzed using templated notes and line-by-line coding, based on codes developed by the study team through an initial review of the data. Themes were derived from further analysis of the data coded for "screening" and "disclosure" for respondents aged 45 and older. KEY RESULTS: Barriers to disclosure of IPV to a healthcare provider included as follows: (a) feelings of shame, stigma, and/or embarrassment about experiencing IPV; (b) screening context not feeling comfortable or supportive, including lack of comfort with or trust in the provider and/or a perception that screening was conducted in a way that felt impersonal and uncaring; and (c) concerns about privacy and safety related to disclosure. Provider demonstrations of care, empathy, and support facilitated disclosure and feelings of empowerment following disclosure. CONCLUSIONS: Middle-aged women may benefit from routine IPV screening and response in the healthcare setting. Such interventions should be sensitive to concerns regarding stigma and privacy that may be prevalent among this population.

Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health.

BACKGROUND: The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services. OBJECTIVE: This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016. APPROACH: Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach. KEY RESULTS: Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening. CONCLUSIONS: Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.

Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness.

Effectiveness of screening for homelessness in a large healthcare system was evaluated in terms of successfully referring and connecting patients with appropriate prevention or intervention services. Screening and healthcare services data from nearly 6 million U.S. military veterans were analyzed. Veterans either screened positive for current or risk of housing instability, or negative for both. Current living situation was used to validate results of screening. Administrative evidence for homelessness-related services was significantly higher among positive-screen veterans who accepted a referral for services compared to those who declined. Screening for current or risk of homelessness led to earlier identification, which led to earlier and more extensive service engagement.

Development and validation of an instrument to assess imminent risk of homelessness among veterans.

OBJECTIVES: Veterans are overrepresented within the homeless population compared with their non-veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among veterans accessing VA health care. METHODS: The study team developed initial assessment items, conducted cognitive interviews with veterans experiencing homelessness, refined pilot items based on veterans' and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk. RESULTS: One-third of veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not. CONCLUSION: This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for veterans who are experiencing or are at risk for homelessness.

Universal screening for homelessness and risk for homelessness in the Veterans Health Administration.

We examined data for all veterans who completed the Veterans Health Administration's national homelessness screening instrument between October 1, 2012, and January 10, 2013. Among veterans who were not engaged with the US Department of Veterans Affairs homeless system and presented for primary care services, the prevalence of recent housing instability or homelessness was 0.9% and homelessness risk was 1.2%. Future research will refine outreach strategies, targeting of prevention resources, and development of novel interventions.