Role of Victims' Services in Improving Intimate Partner Violence Screening by Trained Maternal and Child Health-Care Providers - Boston, Massachusetts, 1994-1995

From 1992 to 1996, approximately 1 million incidents of nonfatal intimate partner violence (IPV) occurred each year in the United States; 85% of victims were women (1). In 1989, pediatric research found a concurrence of victimization of mothers and their children and supported a recommendation that maternal and child health-care providers (HCPs) pursue training and advocate for increased access to services to promote the safety and well-being of mothers and their children (2). From 1992 to 1997, the Pediatric Family Violence Awareness Project (PFVAP), a training project for maternal and child HCPs, promoted prevention of and intervention for IPV in Massachusetts (3). In 1994, PFVAP conducted a pilot evaluation in two urban community health centers to determine whether HCPs trained to conduct IPV assessment would increase their screening rates of women at risk for IPV if an on-site referral service for victims was available. This report summarizes the results of the pilot project, which indicate that IPV screening rates did not increase after implementing on-site victim services.

Screening rates were assessed for 14 HCPs at two community health centers (centers A and B) in a low-income, racially mixed, urban community in the Boston area. Because the two centers were dissimilar in patient demographics and other characteristics, one could not be compared with the other. Therefore, a phased intervention design was used; IPV screening was measured during two 10-week periods (phases 1 and 2). Phase 1 followed a 2-hour group training session to teach HCPs to implement a brief screening protocol* of female patients and mothers of pediatric patients aged 0-12 years during routine visits using a recommended screening schedule.** Phase 2 followed implementation of on-site victim services that offered weekly support groups separately for battered women and children using the identical protocol as in Phase 1. Between the end of phase 1 and the beginning of phase 2, there was a 3-month period.

To document screening in each phase, HCPs recorded during each visit with each female adult patient and each mother of a pediatric patient whether 1) the patient received IPV screening and who performed the screening; 2) any family members were present during the patient visit; and 3) a staff interpreter was present during the visit. Date of birth, race/ethnicity, marital status, date and type of visit, and diagnosis were gathered from the patients' files. A physician subsequently coded diagnoses into the following categories: routine health-care maintenance, prenatal care, acute/sick, chronic problem, injury, psychosocial, human immunodeficiency virus/sexually transmitted diseases (HIV/STD), and pain.

For both phases, an observed screening rate was calculated for each HCP and defined as the proportion of the HCPs' patients seen and screened by the HCP during that period. Although the PFVAP protocol recommended screening some patients (pregnant women and mothers of children aged less than 2 years) more than once a year, patients who were screened at least once during phase 1 were considered "previously screened" and were not included in calculating phase 2 screening rates.

The combined data from both health centers and both phases (after exclusions) (Table 1) comprised 14 HCPs, 642 patients, and 1352 patient visits. Each patient's final screening status (ever or never screened) was based on combined data from each phase and was evaluated relative to patient demographics and visit characteristics by two separate logistic regression models.

Eleven (79%) of 14 HCPs did not demonstrate increased screening during phase 2, following on-site services implementation. Unadjusted combined screening rates for both health centers decreased significantly from phase 1 (33% patients screened) to phase 2 (23%) (p less than 0.03). For each phase, health center A had approximately twice the documented screening rate of health center B. On average, screening rates declined 7.4% (standard deviation [SD]=15.7 percentage points) at health center A and 14.1% (SD=17.5 percentage points) at health center B.

At both health centers, unadjusted individual HCP screening rates varied during both phases from 1.8% to 92.8% during phase 1 and from 0 to 94.9% during phase 2. The degree of change in HCP screening rates also varied widely. Individual HCP screening rates of decline ranged from 1.8 to 46.6 percentage points. For the three HCPs who demonstrated increases between phase 1 and phase 2, the increase ranged from 0.6 to 24.7 percentage points.

Analyses of visit, HCP, and patient characteristics controlled for health center and used combined rates from both phases to improve the stability of estimates. Several aspects of patient visits predicted the likelihood of screening. Patients were screened more often during routine visits (p less than 0.01). However, screening was 23 times more likely during adult medical visits (p less than 0.01) and 10 times more likely during gynecologic visits (p less than 0.01) than during pediatric visits. Diagnostic categories also were related significantly to screening status. Patients seeking treatment for pain were four times more likely to be screened (p less than 0.03). A combined variable of injury, HIV/STD, and psychosocial problems also was a significant predictor of screening (p less than 0.04). Of the patient characteristics examined, only unknown marital status was a significant predictor of screening status, with women of unknown marital status less likely (p less than 0.01) to be screened than married patients.

Reported by L McKibben, MD, AC Hauf, Carney Hospital; A Must, PhD, Dept of Family Medicine and Community Health, Tufts Univ School of Medicine, Boston; EL Roberts, MSW, Women's Health Unit, Bur of Family and Community Health, Massachusetts Dept of Public Health. Family and Intimate Violence Prevention Team, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

The results of this study suggest that the availability of on-site services for IPV victims alone may not be sufficient to overcome trained HCPs' perceptions of IPV as a problem for which they are ill-prepared to intervene (4). Systems approaches, such as continuous quality improvement in community health centers, may be more likely to sustain improved IPV screening rates through institutional policies linked to accountability (5). The impact of case mix on provider- and institutional-level IPV screening rates also requires more study. However, clinicians' adherence to the recommended practices to screen routinely all women at risk for IPV should be encouraged (6,7).

The findings in this report are subject to at least three limitations. First, because a convenience sample of community health centers was used, the results cannot be generalized to other community health centers or HCPs in the rest of Massachusetts or elsewhere. Second, the quasi-experimental design, which lacked a concurrent control, does not account for secular changes in screening behavior that may have occurred over the course of the study. Finally, phase 2 was delayed to involve the community health centers' administrative and clinical staff in the process of selecting IPV advocates and to address other administrative details of service development. Because data were not collected on the screening rates of HCPs immediately before phase 2, the effects of the on-site victims' services on individual HCPs cannot be determined fully.

Maternal and child HCPs see many battered women and their children in various settings, but rarely ask about family violence and IPV (6-9). Practitioners need additional training and support to assess and manage complex cases of family violence longitudinally (10). Further research to explore effective IPV interventions in health-care settings is needed.

References

1. Greenfield LA, Rand MR, Craven D, et al. Violence by intimates: analysis of data on crimes by current or former spouses, boyfriends, and girlfriends. Washington, DC: US Department of Justice, 1998. (Bureau of Justice Statistics factbook, publication no. NCJ-167237).
2. McKibben L, DeVos E, Newberger E. Victimization of mothers of abused children: a controlled study. Pediatrics 1989;84:531-5.
3. McKibben L, Roberts EL. The Pediatric Family Violence Awareness Project curriculum: a collaborative approach to family violence education. Workshop presented at the annual meeting of the Ambulatory Pediatric Association, Washington, DC, May 1996.
4. Sugg NK, Inui T. Primary care physicians' responses to domestic violence: opening Pandora's box. JAMA 1992;267:3157-60.
5. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med 1998;128:651-6.
6. Flitcraft AH, Hadley SM, Hendricks-Matthews MK, et al. Diagnostic and treatment guidelines on domestic violence. Chicago, Illinois: American Medical Association, 1992.
7. American Academy of Pediatrics. The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics 1998;101:1091-2.
8. Stark E, Flitcraft AH. Spouse abuse. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York, New York: Oxford University Press, 1991.
9. Gazmararian JA, Lazorick S, Spitz AM, et al. Prevalence of violence against pregnant women. JAMA 1996;275:1915-20.
10. Saunders DG, Kindy P. Predictors of physician's responses to woman abuse: the role of gender, background, and brief training. J Gen Int Med 1993;8:606-9.

* Suggested questions were 1) "I ask all my patients, do you feel safe in your home?"; 2) "Is anyone hurting you, harassing you, or making you feel afraid?"; and 3) "At any time, has your partner ever pushed, hit, or kicked you?"

** The recommended schedule consisted of screening 1) adult and adolescent females during routine gynecologic, internal or family medicine, or pediatric visits annually; 2) mothers of pediatric patients aged 2-12 years annually; 3) mothers of pediatric patients aged 0-2 years twice annually; and 4) patients during prenatal-care visits once per trimester.

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