Intimate Partner Violence Against Women Unmet Needs for Care and Helpseeking Behavior

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Intimate Partner Violence Against WomenUnmet
Needs for Care and Helpseeking Behavior

• Stacey Plichta, Sc.D.

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Overview

• There is abundant evidence that IPV negatively
  affects both physical and mental health, and that
  these effects can be long-term.
• It is clear that IPV victims are present in the
  health care system in the same or greater numbers
  than other women. However, little is known about
  the factors that lead women to either seek or
  avoid care.

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Purpose

• This study seeks to fill a gap in the literature
  by addressing two questions
• What is the relationship of experiencing intimate
  partner violence against women (IPVAW) to having
  an unmet need for medical care in a
  community-based sample of women?
• Among women harmed by IPVAW, what factors are
  associated with seeking out medical care for
  health conditions related to the violence?

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Does IPV Really Happen?

• It is well established and generally accepted
  that women are at significant risk of IPV, with
  over 5.3 million IPV victimizations occurring
  each year.
• Lifetime prevalence 22.1-34.5
• Incidence 6-9 of all women age 18-64
• Lower rates, but still occurs in older (65) women

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Does IPV affect health?

• There is abundant evidence that IPV negatively
  affects both physical and mental health, and that
  these effects can be long-term.
• These effects are summarized in numerous
  literature reviews dating from 1992-present, as
  well as some more current studies.
• Few scholars seriously question the connection
  between IPV and poorer health status, although
  the mechanism is still under investigation for
  longer term physical problems such as chronic
  headache and GI issues.

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Health IPV

• Potential Short Term Effects
• Mortality
• Injury
• Chronic pain
• Poorer pregnancy outcomes
• Unintended pregnancy
• Sexually transmitted diseases
• Decreased immune response
• Mental health problems

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Health IPV

• Potential Long Term Effects
• Disability (physical and/or sexual)
• Gastrointestinal disorders
• Traumatic brain injury
• Post-traumatic stress disorder
• Depression anxiety
• Suicidal thoughts, suicide attempts, suicide
• Substance Abuse/Addiction
• Increased risk of future victimization

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How much does IPV cost?

• CDC Estimates
• 5.8 Billion each year
• 4.1 Billion direct medical and mental health
  care costs.

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How Much Does IPV Cost?

• IPV costs health care plans significantly more
  per year than other women
• Undetected IPV can also be costly, as one study
  found that resident physicians spent 2x as much
  on lab and screening tests

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Are IPV Victims in the Healthcare System?

• IPV victims are at least as likely, if not more
  likely, to be found in both primary and specialty
  health care settings, as well as in the emergency
  department (ED).

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IPV Victims in Inpatient Settings

• The CDC estimates that more than 807,000
  overnight hospital stays are directly due to IPV
• One survey of 127 women at a surgical trauma
  service found that 18 screened positive for
  recent IPV
• Another study, of 131 consecutive female
  admissions to a non-trauma unit found a lifetime
  rate of IPV of 26

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IPV Victims in Primary Care

• The number of outpatient physician visits due
  directly to IPVeach year is estimated to be more
  than 971,000 by the CDC.
• The CDC also estimates that more than 232,000
  dental visits, and more than 1 million physical
  therapy visits each year are directly because of
  IPV

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IPV Victims in Primary Care

• Population-based surveys indicate that women who
  are abused obtain routine care at least as often
  as others
• Studies in clinical settings have similar
  findings
• Primary care settings typically find lifetime
  prevalence rates ranging from 12 to 46, and
  1-year prevalence rates ranging from 5 to 32

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Unmet Needs for Care

• Despite the fact they use health care at a
  similar level as do other women, IPVAW victims
  are likely to have unmet needs for medical care
  than are other women
• A nationally representative survey of women (CWF
  1998) found that IPVAW victims were twice as
  likely to say they had an unmet need for medical
  care than were others even when health status,
  access to care, and demographic characteristics
  are controlled for.
• Few other studies, however, have examined this
  relationship using community based samples and
  multivariate statistics.

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IPV Victims Impressions of HCP

• There is a limited literature which indicates
  that IPV victims report less satisfaction and
  worse communication with their providers than do
  other women.

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IPV Victims Impressions of HCP

• IPV victims report less satisfaction and worse
  communication with their providers than do other
  women.

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Are IPV Victims in the Healthcare System?

• The general consensus in the literature is that
  abused women are present in the health care
  system, but are not detected without active
  assessment on the part of the health care
  provider.

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Purpose

• This study seeks to examine the relationship of
  IPVAW to having an unmet need for medical care in
  a community-based sample of women.
• This study also examines the factors related to
  seeking out medical care for health conditions
  related to IPVAW in the same sample.

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Methods

• This study was a cross-sectional, random-digit
  dial telephone survey of community-residing women
  in the Virginia Beach-Norfolk-Newport News MSA
  (population 1.5 million).
• Telephone calls were made over a two month period
  by trained interviewers using a CATI system.
• A 20 minute survey, largely based upon the BRFSS,
  asked women about
• IPVAW Health status
• Access to care Use of health services
• Patient-provider relationships

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Methods

• Lifetime IPVAW was ascertained by two questions
• 1. An intimate partner can mean someone you dated
  or a spouse. Has an intimate partner ever
  threatened to hit, slap, push, kick, or
  physically hurt you?
• 2. Has an intimate partner ever hit, slapped,
  pushed, kicked, physically hurt you, or forced
  you to have sex?

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Methods

• Limitation of the question
• Single item IPV questions typically lead to
  underreporting and lower estimates of IPV
• Does not measure other types of abuse such as
  emotional, financial or stalking
• Was asked over the phone this may lead to
  underreporting

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Methods

• A total of 1,103 women responded.
• Of these, 240 (22) reported lifetime IPVAW or
  threat of IPVAW
• Of these 240, most (85 or 204) reported lifetime
  IPVAW that went beyond the threat stage.

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Description of Sample

• The survey respondents are similar to women
  living in the MSA.
• Average age 48 years (sd 16.7) (range 18-99)
• Ethnically Identity
• 70 are White
• 25 are African-American
• 5 are other
• Marital Status
• 59 are married
• 26 are single or widowed
• 15 are divorced or separated

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Description of Sample

• Household Income
• 35 have a household income of
• 40,000 or less.
• Access to Care
• 5 have no usual place of care
• 15 Use public clinics
• 77 Have a private MD
• 8 Use an employer provided
• health center.
• 89 were insured for all of the past year.

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Results

• Results related to the first research
  questionIs IPV related to having an unmet need
  for care?
• Note that IPVAW here is defined as IPVAW or
  threat of IPVAW

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Results

• Overall, 11 of the women in the study needed
  medical care in the past year but did not receive
  it.
• Women with lifetime IPVAW were significantly more
  likely to report an unmet need for care than
  other women (19.6 vs. 7.8, plt.00

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Results

• USE OF HEALTH CARE
• The average number of visits per year was 5.23
  (sd 7.21) and this did not differ between IPVAW
  victims and other women.
• The use of preventive services did not differ
  between the two groups.
• Women with lifetime IPVAW were significantly more
  likely to have had an ED visit in the past year
  (35 vs. 20, plt.00).

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Results

• Demographic differences
• Compared to other women, those who reported
  lifetime IPVAW were
• Younger (average age 43.9 vs. 49.0 plt.00)
• More likely to be divorced (26 vs. 12, plt.00)
• Similar ethnically to other women
• More likely to be lower income (39 vs. 31
  plt.02)

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Results

• Health Status differences
• Compared to other women, those who reported
  lifetime IPVAW were
• No more likely to rate their health as fair/poor
  than were other women (13 overall)
• More likely to report being diagnosed with an
  anxiety or depressive disorder (28 vs. 18,
  plt.00)

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Results

• Health Access Differences
• Compared to other women, those who reported
  lifetime IPVAW were
• More likely to be uninsured for at least part of
  the year (19 vs. 9, plt.00).
• More likely to have no health care or to rely on
  public clinics (10 vs. 5, plt.00)
• More likely to report poor communication with
  their MD (13 vs. 7, plt.01)

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Results
Logistic Regression Model Predictors of Having an Unmet Need for Care in the Past Year Logistic Regression Model Predictors of Having an Unmet Need for Care in the Past Year Logistic Regression Model Predictors of Having an Unmet Need for Care in the Past Year
Variable OR (CI) Beta (se)
Ever experienced IPV 2.23 (1.35, 3.69) 0.80 (.26)
Poor communication with MD 6.16 (3.36, 11.30) 1.81 (.31)
Uninsured for part/all of the past year 6.07 (3.38, 10.91) 1.80 (.30)
Has private MD or work clinic as their usual source of care 1.0 Reference 1.0 Reference
Has public clinic as usual source of care 1.89 (.986, 3.62) .64 (.33)
Has no usual source of care 2.39 (1.06, 5.40) .87 (.42)
Rates own health as fair/poor 2.81 (1.52, 5.19) 1.03 (.31)
Note This model also controls for age, ethnicity, marital status, income and a diagnosis of anxiety or depression. None of these were significant predictors of having an unmet need for care. Note This model also controls for age, ethnicity, marital status, income and a diagnosis of anxiety or depression. None of these were significant predictors of having an unmet need for care. Note This model also controls for age, ethnicity, marital status, income and a diagnosis of anxiety or depression. None of these were significant predictors of having an unmet need for care.
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Results

• Women who experienced IPV are twice as likely to
  have an unmet need for care than other women,
  even when SES, health, and access to care
  variables are controlled for.
• Women with any IPVAW also fare worse on other
  factors associated with having an unmet need for
  medical care.

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Results

• Results related to the second research
  questionAmong women harmed by IPVAW, what
  factors are associated with women seeking care
  for injuries or conditions associated with the
  IPVAW?
• Note that IPVAW here is defined as IPVAW that
  occurred (n204).

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Results

• Only 33 sought care for conditions associated
  with the IPVAW.
• Of these, two-thirds disclosed the IPVAW to their
  health care provider.
• There were no overall differences in health care
  utilization ( outpatient visits, use of ED)
  between women who did and did not seek care for
  IPVAW related conditions.

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Results
Logistic Regression Model Predictors of Care-seeking for IPVAW related conditions Logistic Regression Model Predictors of Care-seeking for IPVAW related conditions Logistic Regression Model Predictors of Care-seeking for IPVAW related conditions
Variable OR (CI) Beta (se)
Good communication with MD 5.35 (1.14, 28.3) 1.73 (.82)
Divorced 2.61 (1.07, 6.40) .96 (.46)
Note This model also controls for age, ethnicity, income, higher use of outpatient services, insurance and a usual source of care. Note This model also controls for age, ethnicity, income, higher use of outpatient services, insurance and a usual source of care. Note This model also controls for age, ethnicity, income, higher use of outpatient services, insurance and a usual source of care.
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Results

• A logistic regression model that controlled for
  sociodemographic characteristics, high use of
  services and access to care found that only being
  divorced and reporting good communication with
  their MD significantly increased the odds of
  seeking medical care for IPVAW associated health
  care problems.

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Conclusions

• This study provides evidence that IPVAW victims
  frequently use in the health care system, but do
  still have unmet needs for care.
• There are a number of factors related to having
  an unmet need for care and it appears that prior
  IPVAW victimization is one of them.

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Conclusions

• Health care providers need to ask women about
  experiences of IPV to ensure that their patients
  receive appropriate care and referrals.
• Good patient-provider communication is critical
  to the care of IPVAW victims.
• Women may not even seek out care if they are not
  comfortable with their provider.

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Conclusions

• IPVAW victims will receive sub-optimal treatment
  if their health care providers are unaware of the
  violence.

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Conclusions

• The majority of both heath care providers and
  patients support assessing for IPVAW in the
  clinical setting.
• Few health care settings formally require
• The majority of health care providers do not
  inquire about IPVAW.

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Conclusions

• In general, health care providers do not
  routinely screen or assess women for IPVAW
• Studies report it is difficult to obtain and
  maintain screening behavior in healthcare
  settings.
• Only a minority of women (16-25), even women who
  are abused, report ever being asked about IPV in
  the health setting

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Conclusions

• Physicians report being uncomfortable discussing
  IPV
• A substantial percentage hold negative beliefs
  about women who are abused
• Even those physicians committed to screening for
  IPV find the work difficult and not generally
  supported by the systems within which they work

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Conclusions

• Health care providers are not likely to assess
  women for IPV unless the health care system that
  they work in is supportive of such efforts.
• Health care settings need formal policies and
  protocols in place to assist providers
  communicating openly about IPVAW with patients.

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Conclusions

• Until recently, virtually all peer-reviewed
  articles, policy statements and clinical
  guidelines encouraged health care providers to
  engage in IPVAW screening, treatment and referral
  activities.

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Conclusions

• The U.S. Preventative Task Force has formally
  concluded that insufficient evidence exists to
  support routine screening in the primary care
  screening.
• This may cause further reductions in the level of
  care provided to IPVAW victims, as many health
  care systems and individual practitioners employ
  the U.S. Preventative Task Force guidelines in
  their practice.

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Screening Tools
Author Screen Description Population
McFarlane AAS Abuse Assessment Screen Pregnant
Ernst OAS Ongoing abuse screen ED
Sherin HITS Hurt, Insulted, Threatened, or Screamed at. Family Practice
Feldhaus PVS Partner Violence Scale ED
Neufield SAFE Safety, Afraid/abused, Friend or family aware, Emergency plan Office setting
Smith WEB Womens Experience of Battering Family practice
Brown WAST Women Abuse Screening Tool Family Practice
Campbell DA Danger Assessment IPV victims