Detecting Intimate Partner Violence in Primary Care Settings

1
Detecting Intimate Partner Violence in Primary
Care Settings

• Valerie M. Kramer, MS-1
• Elizabeth C. McCord, MS, MD, FAAFP
• James H. Quillen College of Medicine

2
Introduction Definition of IPV

• Intimate Partner Violence (IPV) a pattern of
  physical and/or sexual abuse perpetrated by one
  spouse or intimate partner upon the other

3
Introduction Effects of IPV

• Common cause of significant morbidity and
  mortality
• Affects 4.8 MILLION females and 2.9 MILLION males
  per year
• Results in approximately 1,830 homicides at an
  estimated cost of 5.8 billion dollars per year

4
Introduction IPV Detection Double Standard

• Universal IPV screening for women since 1992
• To date, no standard screening for men as
  perpetrators or victims of IPV

5
Introduction Rationale for Screening

• Identification of males involved in IPV is
  essential, as it contributes to
• Understanding of the patient and his symptoms
• Reduction of morbidity and mortality
• Cessation of battering

6
Introduction Treatment Programs

• Batterer Intervention and Prevention Programs
  (BIPP)
• Commonly court-ordered
• Therapy
• Results in decreased IPV

7
Research Purpose

• To determine acceptable and effective
  communication and questioning strategies to
  detect IPV in men

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Methods
PHASE ONE
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MethodsScreening Questions Developed from Phase
One Focus Groups
10
Methods
PHASE ONE
Data Collection Screening Items Focus Groups
PHASE TWO
11
Methods Modified Screening Items from Phase Two
Focus Groups
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Methods
PHASE ONE
Data Collection Screening Items Focus Groups
Quantitative Analysis Likert Scale Data
PHASE TWO
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MethodsQuantitatively Selected Screening Items
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Methods
PHASE ONE
Quantitative Analysis Selection of Best 11
Screening Items
Data Collection Screening Items Focus Groups
Qualitative Analysis Selection of Best 8
Screening Items
PHASE TWO
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ResultsEthnicity of Phase Two Participants
n73 Due to missing data
Percentage
Ethnicity
16
ResultsWork Status of Phase Two Participants
n71 Due to missing data
17
Results Relationship Status of Phase Two
Participants
n73 Due to missing data
18
Results Educational Background of Phase Two
Participants
n73 Due to missing data
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Results Gender of Phase Two Participants
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ResultsQuantitatively Selected Screening Items
21
Results How are Things at Home?

• Focus Group Findings
• Doctor might naturally ask this question
• Would be good as an opener
• Kind of, I dont know, set it as a point to
  where its like a friendly, friend-on-friend
  talking you know, How are things? How you been
  doing? kind of break the ice and let them mellow
  out a little bit
• Shows concern
• You know, youre showing a concern

22
Results How are things at Home?

• Recommendation
• Keep this question
• Respondents expressed comfort with the question
• Respondents advocated that it be asked early in
  the conversation with their doctor.

23
Results How is Your Family Life?

• Focus Group Findings
• Same as How are things at home?
• Theyre equal. I rated them the same.
• Not as good as How are things at home?
• I like How are things at home? a lot better
  because lots of people theres no family at their
  home. Like me, I practically dont have any
  family life. Theyre either all dead or gone.

24
Results How is Your Family Life?

• Recommendation
• Eliminate this question
• The same or worse than How are things at home?
• Insensitive to individuals without families.

25
Results Did you ever see violence as a child
between your parents or parental figures?

• Focus Group Findings
• Important question
• Could promote disclosure
• almost anybody thats ever had violence with
  their parents or guardians or whatever, they are
  going to open up to you.
• Might make some people uncomfortable
• Its an important question, but I dont know if
  you should tell it to or bring it up the first
  time in the office.
• Confidentiality

26
Results Did you ever see violence as a child
between your parents or parental figures?

• Recommendation
• Eliminate this question
• Uncomfortable unless good rapport established
• Multiple respondents indicated that it should be
  asked following disclosure of IPV, which would
  limit its effectiveness as a screening item

27
Results Stress Questions -How much stress
have you had lately?-When you are stressed, how
do you vent your stress?-You seem to be under a
lot of stress. What seems to be causing the
stress?

• Focus Group Findings
• Overall the stress questions are good
• Good as opening questions
• So like I say any of those three really as an
  opener I think would get you a lot of feedback.
• You seem to be under a lot of stress was
  preferred to How much stress have you had
  lately?

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Results Stress Questions -How much stress
have you had lately?-When you are stressed, how
do you vent your stress?-You seem to be under a
lot of stress. What seems to be causing the
stress?

• Recommendation
• Keep these questions
• Adjust order of question depending on patients
  symptoms
• Place near the beginning of screening strategy

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Results In general, how would you describe
your relationship? A lot of tension, some
tension, no tension?

• Focus Group Findings
• Good question overall, non-threatening
• reasonable, good straight question, fair,
  pretty harmless, not pointing any fingers
• Respondents indicated both a preference for and
  against the three options at the end
• It options at the end makes you more
  comfortable because youre not having to uh, at
  this point not giving a detailed, uh . .
• at least it would give them something to start
  with.
• You know, you word it like that, theyre going
  to think theyre taking a test.

30
Results In general, how would you describe
your relationship? A lot of tension, some
tension, no tension?

• Recommendation
• Keep this question
• Options provide a starting point
• Place later in the screening strategy

31
Results Do you and your partner work out
arguments with great difficulty, some difficult,
no difficulty?

• Focus Group Findings
• Good question
• Thats a good question.
• (INT) Thats a good question?
• Yeah. You dont feel any pressure in it.
• Should be more open-ended
• You could say, How do you work out your
  arguments?
• Should come later in the screening strategy

32
Results Do you and your partner work out
arguments with great difficulty, some difficult,
no difficulty?

• Recommendation
• Keep this question with changes
• Reword this as an open-ended question
• Place this question later in the screening
  strategy

33
Results I know youve been having trouble
with your nerves lately. People often have
trouble with their nerves when they are having
difficulty in their relationships. I wonder if
youve been having difficulty in your
relationship?

• Focus Group Findings
• Good question
• Potential to sound impersonal
• I think its an excellent statement but I think
  it sounds kind of faulty and like youre just in
  3rd person to some simple thing.
• Because the is just you stating another textbook
  fact in there.
• (INT) (1) Uh huh.
• You know people often have trouble with their
  relationship, blah, blah, blah, if you dont end
  that with something personal, it just sounds like
  you more doctor bull crap.

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Results I know youve been having trouble
with your nerves lately. People often have
trouble with their nerves when they are having
difficulty in their relationships. I wonder if
youve been having difficulty in your
relationship?

• Focus Group Findings
• Could be rephrased to fit patient symptoms
• Just use whatever the patient had told you.
• Yeah.
• You could easily replace nerves with people
  often have trouble with depression, people often
  have trouble with anxiety, people often have
  trouble with sleep deprivation, whenever youre
  having trouble in relationships. It could be
  anything.
• Should come early in the screening strategy

35
Results I know youve been having trouble
with your nerves lately. People often have
trouble with their nerves when they are having
difficulty in their relationships. I wonder if
youve been having difficulty in your
relationship?

• Recommendation
• Keep this question
• Reword the question to fit each patients
  symptoms
• Place near the beginning of the screening
  strategy

36
Results I want you to know that whatever you
tell me is confidential, unless we decide
together we need to talk with someone else, or I
think you or someone else is in serious danger.

• Focus Group Findings
• Respondents valued the discussion of
  confidentiality
• You open up that kind of topic - you should let
  everybody know it should be confidential.
• (INT) Do you all think thats something that
  really ought to be in there or is that something
  you know already and you assume?
• Oh, no. I would like to hear it again though.

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Results I want you to know that whatever you
tell me is confidential, unless we decide
together we need to talk with someone else, or I
think you or someone else is in serious danger.

• Focus Group Findings
• Respondents felt threatened by the unless
  phrase
• I think, wait a minute Im not a killer. Id
  take that out but I dont know other than that,
  that would be a good question to start off with.
  
• (INT) Would you word that that way?
• I think you could just drop that last phrase
  out of it.
• (INT) Yet the problem with that is, its the
  truth.
• Yeah, well, it is who says youve got tell
  people the truth?

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Results I want you to know that whatever you
tell me is confidential, unless we decide
together we need to talk with someone else, or I
think you or someone else is in serious danger.

• Focus Group Findings
• Respondents felt threatened by the unless
  phrase (Cont.)
• No, Im serious, listen, if youre really
  interested in figuring stuff out about this
  person and it would be like I will let you know
  that whatever you tell me is confidential, unless
  we decide we will talk to someone else . . .Cause
  then they cant open up to you like if they do
  hit their wife or their boyfriend or girlfriend
  or whatever theyre not going to tell you . . .
• (INT) Yeah.
• Theyre not going to tell you.

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Results I want you to know that whatever you
tell me is confidential, unless we decide
together we need to talk with someone else, or I
think you or someone else is in serious danger.

• Focus Group Findings
• Respondents felt threatened by the unless
  phrase (Cont.)
• Thats the way I look at it. I feel threatened
  by that last . . .
• Or - you put them in a position where they cant
  trust you, you know? What if you feel like you
  need to talk to someone else on your own and then
  you know, this is supposed to be a discussion
  between two people - not just one counselor
• That last sentence - I was listening and saying
  to myself - seems like youre the judge, jury,
  and the executioner. You know what I mean? Does
  that make sense?

40
Results I want you to know that whatever you
tell me is confidential, unless we decide
together we need to talk with someone else, or I
think you or someone else is in serious danger.

• Recommendation
• Eliminate this question
• Strong reaction against the unless phrase
• The unless phrase might create resistance to
  any disclosure of IPV
• Using the first phrase without the unless
  phrase might mislead the patient or create an
  ethical dilemma for the physician.

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Results Conflict is a serious health problem
for many in our society. It affect the health of
the entire family, children as well as their
parents.

• Focus Group Findings
• No compelling qualitative data to keep or remove
  this question
• Recommendation
• Keep this question
• More research is needed

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Discussion Screening Strategy Recommendations
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Discussion Screening Strategy Recommendations
How are things at home?
Stress Questions
I know youve been having trouble with
Opening Questions
Specific Relationship Screening Items

• How would you describe your relationship?
  Tension
• Conflict is a serious health problem for many
• How do you and your partner work out arguments?

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Future Research

• These results are being used in a federal grant
  proposal to further evaluate this IPV screening
  strategy for men

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This work was supported in part by grants from
the Bureau of Health Professions Health Resources
Administration, awarded toEast Tennessee State
UniversityJames H. Quillen College of
MedicineDepartment of Family Medicine Grant
No. 1 D12 HP 00130 01 Grant No. 1 D 16 HP00145
01.
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References