Intimate Partner Violence and the Role of the Primary Care Provider

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Intimate Partner Violence and the Role of the
Primary Care Provider

• Rebecca L. Cupp
• Advisor
• Julie Gurwell, Ph.D

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Intimate Partner Violence

• CDC Definition Physical, sexual, or
  psychological harm by a current or former partner
  or spouse.
• Characteristics of IPV
• Cycle of Violence
• Phase 1 Tension Building
• Phase 2 Battering
• Phase 3 Honeymoon Phase
• Power of Control Wheel

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IPV Prevalence

• Primary Care Practitioners will be exposed to IPV
  at some point in their practice, if not daily!
• In 2000, 1 out of 4 women in US and 7.6 men
  reported to have been physically assaulted or
  raped by current or former spouse, partner, or
  date in their lifetime.
• Women from Kentucky have higher risk 37.4
  lifetime prevalence.
• 1 out of 9 adult women in KY has been the victim
  of rape.

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Impact on physical and mental health

• Many negative implications, including
• Immediate consequences
• Unplanned/unwanted pregnancy
• STIs
• Trauma
• Death
• Mental health depression, PTSD
• Chronic health problems
• Headaches, Chronic pelvic pain, appetite loss,
  stomach ulcers
• Children exposed to IPV
• Traumatic, life-long impact
• 4-6 fold increase of being abused themselves as
  adults
• Poor weight gain, sleep disturbance, irritability

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Barriers to Communication

• One study found only 13 of women had ever been
  asked about IPV by their healthcare provider.
• Significant Barriers to Communication
• Provider Barriers
• Lack of time, lack of education and experience on
  the topic, taboo of subject
• Patient Barriers
• Fearful to retaliation by partner, need to
  protect partner, patients prior experiences with
  healthcare providers, judgmental attitudes of
  practitioners.
• May believe there is nothing that can be done to
  help them.
• Unique concerns in rural areas
• Social isolation, low economic status, geographic
  barriers

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Risk Factors

• Victim
• Young age, Low educational achievement, Marital
  Conflicts, Traditional Gender Roles, economic
  stress
• Pregnancy, especially in adolescence
• 41 women aged 18 or younger who have children
  have reported being abused.
• Perpetrator
• Victim or witness of abuse at young age, alcohol
  use, low academic achievement, low self-esteem.

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Role of the Health Care Provider

• Often PCPs are victims first contact
• Good opportunity for early detection, evaluation,
  and referral.
• PCP should be trained to identify patients who
  are victims of IPV, and those at high risk of
  being abused.
• Many models used in screening patients

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RADAR Model

• R Routinely inquire about violence
• A Ask direct questions
• D Document Findings
• A Assess Safety
• R Review options and referrals

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R Routinely Ask QuestionsA Ask Direct Questions

• Normalize questions
• HITS
• In the last year, how often has your partner
• Hurt you physically? Insult you or talk down to
  you? Threaten you with physical harm?
• Conflict Tactics Scale
• Have you ever been hit, slapped, kicked,
  otherwise physically hurt by your partner? Have
  you ever been forced to have sexual activiites?
• Written questionnaires available (American
  College of Obstetrics and Gynecology)

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D Document Findings

• Physical Exam May/may not show evidence of IPV
• Ask if patient has any injuries
• Characteristic Injury Patterns
• Various stages of healing, defensive wounds,
  multiple injuries, central injuries, injuries to
  head, neck, mouth.
• Check abdomen in women who are pregnant.
• May present with signs of depression, anxiety,
  etc
• DOCUMENT!!!!! Pictures, drawings, details!

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A Assess Safety

• Assess patients risk of immediate danger.
• Ask if afraid to go home, if there are guns and
  knives in the house, if drugs and alcohol are
  involved, if there are children involved.
• Remind px to call 911 if in immediate danger!
• Develop a safety plan with the victim
• ACOG Recommendation leave bag at friends house
  that includes cash, credit cards, extra clothes,
  important papers. Hide extra set of car and house
  keys.

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R Review Options and Referrals

• Know community resources!
• Shelters, victim advocacy programs
• Services offered, have phone numbers available
• Challenge Rural areas, limited resources
• Mandatory Reporting
• Know reporting mandates in practicing state
• KY Mandatory to report IPV.
• Anytime a child is involved, it is mandatory to
  report abuse.

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• US Preventative Services Task Force
  Recommendation - I No direct evidence that
  screening for IPV leads to a decrease in
  disability or death.
• ACOG Recommends routine questioning regarding
  abuse of all female patients. Screen women
  routinely at preconception visits, family
  planning visits, annual exams

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IPV Commercial..

• http//www.youtube.com/watch?vAvBKlBhfgPc

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SUMMARY

• Imperative that healthcare providers are educated
  to identify victims of IPV, health factors
  associated with abuse, screening tools, and how
  to respond when abuse is suspected or disclosed.
• Incorporating a brief screening protocol into
  practice could potentially save the life of your
  patient.

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References

• American College of Obstetrics and Gynecology
  (ACOG). Screening Tools Domestic Violence.
  Retrieved on December 12, 2007 from
  http//www.acog.org/departments/dept_notice.cfm?re
  cno17bulletin585
• American College of Obstetrics and Gynecology
  (ACOG). Leaving the Violence. Retrieved on
  January 20, 2008 from http//www.acog.org/departm
  ents/dept_notice.cfm?recno17bulletin179
• Bonomi, A.E., Anderson, M.L., Rivara, F.P.,
  Thompson, R.S. (2007). Health Outcomes in women
  with physical and sexual intimate partne r
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• Centers for Disease Control and Prevention
  (CDC). Costs of intimate partner violence against
  women in the United States. Atlanta (GA) CDC,
  National Center for Injury Prevention and
  Control 2003. Available from www.cdc.gov/ncipc/p
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• Center for Disease Control and Prevention (CDC).
  Intimate partner violence during pregnancy A
  guide for clinicians. Retrieved on January 10,
  2008 from http//www.cdc.gov/reproductivehealth/vi
  olence/IntimatePartnerViolence/sld001.htm
• Center for Disease Control and Prevention (CDC).
  Intimate partner violence prevention - Scientific
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  Retrieved on November 29, 2007 from
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• Dienemann, J., Glass, N., Hanson, G., and
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• Division of Child Abuse and Domestic Violence
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  Retrieved on December 12, 2007 from
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• Falsetti, S.A. (2007). Screening and responding
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• Gunter, J. (2007). Intimate partner violence.
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• Kentucky Domestic Violence Association. (2002).
  Domestic Violence in Kentucky Fact Sheet.
  Retrieved on October 29, 2007 from
  http//www.kdva.org/factsheets.html
• Kentucky Domestic Violence Association. Domestic
  Violence Information Power and Control Wheel.
  Retrieved on February 10, 2008 from
  http//www.kdva.org/faq.html
• Kentucky Injury Prevention and Research Center
  (KIPRC). (2004). Kentucky Intimate Partner
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• Murray, C.E., and Graybeal, J. (2007).
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• National Coalition Against Domestic Violence
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• Ramsay, J., Feder, G., Rivas, C., Carter, Y.H.,
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• Rokach, A. (2007). Loneliness and intimate
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• Romito, P. and Grassi, M. (2007). Does violence
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• Romito, P. and Grassi, M. (2007). Does violence
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• Seidel, H.M., Ball, J.W., Dains, J.E., and
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• United States Department of Justice Office on
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• United States Preventative Task Force (2004).
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• Weisman, C.S., Grimely, D.M., Annang, L.,
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• World Health Organization World Health Report.
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• THE END