September 2022

In This Issue: Women's Health Research

Addressing Intimate Partner Violence among Women Veterans: Evaluating the Impact and Effectiveness of VHA's Response

Feature Article

Takeaway: This study will provide a comprehensive evaluation of the implementation and clinical effectiveness of intimate partner violence screening programs in women's health primary care clinics, thereby likely improving healthcare services and reducing morbidity among women VA patients.

Intimate partner violence (IPV) is common among women Veterans, with nearly 20% of women treated in VA primary care clinics experiencing past-year IPV. VA’s Office of Women’s Health (OWH) and the IPV Assistance Program, with input from VA Offices of Primary Care and Mental Health and Suicide Prevention, developed recommendations for implementing IPV screening programs in women’s health primary care. More than two-thirds of women primary care patients receive care in mixed-gender primary care or separate but shared space clinics, but uptake of screening has been slow and inconsistent. In response, researchers partnered with VA’s OWH and the IPV Assistance Program to evaluate OWH’s efforts to use implementation facilitation (IF) to enhance the uptake of IPV screening in low adopting clinics. Given the high number of these clinics throughout VA, expanding IPV screening to all clinics is vital. It is unclear whether resource-intensive IF—a team-based approach that leverages the skills of both external and internal facilitators—could be more effective than implementation as usual in rolling out IPV screening programs in these clinics.

This objective of this ongoing study (November 2019–April 2023) is to comprehensively evaluate IF’s effect on the uptake and clinical effectiveness of IPV screening programs. Specific aims of this study include:

• Assess the degree of reach, adoption, implementation fidelity, and maintenance achieved using two implementation strategies for IPV screening programs.
• Evaluate the clinical effectiveness of IPV screening programs as evidenced by disclosure rates and post-screening psychosocial service use.
• Identify multilevel barriers to and facilitators of IPV screening program implementation and sustainment.

Methods

This study will compare the impact of two implementation strategies (IF + toolkit vs. toolkit + implementation as usual) to assess the reach (i.e., proportion of women screened for IPV; primary implementation outcome) and clinical effectiveness (i.e., proportion of women screening positive for IPV; primary clinical effectiveness outcome) of IPV screening programs across nine VA medical centers. Researchers are collecting quantitative (clinical records data; key informant surveys) and qualitative (key informant interviews) implementation outcomes, as well as quantitative (clinical records data) clinical effectiveness outcomes in the pre-IF, IF, and post-IF maintenance phases. IF was led by OWH external facilitators, and internal facilitators were members of a primary care clinic (e.g., physician, nurse, social worker). In this project, IF was tailored to target multilevel barriers to implementing IPV screening within VHA primary care and from the broader IPV screening literature.

Findings

Thus far, findings from the implementation phase have shown:

• Women seen during the IF period were nearly 3 times more likely to be screened for IPV compared to the pre-IF period.
• Among all screened women, those screened during the IF period were neither significantly more nor less likely to disclose IPV than those screened during the pre-IF period.
• Among all eligible women, those seen during the IF period were more likely to disclose IPV compared to those seen in the pre-IF period.
• Women screened during the IF period were more likely to receive psychosocial services within 60 days post-screen than pre-IF screened women, adjusting for pre-screening psychosocial service use.
• Barriers and facilitators that affect implementation of IPV screening in primary care include:
  • Ability to activate the IPV screening tool in the electronic health record
  • Provider comfort level with screening and addressing positive screens
  • IPV screening implementation team members’ availability (e.g., adequate staffing, workload, and time constraints)
  • Available resources for implementation team including staff training and education
  • Multilevel leadership support and/or buy-in
  • Role clarity for IF, including regular communication and mutual expectations of internal and external facilitators

Anticipated Impact

Given the high prevalence of IPV among women Veterans and its significant health effects, successful implementation of IPV screening programs is expected to improve healthcare services and reduce morbidity among women VA patients. Indeed, findings indicate that IF increases the reach of IPV screening programs in primary care, thereby increasing detection of IPV among patients and strengthening connections to potentially life-saving support services. Additionally, this work is highly relevant to other healthcare contexts.

Principal Investigators: Katherine M. Iverson, PhD, and Christopher Miller, PhD, are investigators with HSR&D’s Center for Healthcare Organization & Implementation Research (CHOIR) at the VA Boston Healthcare System. Dr. Iverson is also part of VA’s National Center for PTSD, Women’s Health Sciences Division, at VA Boston Healthcare System.

Publications

Iverson K, Dichter M, Stolzmann K, et al. Assessing the Veterans Health Administration's response to intimate partner violence among women: Protocol for a randomized hybrid type 2 implementation-effectiveness trial. Implementation Science. May 7, 2020;15(1):29.

Miller C, Adjognon O, Brady J, Dichter M, and Iverson, K. Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review. Implementation Research and Practice. September 7, 2021;2:6334895211039894.

Miller C, Stolzmann K, Dichter M, et al. Intimate partner violence screening for women in the Veterans Health Administration: Temporal trends from the early years of implementation 2014–2020. Journal of Aggression, Maltreatment & Trauma. January 24, 2022;1–19.

View study abstract