A Systematic Review: Intimate Partner Violence among Veterans and Active Duty Service Members

In the United States, intimate partner violence (IPV) poses a significant public health burden that affects both men and women. More than one-third (36%) of women and one-fourth (29%) of men have experienced rape, physical violence, or stalking by an intimate partner in their lifetime. Outcomes associated with IPV include a wide range of social, physical, and mental issues, such as family dissolution, adverse pregnancy outcomes, mental health issues (depression, PTSD, anxiety), incarceration, and death. Military service has unique psychological, social, and environmental factors that may contribute to elevated risk of IPV among active duty service members and Veterans. For example, multiple deployments, deployment-related head trauma, mental illness, and substance abuse can contribute to elevated risk of IPV among active duty service members, Veterans, and their intimate partners.

In order to support the work of VA's Domestic Violence Task Force, the VA Evidence-Based Synthesis Program located in Durham, NC, conducted a systematic review of the literature on the prevalence of IPV among active duty service members and Veterans (Key Question 1), as well as intervention strategies to address IPV (Key Question 2).

Summary of review results:
Compared with population-based studies conducted in samples not selected for active duty or Veteran status, investigators report higher rates of 12-month IPV perpetration and victimization among active duty women service members; considerably higher 12-month IPV victimization rates for active duty men; and comparable rates of both 12-month IPV perpetration among active duty men and lifetime IPV victimization among Veteran women. This review also shows that the 12-month victimization estimate is higher among active duty men than active duty women—a pattern that also has been observed in civilian studies.

Evidence also demonstrates that standardized IPV screening interventions in a healthcare setting increase identification of IPV victimization. Coupled with the prevalence of IPV, these findings support the need to consider adopting standardized IPV screening for use in the VA. However, this evidence review also highlights the need to take a comprehensive approach to implementing such a screening program in the VA. For example, the Institute of Medicine (IOM) recommends that women be screened about current and past violence and abuse in a culturally sensitive and supportive manner, and assuring patient confidentiality and safety is paramount. Additionally, this review highlights the need for developing a detailed plan of action for treatment and follow-up of positive IPV screening results.

Below are more detailed findings from the two Key Questions addressed by this review.

Key Question #1
What is the prevalence of intimate partner violence among Veterans and active duty service members, and does the prevalence vary by cohort (e.g., Vietnam era, OEF/OIF/OND era), gender, or race?

Of the 25 unique studies of IPV prevalence among U.S. active duty and Veteran populations used in this systematic review, 13 (25 articles) evaluated prevalence among active duty service members and 12 (14 articles) among Veterans. Findings show:

• The overall prevalence of 12-month IPV perpetration among active duty service members was 22%, and victimization was 30%. Both estimates had high variation in study outcomes between studies (i.e., high heterogeneity)
• Of the 12 studies that assessed IPV among Veterans, only 5 assessed IPV perpetration. The prevalence of IPV perpetration within the last year varied considerably (15% to 60%). However, samples consisted of specialized populations (e.g., Veterans seeking relationship help, newly returning OEF/OIF Veterans referred to behavioral health) with a high mental health burden, or were gender-specific samples.
• Only eight studies assessed IPV victimization among Veterans. None of these studies provided estimates for male Veterans. Only two studies provided an estimate of 12-month prevalence; estimates ranged from 7% to 12%.
• Among women Veterans, the prevalence of lifetime IPV victimization was 35%. Again, heterogeneity was high.
• The 12-month victimization estimate is higher among active duty men than active duty women—a pattern that has been observed in civilian studies.
• Among active duty populations, era of service, IPV severity, and gender all showed group differences, but each pooled sub-group also showed high heterogeneity. Thus, the variability in prevalence is likely due to a combination of factors.

Key Question #2
For persons who are at risk for, experience, or commit intimate partner violence, what interventions are associated with decreased exposure to intimate partner violence and its associated physical harms, mental harms, or mortality?

This literature review identified four good-quality and two fair-quality systematic reviews (SR) that evaluated interventions aimed at decreasing exposure to IPV and its associated harms. Findings show:

• No SRs were identified that evaluated primary prevention strategies for IPV. Most secondary interventions focused on reducing victimization.
• Standardized IPV screening interventions in healthcare settings increased the identification of victims of IPV when compared with non-standard or non-universal screening. Screening interventions may decrease recurrence of IPV, though the effect is not sustained over time.
• Multi-component screening interventions that included institutional support, effective screening protocols, initial and ongoing training of providers, and immediate access to referral services increased rates of IPV screening, disclosure, and identification. Using multi-component screening interventions also has the potential to increase provider self-efficacy to perform IPV screening.
• Other interventions (counseling and advocacy) showed decreases in IPV victimization; however, the evidence is weak and often inconsistent.

Future Research:
Future research on IPV should be conducted among nationally representative samples of Veterans. Moreover, investigators identified no SRs of primary IPV prevention strategies; all SRs summarized literature on secondary prevention strategies (e.g., IPV screening). However, current evidence suggests that screening women for IPV can identify women who have been exposed to IPV. In the absence of strong evidence to support any single strategy to reduce risks associated with IPV in screen-detected populations, behavioral and advocacy interventions should be considered as adjuncts to IPV screening programs because they have some partial impact on IPV-related mental or physical health outcomes—and show limited evidence that they are associated with harms.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.

Reference

Gierisch JM, Shapiro A, Grant NN, King HA, McDuffie JR, Williams JW. Intimate Partner Violence: Prevalence Among U.S. Military Veterans and Active Duty Service Members and a Review of Intervention Approaches. VA-ESP Project #09-010; 2013.

View the full report (**VA Intranet only**):
http://vaww.hsrd.research.va.gov/publications/esp/partner_violence.cfm

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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