1. Intimate Partner Violence Against Women Unmet Needs for Care and Helpseeking Behavior Stacey Plichta, Sc.D.

2. 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.

3. 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?

4. 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. 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% Lifetime prevalence: 22.1%-34.5% Incidence: 6%-9% of all women age 18-64 Incidence: 6%-9% of all women age 18-64 Lower rates, but still occurs in older (65+) women Lower rates, but still occurs in older (65+) women

5. 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.

6. Health & IPV Potential Short Term Effects Potential Short Term Effects Mortality Mortality Injury Injury Chronic pain Chronic pain Poorer pregnancy outcomes Poorer pregnancy outcomes Unintended pregnancy Unintended pregnancy Sexually transmitted diseases Sexually transmitted diseases Decreased immune response Decreased immune response Mental health problems Mental health problems

7. Health & IPV Potential Long Term Effects Potential Long Term Effects Disability (physical and/or sexual) Disability (physical and/or sexual) Gastrointestinal disorders Gastrointestinal disorders Traumatic brain injury Traumatic brain injury Post-traumatic stress disorder Post-traumatic stress disorder Depression & anxiety Depression & anxiety Suicidality Suicidality Substance Abuse/Addiction Substance Abuse/Addiction Increased risk of future victimization Increased risk of future victimization

8. How much does IPV cost? CDC Estimates: CDC Estimates: $5.8 Billion each year $5.8 Billion each year $4.1 Billion direct medical and mental health care costs. $4.1 Billion direct medical and mental health care costs.

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

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

11. IPV Victims in Inpatient Settings The CDC estimates that more than 807,000 overnight hospital stays are directly due to IPV 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 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% Another study, of 131 consecutive female admissions to a non-trauma unit found a lifetime rate of IPV of 26%

12. 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 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 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

13. IPV Victims in Primary Care Population-based surveys indicate that women who are abused obtain routine care at least as often as others 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 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% Primary care settings typically find lifetime prevalence rates ranging from 12% to 46%, and 1- year prevalence rates ranging from 5% to 32%

14. 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 multivariate statistics. 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 multivariate statistics. Unmet needs for care are likely to exist even among women with injuries directly due to IPV. Several population-based studies found that only between 17% -34% of women injured by IPV seek medical care for the injuries. Unmet needs for care are likely to exist even among women with injuries directly due to IPV. Several population-based studies found that only between 17% -34% of women injured by IPV seek medical care for the injuries.

15. IPVAW victims who were treated by one urban emergency medical services (EMS) system had a significantly higher refusal-to-transport rate than others (23% vs. 7%). Even among women strangled multiple times by an intimate partner, only 39% sought medical care for injuries resulting from the strangling. Unmet Needs for Care

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

17. Unmet Needs for Care The general consensus in the literature is that women who are abused are present in the health care system but are not detected without active screening on the part of the health care provider. The general consensus in the literature is that women who are abused are present in the health care system but are not detected without active screening on the part of the health care provider.

18. IPV Victims Impressions of HCP IPV victims report less satisfaction and worse communication with their providers than do other women. IPV victims report less satisfaction and worse communication with their providers than do other women.

19. Purpose This study seeks to examine 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. This study also examines the factors related to seeking out medical care for health conditions related to IPVAW in the same sample.

20. Methods This study was a cross-sectional, random-digit dial telephone survey of 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

21. Methods Lifetime IPVAW was ascertained by two questions: 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?

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

23. 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. Methods

24. 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

25. 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. Description of Sample

26. Results Results related to the first research question: Is IPV related to having an unmet need for care? Results related to the first research question: Is IPV related to having an unmet need for care? Note that IPVAW here is defined as IPVAW or threat of IPVAW Note that IPVAW here is defined as IPVAW or threat of IPVAW

27. 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%, p<=.00

28. 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. 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%, p<=.00). Women with lifetime IPVAW were significantly more likely to have had an ED visit in the past year (35% vs. 20%, p<=.00). Results

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

30. Health Status differences Health Status differences Compared to other women, those who reported lifetime IPVAW were: 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) 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%, p<=.00) More likely to report being diagnosed with an anxiety or depressive disorder (28% vs. 18%, p<=.00) Results

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

32. Results Logistic Regression Model: Predictors of Having an Unmet Need for Care 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 1.0Reference 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.

33. Women who experience 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. Results

34. Results Results related to the second research question: Among women harmed by IPVAW, what factors are associated with women seeking care for injuries or conditions associated with the IPVAW? Results related to the second research question: Among 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 (n=204). Note that IPVAW here is defined as IPVAW that occurred (n=204).

35. Results Only 33% sought care for conditions associated with the IPV. Of these, two-thirds disclosed the IPV 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.

36. Results

37. Results 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) Divorced2.61 (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.

38. 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. Results

39. Conclusions This study provides evidence that IPVAW victims frequently use in the health care system, but do not necessarily receive the services that they need. This study provides evidence that IPVAW victims frequently use in the health care system, but do not necessarily receive the services that they need. 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. 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.

40. 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. Conclusions

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

42. While the majority of both heath care providers and patients support screening for IPVAW in the clinical setting, few health care settings formally require this and the majority of health care providers do not inquire about IPVAW. Conclusions

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

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

45. However, 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. Conclusions

46. 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. Conclusions

47. Of concern is a recent decision by the U.S. Preventative Task Force, which 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. Conclusions

48. Screening Tools AuthorScreenDescriptionPopulation McFarlaneAAS Abuse Assessment Screen Pregnant ErnstOAS Ongoing abuse screen ED SherinHITS Hurt, Insulted, Threatened, or Screamed at. Family Practice FeldhausPVS Partner Violence Scale ED NeufieldSAFE Safety, Afraid/abused, Friend or family aware, Emergency plan Office setting SmithWEB Women’s Experience of Battering Family practice BrownWAST Women Abuse Screening Tool Family Practice CampbellDA Danger Assessment IPV victims