Understanding Barriers to Obtaining Assistance for Victims of Intimate

Partner Violence

Myra Berry, Dawn Fadden, Starr Ferrari, Heidi Grondahl, Kimberly Miller & Resty Namata

December 3, 2008

Research in Nursing

Fairview WomanKind Program, Minneapolis, MN

Research by Short, L.M., Hadley, S.M., & Bates, B. (2002)

Three intervention hospitals Professionals staff were evaluated and provided education to

enhance their ability to recognize, relate to, and refer IPV victims

Difference in IPV victims identified Intervention Hospitals 1719 : Comparison Hospitals 27

Healthcare Provider Education FocusKABB

Knowledge Recognition of Signs Understanding of complexity of IPV

Attitudes Build confidence in ability identify and support IPV

victims Develop sense of responsibility to identify IPV

Beliefs Challenged acceptance of IPV myths

Behaviors Improved ability to develop rapport/trust

Evidence Based Project

Barriers to health care for IPV victims. Provider attitudes Fear/Mistrust

Research points to new topic: How is IPV experienced uniquely in different

populations of women? Adolescents, Pregnant women, Immigrant, Lesbians

Presentation Overview

Background & Purpose Method Results Conclusion.

Intimate Partner Violence

IPV is physical, sexual or emotional abuse directed from one intimate partner towards another – including threats of the above mentioned types of abuse. An intimate partner is any individual who is currently, or was in an intimate relationship with the victim.

Center for Disease Control, 2006

An Astounding Statistic

Worldwide, up to 50% of women have been victims of IPV at some point in their lives Reports of IPV are universally under-reported

by victims, and thus, the problem remains hidden and the abuse continues.

(Wong, Jonge, Wester, Mol, Romkens & Lagro-Janssen, 2006)

Why is this important? Screening is not accurate, nor does it capture all

victims. Health care professionals should comprehend

how IPV effects its victims. Health care professionals must also acknowledge

the financial burden IPV victims bring to the health care system.

Center for Disease Control, 2006

Financial Burden of IPV

IPV cost the health care system an estimated 5.8 billion dollars in 1995. 95% confidence interval: ($3.9 to $7.7 billion)

(Max, Rice, Finkelstein, Bardwell & Leadbetter, 2004)

Health Care Utilization

Mental Health Services Emergency Department Ob-GYN or Women’s Health Clinics Primary Care Clinics Pharmacy

Method Databases

Medline Cinahl Google Scholar Ovid ERIC

PubMed PsycINFO Science Direct InfoTrac Academic

Search Terms Included a variation of the following:

Abuse, battered, violence, women, partner, provider, physician, care provider, clinician, disclosure, reporting, attitude, characteristics, attributes, traits, domestic, assault, barriers, violence, practitioner, health care, health services, pregnancy, domestic violence, physical, sexual, costs, economy, expenditures, trust

Barriers - Attitudes

Studies of attitude of providers showed:

Disclosure of IPV was influenced by the perceived behavior of the care provider.

Women were more likely to disclose IPV if:They perceived the provider to appear to be sympathetic, caring, respectful, a good listener, non-judgmental, comfortable with the topic of abuse, and interested in the patient and their welfare.

Important Information About IPV Victims

Failure to recognize Readiness Motivation The lives of IPV victims are very

complex Care and support by healthcare

providers

An Interesting Correlation In 3 of the 5 studies abstracted :

Only 12-29% of the IPV victims used in these studies had ever been directly asked about abuse by their provider.

In 2 of these 3 studies, of the women who were asked about IPV, greater than 75% of them disclosed the abuse when directly asked.

IPV Victims Fear

Law enforcement will become involved without their consent

Losing the children Losing an intact family/good part of relationship Retribution by the perpetrator Requiring disclosure of the IPV Involvement from healthcare provider will cause

the violence to increase Feeling rejected or devalued by healthcare

providers

Factors that Cause IPV Victims to Mistrust Providers

Healthcare provider appears uninterested or callous

Healthcare system requires reporting to law enforcement

Feeling entrapment or disempowerment Feeling forced to enter a shelter

IPV & Immigrant /Epidemiology

15% of US Population is foreign born Intimate partners abuse immigrant women by 40-80% & immigrants are disproportionately involved in domestic violence homicides.

23%

17%

12%

0%

5%

10%

15%

20%

25%

Black Hispanic White

Graph of MFIPV for different races

Black

Hispanic

White

Gupta, J. et al, 2008

Caetano, 2003

Pre-migration violence - men

30%

0%

5%

10%

15%

20%

25%

30%

1

IPV perpetuators, who had experienced political violence

IPV perpetuation,had experiencedpolitical violence

Percet of 2229 immigrant men who reported

20.10%

17%

9.50%11.20%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

PolitcalViolenceexposure

Perpetrationof IPV or SPV

in past year

Physical

perpetration

Sexual

perpetration.

Politcal Violenceexposure

Perpetration of IPV orSPV in past year

Physical perpetration

Sexual perpetration.

Gupta et al (2008)

IPV & immigrant … Haitians/Latina

Haitian Women Experience: View IPV in Culture Context. Do not report abuse to avoid. Mainstream IPV services are inaccessible

Latina women: Responded to indirect questions about feelings than

to direct ones.

Latta et al (2005)

Wrangle et al(2008)

IPV & Immigrants …SomaliSomali women acculturation Predictors of partner aggression

English proficiency, longer time in US

& fewer American friend. (p < .00).

Predictors of intimate partner physical assault English proficiency, longer time spent in US & more

American friends. (p < .00).

Nilsson (2008) quantitative study of Acculturation

IPV & Immigrant … South Asian

Emotional abuse by in-laws reported by 55% of depth interviewees.

Raj, A., et al. (2006)

Train providers to: Tailor abuse services for immigrant women Screen for

In-law abuse in South Asians. Acculturation in Somali refuges pre-migration violence exposure - PTSD in men.

Lesbian Victims of IPV

Rate is roughly equal to the rate of IPV in heterosexual relationships

Language and attitudes Unique safety needs Re-victimization from healthcare providers and

other IPV victims

IPV During Pregnancy

The American College of Obstetricians and Gynecologists estimates the prevalance of IPV at 23% during pregnancy of the women seeking prenatal care

(Chambliss, 2008)

Pregnancy

Assessment for IPV should be assessed at multiple encounters.

Poor neonatal/maternal outcomes can result in the year preceding pregnancy and during pregnancy.

Pregnancy

Women at highest risk: Age less than 24 Native American High school education or less Those who did not seek prenatal care in first

trimester Those who smoke and use alcohol.

IPV and Adolescents Studies showed:

Significant barriers to disclosure and identification, similar to adult findings

Reasons for disclosure of IPV are complex Reasons for seeking care in general are often

structural

Summary and ImplicationsHealthcare providers need to:• Become experts on the subject of IPV

• Know risk factors for all ages, demographics• Cultural differences in IPV

• Promote victim autonomy• Learn to recognize the deficiencies of screening

as well as their attitudes and feelings toward IPV• Identify and eliminate barriers for screening of

IPV

Summary and Implications Providers need to consider engaging in education

and efforts designed to help increase disclosure. Early detection and screening of IPV can have an

effect on maternal/neonatal outcomes. Understanding abused adolescents’ concerns for

interacting with health care providers is essential to form a working relationship for health promotion and disease/trauma prevention.

Missing or Inadequate Topics

Due to insufficient assessment, it is difficult to determine all the true barriers

Lack of services to rural populations and special populations

Cultures of silence and isolation Fear and intimidation by perpetrators Better understanding of the complex nature of IPV

victims lives

Missing or Inadequate Topics Enhanced flexibility in IPV victim resources Language barriers Culturally sensitive resources Lack of adequate funding for services Fear of law enforcement or failure to act

APN Leadership Opportunities Provide education about IPV Capitalize on “readiness” for intervention Empower IPV victims to make own decisions Don’t require disclosure to obtain assistance Provide multiple options for assistance Provide counseling regarding safety strategies,

legal resources, and understanding relationships Consistency in care – “always ask”

APN Leadership Opportunities Become experts in establishing IPV victim-

friendly healthcare environments Identify and eliminate barriers to resources Establish valued services and referral sources Educate colleagues regarding identification of

IPV victims Promote IPV victim autonomy in decision-

making Identify and address the needs of special IPV

victim populations

Fairview WomanKind Program, Minneapolis, MN

612-672-2700

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