Intimate partner violence (IPV; i.e., physical, sexual, and psychological aggression and stalking by an intimate partner) against women is a major health concern world-wide and in the United States. IPV experiences are particularly prevalent among women Veterans. Women who experience IPV present frequently in health care settings, especially primary care, providing opportunities for detection and intervention. The Veterans Health Administration (VHA) is implementing IPV screening programs in women's health primary care. As the implementation of IPV screening programs is still in its infancy, there is a time-sensitive opportunity to learn from VA Medical Centers (VAMCs) that have implemented IPV screening programs into primary care clinics to inform the scale-up and spread of best practices.
This study provided a first look at the "what," "how" and "why" of successful implementation of IPV screening programs in VHA. The Specific Aims were to: 1) characterize best practices of IPV screening programs in VHA through key stakeholder interviews with clinicians and administrators at five early and five late adopting facilities; 2) understand multilevel barriers to and facilitators of IPV screening program implementation through the interviews with key stakeholders at early and late adopting facilities; and 3) identify promising implementation strategies that can enhance future implementation effectiveness of IPV screening programs in VHA.
We utilized a qualitative research design guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework (Harvey & Kitson, 2015). We used our VHA operational partners in the National IPV Assistance Program and Women's Health Services national practice scans to identify sites actively screening for IPV (early adopting) and sites that had not yet implemented or were in the process of implementing IPV screening (late adopting sites) across VAMCs nationwide. We purposefully sampled six early adopting sites and five late adopting sites, and conducted semi-structured key informant interviews with 32 clinicians and administrators (e.g., Women's Health Medical Director, IPV Assistance Program Coordinators), across 11 VAMCs. Interviews assessed the IPV screening and response practices used in the clinics, barriers to and facilitators of IPV screening program implementation, and site-specific implementation strategies, which were subsequently mapped to the Powell et al. (2015) implementation strategies. Transcripts were coded using a hybrid inductive-deductive content analysis approach, coupled with matrix analysis. We completed the analysis by sorting themes and grouping findings across early and late adopting sites.
Five successful clinical practices were identified (use of a specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, colocation of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified. A dozen discreet implementation strategies (e.g., identify and prepare champions, conducting ongoing training, facilitate relay of clinical data to providers) were associated with successful IPV screening programs.
This study of IPV screening and response implementation in VHA provides important insights and successful clinical practices that can be applied within and outside VHA settings, mitigating identified potential barriers. Findings are being adopted by our VHA operations partners in Women's Health Services and the IPV Assistance Program to inform screening and responses practices, and guide implementation strategies for a planned national rollout of IPV screening programs across primary care clinics nationwide. This project also provided the impetus and preliminary work for a funded SDR planning grant (SDR 18-150).
- Adjognon OL, Brady JE, Gerber MR, Dichter ME, Grillo AR, Hamilton AB, Stirman SW, Iverson KM. Getting Routine Intimate Partner Violence Screening Right: Implementation Strategies Used in Veterans Health Administration (VHA) Primary Care. Journal of the American Board of Family Medicine : JABFM. 2021 Mar 1; 34(2):346-356.
- Dichter ME, Makaroun L, Tuepker A, True G, Montgomery AE, Iverson K. Middle-aged Women's Experiences of Intimate Partner Violence Screening and Disclosure: "It's a private matter. It's an embarrassing situation". Journal of general internal medicine. 2020 Sep 1; 35(9):2655-2661.
- Iverson KM, Adjognon O, Grillo AR, Dichter ME, Gutner CA, Hamilton AB, Stirman SW, Gerber MR. Intimate Partner Violence Screening Programs in the Veterans Health Administration: Informing Scale-up of Successful Practices. Journal of general internal medicine. 2019 Nov 1; 34(11):2435-2442.