Impacting nearly 12 million people a year, domestic
violence (DV) and intimate partner violence (IPV) is a
likely reality for the next woman or man who comes to a
rural healthcare facility. From the "do's and
don'ts" of screening to the "do's and
don'ts" when violence is disclosed, rural
providers need to be prepared to meet the challenges of
this ongoing public health crisis.
Domestic Violence: Definitions
According to the National Domestic Violence Hotline,
domestic violence (DV) is also referred to as intimate
partner violence (IPV) and several other phrases that
describe behaviors of one partner to maintain power and
control over another. The Hotline offers
plain language definitions and examples of DV and
IPV, which include not only physical, emotional, and
sexual abuse, but also sexual and reproductive coercion
and financial and digital abuse.
First Steps in Addressing Rural DV/IPV: Awareness and
Dr. DeShana Collett is a practicing physician assistant
(PA) and an Associate Professor at the University of
Kentucky (UK) College of Health Sciences. Because DV is
so common and rural resources so scarce, Collett said she
wants their PA graduates to be aware of the condition's
complexities and comfortable with possible interventions.
"I believe the first step in decreasing
violence is awareness and tying in the proof
that domestic violence-associated trauma impacts overall
health and well-being," she said. "I
would say it is an effortless task to weave in the
education of IPV as a health condition because of its
commonality. We know that patient care skills applied
during encounters with DV and IPV patients will also be
similar to many other health conditions that our students
With more than a decade of teaching comes the experience
of integrating DV into standard curriculum, Collett said.
She tells students that screening for DV should actually
start with the moment the patient walks through a clinic
door, sits in the waiting room, and looks around at
posters on the wall or educational messages in a clinic
"Building on an 'everywhere and everyone'
philosophy, I tell my students that awareness is
important for the receptionists, the medical assistants,
and nursing staff," she said. "We all
have multiple opportunities to screen and be aware
because the problem is everywhere. It takes all of us to
educate and win the fight to end violence and I remind
them, it's not just women, it's men, it's adolescents,
and geriatrics as well."
Advocacy organizations said that healthcare providers
should feel free to reach out to their community
resources and proactively build
organization-to-organization and person–to-person
relationships so they are not alone in trying to care for
these patients, especially in emergent situations.
Maren Woods is Program Director for Praxis
Rural Advocacy and Interagency Responses to Violence
Against Women, a technical assistance program for
grant-funded communities working on violence issues. She
said in their work with hundreds of rural advocacy
programs, a walk-through is one approach they've heard
about that seems to help build these types of
"A clinic walk-through is where a domestic
violence advocate can go through the clinic on a mock
visit, Woods said. "Feedback can be given on
what's in the waiting room, the exam room, how the clinic
team might respond to different patient scenarios. It's
sort of a 'meet and greet,' where the advocate can give
their lens to safety, information, and protocols. And it
builds partnerships between the community's non-clinical
and clinical teams."
DV and IPV in Rural Settings: The Differences
Examine the "ruralness"
around prevalence, provider knowledge gaps, and
healthcare expenditures for DV/IPV.
UK's Collett said because nearly 25% of their program's
graduates who stay in Kentucky will practice in a rural
county, she has to prepare students for dealing with DV
in that setting. That starts with acknowledging the list
of factors studied long ago found to be associated with
DV in rural areas including geographic isolation,
transportation limits, and patriarchal attitudes
regarding gender roles, religious beliefs, and the issues
about small community confidentiality that extend to law
enforcement teams, criminal justice, and the community's
healthcare providers. With these factors in mind, she
said she reminds students to still just start with being
"I believe there's not a 'rural approach' to
screening," she says. "It's more
important to stay patient-centered. I tell students the
most important thing they need to do is make it clear to
their patients that a rural clinic can be a safe place
when they're ready to talk to someone."
Sample Suggestions for Domestic Violence
Normalize screening as confidential and applying to
all women because of DV's overall health impact.
"I don't know if this is a problem
for you, but many of my/our female patients are in
relationships where they don't always feel
Use gender-neutral terms with specific questions:
"Has your partner ever hit,
choked, or physically hurt you?"
Remember it takes courage to disclose, so
repetitive screening is important.
Remember the danger associated with leaving a
Recommend a follow-up visit.
Don't bury screening in a checklist of other
screening items: do you use sunscreen, do you feel
threatened, do you wear seatbelts.
Don't avoid eye contact when asking screening
A Surgical Specialist Speaks Out About DV Screening
Though the U.S. Preventive Services Task Force domestic
violence screening recommendations have varied since
1996, with the Affordable Care Act implementation came
the Health Resources & Services Administration's Women's
Preventive Services Guidelines that included DV/IPV
Dr. Gregory Della Rocca, a busy orthopedic trauma surgeon
at the University of Missouri — as well as a
prolific domestic violence researcher — said he
believes screening actually starts with every
healthcare provider thinking about domestic violence when
they ask the universal question of any injured
patient: How did this happen?
He said he also knows that for his patients, that
question is even more important. With over 50% of his
practice referred from rural Missouri, Della Rocca points
out the orthopedist's role in screening the injured
patient: Knowing that violence often escalates over time,
if any of his patients were in a violent situation, they
might be at even greater risk for more severe injury. He
also notes that despite his – and most orthopedists' –
roster of 50 patients in a usual clinic day, screening
can be done, especially with trained staff and as a
result of the trusting relationships built over the
timespan needed for an orthopedic injury to heal.
It's important to point out that sometimes it's that
seventh time when a patient finally has the courage to
say, 'I didn't fall down the stairs. I was pushed.'
"I get referrals for acute traumatic injuries
and injuries that haven't healed correctly,"
Della Rocca says. "That means I will see
patients multiple times until the injury heals, sometimes
up to seven times in a year. For some of those patients,
that might mean seven screening opportunities, compared
to a primary care provider's annual screen or an ER
doctor's one-time occasion. It's important to point out
that sometimes it's that seventh time when a patient
finally has the courage to say, 'I didn't fall down the
stairs. I was pushed.'"
Della Rocca said, in addition to his clinical work and
research, he frequently gives presentations on DV,
especially since the topic is becoming an important issue
American Orthopaedic Association leaders. In those
presentations, he emphasizes DV research supports several
other important facts.
"Though women might not be ready to disclose
domestic violence, research shows they want to be
asked about it," he said. "In
addition, the data clearly shows that injuries to the
arms and legs are the second-most common type of injury
that women sustain from physical violence, with head and
neck injuries being first."
Screening: When a Negative Might Be a Positive
Experts acknowledge that, sometimes when a DV/IPV screen
is negative, the provider senses "all is not
right." A June 2018 paper, Intimate
Partner Violence: What Health Care Providers Should
Know, highlights examples of negative screening when,
clinically, there's a hint that a problem exists. For
example, physical exam findings might reveal injuries in
various stages of healing. Other times, it might be a
patient with little emotion about a serious injury or the
recognition that a given cause for an injury or problem
doesn't quite fit the injury's appearance.
UK's Collett explained that it's not uncommon for the
patient to have certain complaints in the setting of a
normal physical exam, for example: stomach aches, bowel
problems, abdominal pain, or chronic pain complaints. In
this situation, she said asking the patient why they
think this illness is occurring might help bring out more
But if it's an abuse-triggered symptom that's brought
them in, they still might not tell you and you
cannot force them to disclose.
"Patients don't come to the provider because of
a symptom," she says. "They're coming
because the symptom is impacting their quality of life.
Sometimes just asking, 'Why do you think you're having
this symptom?' starts a trusting relationship. But if
it's an abuse-triggered symptom that's brought them in,
they still might not tell you and you cannot force
them to disclose."
When Screening Leads to Disclosure: Now What?
Experts point out that when a patient does
disclose their violent situation, the first assessment is
the current situation's seriousness for the patient
followed by asking if others are at risk, or if there are
children to consider.
"When we identify a victim in imminent danger,
that's easy: it's a phone call to the police,"
Della Rocca says. "But most of the time the
situation is that a patient discloses and expresses
interest in getting help. In that case, I realize I'm
fortunate because I'm in a big academic medical center
with social workers on call all the time, unlike rural
providers who might not have this resource. The social
workers will come down to the clinic and take things from
Sample Suggestions for Providers When Violence
Has Been Disclosed
Thank the patient for the confidence they've
demonstrated and assure them the violence is not their
Remember the danger associated with leaving a
Ask the patient if they'd like to be connected with
Offer the National Domestic Violence Hotline
number, even suggesting a safe place in the clinic to
use a clinic phone: 1-800-799-SAFE (7233). Available
24-7-365 in 170 languages. All calls confidential and
Assess need for child protective services.
Don't give exact direction, like "you
need to leave."
Della Rocca also said it's important to consider not just
the patient's safety, but staff safety.
"Providers need to be aware that the most
dangerous time for a victim is when the batterer
recognizes the partner is about to leave or that the
violence has been disclosed to a third party,"
he says. "Sometimes we're even reluctant to
provide physical resources because those things wander
into purses and purses wander into the batterer's hands
more often than not. If the batterer finds advocacy
evidence, they realize, 'I've been found out,' and the
violence might escalate. With that said, I also have to
mention you have to consider your clinic staff's safety
In contrast to disclosure processes in an urban academic
outpatient specialty setting, Kentucky's Collett focuses
on preparing PA students for dealing with DV and IPV in a
primary care setting located in resource-scarce rural
"When you are not a seasoned clinician and you
begin practicing in a rural community, the first thing I
emphasize is that you have to remember the patient is an
individual and you cannot be judgmental,"
Collett says. "You have to empower the patient
you're concerned about, encourage them. But if they're
not ready to talk to you, you can't push them to tell you
what is going on. I also tell students it's their job to
make the patient aware of resources, but they can't just
always hand the patient a pamphlet — because
their partner will know they have disclosed their abuse
if they find this information. Another option is to make
ongoing follow-up appointments. Violence is a chronic
issue and it will take time. The provider is there to
help and support, not to judge.
"Of course, in rural areas, even a follow-up
appointment may not be an option because of
transportation issues. The patient might not be able to
talk to the local advocate, because that advocate is the
batterer's relative. I know similar issues come up with
law enforcement. Access to shelters is yet another issue.
For example, having one shelter that provides services to
five counties can be problematic, as well as those that
provide services to women and children and not male
victims. Students need to be aware these challenges might
exist when trying to help a patient. Again, education and
awareness is the first step in making a difference for
Universal DV/IPV Screening: An Oregon FQHC Is Getting It
Both Collett and Della Rocca emphasized the importance of
administrative support around DV/IPV screening. Quality
Director and Registered Nurse Denise Weiss at Rinehart
Clinic, a Federally Qualified Health Center (FQHC) in
Wheeler, Oregon, agrees. Weiss explained that when
Tillamook County Women's Resource Center [now named
Change], a nonprofit organization delivering advocacy
services, received Safer Futures (no longer available
online) funding, the collaboration between advocacy group
and medical providers began with CEO support.
"Our leadership team set the tone by closing
the clinic for 4 hours so the entire clinic staff could
focus on the project's required training around
trauma-informed care," Weiss said.
"We clearly understand that, in addition to our
patients' safety, there are major implications in how
domestic violence and interpersonal violence impact
hypertension and diabetes, in addition to other chronic
medical conditions. Expanding to include DV/IPV clinical
services clearly brings another level to quality patient
After initial training, Weiss said the Resource Center
team came to the clinic and identified several important
screening barriers, a process similar to that described
by Praxis International's program director Woods.
"We weren't consistently screening, probably
because of our obligation as mandatory
reporters," Weiss said. "But the
Resource Center took the lead. They're the experts and
they've done a really good job of helping us with that
difficult conversation. They helped us work out what
questions to ask and how to determine when to stop the
conversation because we also need to disclose to our
patients the Oregon rules around mandatory reporting. For
example, the 'I'll be required to report,' piece, and
then how to add, 'However, we do have a relationship with
domestic violence advocates who operate under different
reporting parameters. If you'd like, I can get that
specialist to come talk with you.'"
Now Weiss said screening has turned around nearly 180
degrees: in part, because the clinic has started a
universal screening practice linked to a mandatory solo
patient rooming protocol.
"Our goal is every patient roomed separately,
every time," Weiss said, noting of course there
will be certain exceptions. "We have signage in
our lobby. Our medical assistants are trained that if two
people stand when one name is called, they can explain,
'I'm sorry, we now room all of our patients separately.
If your partner wants you after we've done our initial
vitals and screening, we'll come and get you. I know I
used to room you together, but we've had a change and now
I'm required to room you separately. It's part of my job.
Mother/son, father/daughter, or the parent and child
who've come together to the clinic for 20 years? That
doesn't mean there's a safe relationship at home. We
owe it to our patients to have time by
"Mother/son, father/daughter, or the parent and
child who've come together to the clinic for 20 years?
That doesn't mean there's a safe relationship at
home," Weiss said. "We owe
it to our patients to have time by themselves."
Weiss said another key to their work has been co-locating
the Resource Center's health programs advocate on-site
once weekly. When assistance is requested, a
warm handoff happens immediately. When the advocate
is absent, Rinehart's two clinical social workers step in
to help get patients to the right care.
"That's the clinical language we're used
to," Weiss said. "'We need to get you
to the right care, so we'll hand you off to the
specialist for this condition.' Language like that makes
sense to providers and to patients. The right specialist
doing the right job. We're having success with this
With a perspective gained from many years as a physician practicing in rural and urban locations, Dr. Kay Miller Temple writes on a variety of rural health topics and programs for RHIhub's Rural Monitor and Models and Innovations. She has a master's degree in Journalism and Mass Communication. Full Biography