The Ruralness of Domestic and Intimate Partner Violence: Prevalence, Provider Knowledge Gaps, and Healthcare Costs
Late Life Domestic Violence: No Such Thing as “Maturing Out” of Elder Abuse
Indigenous People and Domestic Violence: Who’s Bringing Solutions
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.
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 Screening
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 will encounter.”
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 room.
“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 International’s 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 relationships.
“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
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 patient-centered.
“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 Screening
- 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 safe.”
- 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 DV/IPV situation.
- 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 questions.
- Don’t force disclosure.
Other Sources: Stanford Medicine Domestic Abuse and the CDC’s National Center for Injury Prevention and Control Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings
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 screening.
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 for 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 information.
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 there.”
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 fault.
- Remember the danger associated with leaving a DV/IPV situation.
- Ask the patient if they’d like to be connected with resources.
- 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 anonymous.
- Assess need for child protective services.
- Don’t give exact direction, like “you need to leave.”
Source: Intimate-Partner Violence — What Physicians Can Do, New England Journal of Medicine, November 2012; Intimate Partner Violence, Committee Opinion, American College of Obstetricians and Gynecologists, February 2012.
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 as well.”
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 areas.
“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 this problem”
Universal DV/IPV Screening: An Oregon FQHC Is Getting It Done
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 Tides of 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 care.”
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 themselves.
“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 approach.”
Medical Provider Training Resources
National Indigenous Elder Justice Initiative
National Resource Center on Domestic Violence
- Domestic Violence: Understanding the Basics
- Advocacy Beyond Leaving: A Guide for Domestic Violence Advocates
Legal Information For Providers
- Compendium of State Statutes and Policies on Domestic Violence and Health Care, 3rd Edition.
- Mandatory Reporting of Domestic Violence to Law Enforcement by Health Care Providers
Centers for Disease Control and Prevention
- Elder Abuse
- Intimate Partner Violence
- Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings
- Youth Violence
Health Resources & Services Administration
Massachusetts Medical Society
- Intimate Partner Violence: The Clinician’s Guide to Identification, Assessment, Intervention, and Prevention
Rural Health Information Hub