Jun 25, 2010

Implementing Intimate Partner Violence Screening in

Family Planning Centers

by Vicki Breitbart, EdD, LCSW and Lisa Colarossi, PhD, LCSW

Vicki Breitbart, EdD, LCSW

Vice President of Planning, Research, and Evaluation

Lisa Colarossi, PhD, LCSW

The authors would like to thank the many people who have contributed over time to the work

described in this paper, including Drs. Leslie Davidson and Vaughan Rickert at Columbia

University, and Anne Robinson, Leslie Rottenberg, and Jini Tanenhaus from Planned Parenthood

of New York City. The opinions expressed in this article do not necessarily reflect those of

Planned Parenthood Federation of America, Inc. Research discussed in this paper were funded

by the Centers for Disease Control (U49 CE000731) and the Robert Wood Johnson Foundation.

Implementing Intimate Partner Violence Screening in an Urban Family Planning Center

At Planned Parenthood of New York City (PPNYC), which serves a large number of clients

annually from diverse racial, ethnic, and age groups, staff from our three health care centers

perceive intimate partner violence (IPV) as a pressing and critical issue. In 1998 when revisions

and referral. All health care clients are screened for IPV, regardless of gender or type of

relationship, including marital, dating, and same-sex partnerships. Since PPNYC’s clients are

primarily women (98%), this paper focuses on female clients.

Research to Develop a New Screening Tool

In 2003, researchers from PPNYC and Columbia University began a collaborative investigation

into the prevalence and nature of intimate partner violence in young women ages 15 to 24 years.

The focus of this project was to develop an IPV screening approach to identification,

management, and referral within health care settings that would be acceptable to younger

women, who had not been the focus in previous publications about screening. It included the

development and testing of a comprehensive IPV screening tool and a provider training

activities of the health care setting. The definition of IPV we used to guide this project was as

follows: a pattern of assaultive and coercive behaviors that may include physical injury,

psychological abuse, sexual assault, progressive social isolation, stalking, deprivation,

intimidation, and threats. We looked at these behaviors as perpetrated by someone involved in

an intimate relationship where the actions were aimed at establishing control by one partner over

another. The initial research project had two phases.

In Phase I of the project (see Zeitler et al., 2006), we conducted an anonymous survey to

investigate the attitudes and expectations of young women concerning physical, verbal, and

sexual intimate partner violence as well as their attitudes toward screening by health care

providers. Women completed an audio-assisted computer survey that employed the validated

asked. Ninety percent (580) of women responded positively to being screened, saying that they

would not mind answering screening questions in the health care setting. Among the choices for

whom they would want to talk to about IPV more women reported that they wanted to speak

with a health care provider (95%) compared to their mother (90%) or a counselor (89%).

found that the language used to ask the questions was of paramount importance. For example,

women reported discomfort with the word “abuse” and said that they preferred responding to

descriptions of behaviors rather than labels. Based on the results of Phase I, we developed

training for providers and provisional screening tools that were piloted in the same health center

six months later.

In Phase II (see Rickert et al., 2009), we piloted three sets of screening questions that were added

also assessed provider feasibility and acceptability across the three screening approaches and

found no significant differences. Providers, on the average, were comfortable talking about IPV

with any of the approaches. Overall, the findings from Phase II of the study suggested that brief

screening for IPV could easily be incorporated into health care services without interrupting the

patient flow.

Policy and Practice Changes Resulting from the Initial Phases of Research

The researchers brought these findings to PPNYC health care providers and administrators for a

discussion about how the study could impact their practice. Additionally, other new studies

provided evidence that the use of standardized screening questions increased the frequency of

provider discussions with patients about IPV and of higher identification rates among OB/GYN

clinics that implemented screening protocols versus those that did not (e.g., Trabold, 2007). This

may be due to the “normalizing” of IPV screening questions for both patients and providers by

including the questions within the routine context of collecting medical history information

(Owen-Smith et al., 2008). This also signals to patients that abuse is viewed as an important

researchers to develop the new policy and screening tool. The revised screening tools included

the new questions shown in table 1. The revised policy included universal screening of all

patients as part of their medical history. A written and verbal screen is conducted, and patients

are referred to an on-site social worker for further assessment and planning and additional

referrals to local IPV organizations and hotline numbers. Not only did this research impact the

policy and practices of PPNYC, but the umbrella organization for this agency center, Planned

Table 1. Screening questions

percent (85) of women completing the newer form disclosed current and/or past IPV, compared

to 9% (38) of women who answered the older questions. No reporting differences were found by

race/ethnicity, health center location, marital status, primary language, payment, or service type.

Further logistic regression analyses revealed that after controlling for age, women completing the

new screening form were more than 2.5 times more likely to report past and current violence

(mutually exclusive) and over 4 times more likely to report experiencing both past and current

violence compared to women who reported the original screening form.

constraining or stigmatizing as using language such as “abuse” and definitive yes/no responses

without a context that were used on the older form.

To further evaluate our updated screening policy for provider barriers to screening, we conducted

five focus groups with seventy-five PPNYC health care providers, of whom 65 (87%) also

sample questions from the survey). Providers included certified nurse-midwives, nurse

reproductive health as well as for responding to disclosures of violence (Colarossi, Breitbart, &

Betancourt, 2009b). As a result, a training session was scheduled with a trainer from the Family

Violence Prevention Fund on reproductive control and related counseling techniques.

In the last 10 years, research on IPV and reproductive health has expanded in both breadth and

mechanisms of influence and empirically based screening practices. Evidence for mechanisms of

influence, including birth control sabotage, pregnancy manipulation, health care monitoring, and

partner refusal to use a condom (Levenson, 2009; Miller, 2007; Williams, Larsen, & McCloskey,

2008; Wingood & DiClemente, 1997) support an expanding role for reproductive health

professionals. Future directions for research should include a focus on the ways to reduce

pregnancy risks associated with partner control or coercion of birth control such as the provision

of long acting contraceptives. We will be considering how to integrate general IPV screening

questions with questions focused on reproductive control. Partner control over condom use also

and expanded education and outreach services to immigrant communities with specialized

expertise in language and cultural barriers.

experiencing abuse. Making a referral is not as helpful as facilitating access for a survivor

between well-trained health care and social service providers knowledgeable about partner

violence. To promote such relationships, increased cross-training is needed about the specific

connections between physical and sexual violence, reproductive coercion, and reproductive

health, including relationship dynamics that: inhibit the use of condoms, interfere with birth

control methods and lead to unwanted pregnancy; monitor or restrict access to health care; and

impact pregnancy continuation and termination.

health provider nor be able to take advantage of health care options that may be helpful. There is

a need for more provider training, but also for public campaigns and health center waiting room

visual materials to increase knowledge and understanding about the link between reproductive

health and intimate partner violence.

Table 2. Examples of questions on the provider survey

Please indicate how much you agree or disagree with each statement

to know whether you agree or disagree that each factor below makes it more difficult to

Colarossi, L. G., Breitbart, V., Betancourt G. (2009b). Provider Barriers to Screening for

Partner Violence in Reproductive Health Clinics: A Mixed Method Study. Biannual meeting of

the Family Violence Prevention Fund, New Orleans, LA.

Hathaway, J.E., Willis, G., & Zimmer, B. (2002). Listening to survivors’ voices: Addressing

partner abuse in the healthcare setting. Violence Against Women, 8(6): 687-719.

Levenson, R. R. (2009). Male reproductive control of women who’ve experienced intimate

partner violence in the United States: An unexplored dimention. Biannual meeting of the Family