Enhanced Versus Basic Referral for Intimate Partner Violence in an Urban Emergency Department Setting

Abstract

Background

Victims of intimate partner violence (IPV) frequently do not disclose abuse to medical providers. Therefore, research has examined the most effective screening and referral methods to help identify victims of abuse and connect them to needed resources.

Objectives

To determine the efficacy of referrals intended to connect IPV victims with behavioral health resources, while taking into consideration demographic and mental health variables.

Methods

We examined a convenience sample of medically stable individuals in an emergency department setting. Participants were given the Mini-International Neuropsychiatric Interview and Partner Violence Screen measures to assess mental health and IPV victimization. Individuals that screened positive were randomized to a basic or enhanced referral and given a follow-up interview to determine referral success. Referrals were considered successful if an individual scheduled an appointment with provided behavioral health resources within the follow-up interval.

Results

Two-hundred and one individuals were enrolled. Forty-one (20.4%) participants screened positive for IPV victimization. Male and female participants in the enhanced referral group were more likely to have a successful referral than those in the basic referral group, with a large effect size such that 72.7% of participants in the enhanced referral and 15.7% of participants in the basic referral group contacted referral resources. Both referral type and marital status significantly predicted referral success.

Conclusion

Comorbidity with mental health concerns measured as high within those that screened positive for IPV victimization. The enhanced referral showed to be an effective way to encourage participants to contact behavioral health resources.

Introduction

Intimate partner violence (IPV) is a prevalent issue leading to both physical injuries and poor mental health among a variety of victims (1). A recent compilation of research found that 23% of women and 19% of men have experienced physical IPV throughout their lifetime (2). Victims of IPV often experience physical health problems, including an increased risk for chronic pain, chronic disease, cardiovascular problems, nutritional deficits, mild traumatic brain injury, and postconcussive syndrome (3). Many victims of IPV also report high rates of mental health concerns, including an increased risk for anxiety, depression, posttraumatic stress disorder, and alcohol or substance abuse issues (1).

Despite the negative consequences experienced by victims of IPV, research displays high rates of nondisclosure of abuse (4). At least 20% of male and female victims have never told anyone about their abuse, including family members, friends, and health professionals (4). Barriers to disclosure often include fear of repercussion, such as increased abuse or negative response from family and friends (5). Research shows, however, that most women report that they would feel comfortable discussing IPV information with their health care providers and believe that physicians should routinely screen for this issue 6, 7, 8. These findings, taken together with extensive research supporting routine screening for IPV, emphasize the importance of directly screening and identifying these victims (9).

After identifying victims of IPV, providing referrals to mental health or domestic violence professionals is shown to be an effective way to connect victims with supportive resources. Organizations including the American Medical Association and the Utah Department of Health recommend referral to a minimum of 1 resource, including victim advocacy programs, domestic violence victims’ shelters, or mental health professionals (10). Research also suggests, albeit with a significant paucity, that referrals given in primary and emergency care settings can improve the likelihood that victims will seek help 11, 12. Despite promising findings on the efficacy of referrals in primary and emergency health care settings, victims often remain noncompliant with referral recommendations, reporting a lack of understanding about the seriousness of the issue and a belief that they must end the relationship as factors that may decrease likelihood to engage in intervention (13).

Research examining referrals for IPV victims in an emergency department (ED) setting indicate that as many as 85% of victims were willing to speak with a domestic violence advocate. However, only 54% of these individuals agreed to follow-up with ongoing case management (11). Therefore, although many victims were willing to discuss their victimization while in emergency care, only 48% of victims received follow-up care after discharge. These findings suggest that referrals for victims of IPV can be effective, but many victims remain noncompliant and do not connect with needed resources (11). In addition, many barriers to screening and referral in the ED exist, including lack of training, lack of knowledge about domestic violence, time constraints, and lack of a system-wide standard intervention for victims of IPV 12, 14. Finding an effective screening and referral method that can be implemented in primary and emergency health settings may increase the likelihood of a standardized response to the identification of IPV victims.

The primary goal of this investigation was to compare the efficacy of basic and enhanced referral systems in their ability to encourage victims of IPV to seek behavioral health support services after discharge from the ED, while considering demographic and mental health characteristics. Given the high comorbidity between IPV victimization and psychiatric concerns, participants were referred to on-site hospital behavioral health resources, which also employ domestic violence advocates.