Domestic Violence (IPV) Research

Project Proposal – MS4 Research Elective

Introduction:

IPV is associated with a number of negative health outcomes including increased risk of depression, anxiety, suicide, poor health, ER visits, physical or sexual assault and homicide. The high prevalence and widespread health effects of IPV, make it an important issue in primary care practices, but it is often difficult for physicians to know what interventions are needed. In turn, this leads to insufficient or even counter-productive interventions.

A common theme in IPV is isolation from friends and family due to shame about the abuse and a desire to hide the problems in the relationship. However, as women move on from an abusive relationship, they commonly find strength in friends, family and community support groups that enable them to leave the abuser. These societal connections encourage change in the form of passive external impetus toward action, rather than active internal resolution toward action on the part of the IPV recipient. This can be contrasted to active external motivators such as IPV crises (i.e. physical or sexual assault) and third-party interventions (i.e. arrests made by police) that force a spontaneous reaction by the IPV recipient without requiring change.

The physician and other healthcare providers primarily play the role of passive external motivators (PEMs), but physicians have the added advantage of a non-threatening and non-judgmental role which distinguishes them from friends and family whom IPV recipients may feel the need to hide “shameful” details from. Many women in abusive relationships describe difficulties maintaining privacy on their phones or computers and are unable to safely and reliably store electronic or physical evidence of abusive episodes. Healthcare providers also hold a unique role in the fact that they are able to accurately, privately and securely document details about injuries and episodes of abuse in both written and picture form in the medical record.

Problem:

• After screening, the role of physician in addressing IPV is poorly defined in current research and practice guidelines, which hinders PCP ability to provide necessary care and support to IPV recipients

Despite the presence of well-established patterns of abuse and IPV recipient responses as recipients progress towards resolution of an IPV situation, modelling the path towards behavioral change is more complicated in IPV than in models used to treat substance abuse because 1) an IPV relationship necessarily involves at least two parties, 2) dysfunctional behavior is not solely due to actions of IPV recipient, 3) IPV recipient often undergoes alterations in personality as well as biopsychosocial changes as a result of the relationship that may alter the typical progression through the stages of change.

The goal of this project is to derive a behavioral change model that will inform physicians and other “passive external motivators” as to the most effective interventions to enable IPV resolution once IPV recipients are identified via routine positive screening or self-identification. To create this IPV-specific stage-based model, I will use qualitative interviews of female IPV recipients and will investigate 1) recipient-created “change maps” that mark progression through the model, with an emphasis on “turning points” that caused change and “interventions” (input or assistance from PEMs), 2) specifically investigate the effectiveness of interventions that occurred during encounters with healthcare providers, and 3) assess changes in personality and biopsychosocial characteristics of IPV recipients using self-identified changes on quantitative graphics that can be used for continued quantitative input in clinical encounters. I hope to create a formula for physician action after positive IPV screening that will be streamlined and easy to implement in clinical practice and will optimize IPV interventions during healthcare encounters. I also hope to create an IPV severity staging model which will help inform patients of their personal risk based on the factors making up the safety assessment tools (aka self-reevaluation [Zink et al 2004]). Finally, I hope to investigate ways that changes in personality and biopsychosocial profiles affect progression through the stages of change model and the likelihood that a woman will achieve IPV resolution.

Specific Aims:

1. Model a multi-stage process of IPV resolution with a recipient-centric approach to inform best types of stage-based physician intervention in IPV situations using literature review and previously published studies on best-practice interventions and society guidelines as well as interactive, “brainstorming” discussion with women (n=10) who have experience with the resolution of a prior IPV relationship and who are active in efforts to help other women in IPV situations
2. Create a robust, streamlined model for most effective interventions by passive external motivators based on recipient self-identified stage in IPV resolution so that physicians can quickly and easily provide support as a non-judgmental, non-threatening professional presence
   1. Obtain real-time feedback on intervention model from women in the community who voluntarily participate in the study.
   2. Interview women about their experiences and create “change maps” as seen in Chang et al. 2006. Unlike Chang et al, do not limit interviews to women in DV shelters
   3. Review ongoing anecdotes and recommendations for physician interventions by asking about effective and ineffective interventions in IPV recipients’ change map and asking about what recipients wished healthcare providers had done differently.
   4. Specifically, detail whether notes/pictures from healthcare encounters were used as evidence in IPV resolution (TRO, divorce proceedings or criminal investigations)
3. Define a staging criterion for IPV and use this staging model as a risk assessment tool and as a way to contextualize reported stages of change findings within the framework of the cycle of abuse with the intention of aiding IPV recipient self-reevaluation (similar to using ASCVD risk in smoking cessation counseling)

Methods:

1. Selection criteria:
   1. Preliminary participants (SA #1: creation of IPV resolution model) will be women who are known to the author and have previously indicated interest in assisting with IPV research project. This will be a biased sample, but will simulate the process of IPV resolution through strengthening of connections with IPV recipient’s friends and family members.
   1. Recipient interviews: Contacts will be referred through Domestic Violence Advocacy Committee, word-of-mouth or community outreach in the form of flyers and public advertisements. Criteria may include: AOx3, English-speaking, childless, adult women in heterosexual relationships without active substance-abuse interventions (i.e. not in rehab).
2. Standardized Interview questions: TBD
3. IRB
   1. Behavioral/Social sciences research