Intimate partner violence (IPV) occurs in an estimated 2 million women in the United States each year and in up to 26% of American women over the course of their lifetime. IPV involves any pattern of assaultive and coercive behaviors, including physical injury, psychological abuse, and sexual assault. Other components of IPV include social isolation, stalking, deprivation, and intimidation or threats from someone who was or is in an intimate relationship with the victim. Studies indicate that IPV is more common among individuals visiting the ED for care. The prevalence of IPV in the ED in the past year ranges from 12% to 19% in published research. The estimated lifetime prevalence of IPV in the ED ranges from 44% to 54%.
In 2004, the Joint Commission updated its basic standards for hospital policies and procedures to increase the identification of IPV within EDs and hospital-based ambulatory care centers. These standards are uniform for all hospitals but do not acknowledge the potential resource differences between rural and urban EDs. Geographic and economic barriers to seeking healthcare in rural areas are often greater than those of non-rural settings, and alternatives for follow-up care and referrals may be limited.
Rural EDs Lagging in IPV Resource Availability
My colleagues and I conducted a study that assessed differences in IPV resource availability between urban and rural EDs. Published in the May 2011 Western Journal of Emergency Medicine, the study examined results from standardized telephone interviews of ED directors and nurse managers on six IPV-related resources:
1) official screening policies
2) standardized screening tools
3) public displays regarding IPV
4) on-site advocacy
5) intervention checklists
6) regular clinician education.
Overall, rural EDs appeared to have fewer resources to address IPV. Most types of studied IPV resources were less often available at rural EDs compared with urban EDs. For example, 38% of urban EDs reported having full-time on-site advocates for IPV victims, compared with 6% of rural EDs. Use of potentially lower-cost resources, such as public displays on IPV and standardized intervention checklists, was also greater in urban settings. It was concerning that 27% of rural services reported none of the six IPV resources examined, while all urban hospitals reported having at least two IPV resources and 65% had four or more.
Important Implications for Rural EDs
Several potential solutions are available for rural area EDs that have limited IPV resources. For example, IPV management guidelines or patient educational posters and pamphlets are relatively inexpensive to develop and use, especially with non-profit domestic violence groups and medical societies now providing these resources for free or at low cost. On an institutional level, existing leadership and continual medical education activities can be modified to include material on IPV. They can also emphasize skills that will allow emergency physicians to train others within their ED.
Collaborations between EDs at the state and county level may allow for a variety of educational initiatives to improve the management of IPV. State and national hotlines are available 24/7 for counseling patients experiencing IPV, and telemedicine is an intriguing new possibility for counseling victims in rural locations. While more research is needed to identify specific barriers to obtaining IPV resources, cost-effective steps can be taken by rural hospitals to improve their assessment and care of IPV victims in the ED.
Readings & Resources (click to view)
Choo EK, Newgard CD, Lowe RA, et al. Rural-urban disparities in emergency department intimate partner violence resources. West J Emerg Med. 2011;12:178-183. Available at: http://escholarship.org/uc/item/83n18707.
Coker AL, Flerx VC, Smith PH, et al. Intimate partner violence incidence and continuation in a primary care screening program. Am J Epidemiol. 2007;165: 821-827.
Kramer A, Lorenzon D, Mueller G. Prevalence of intimate partner violence and health implications for women using emergency departments and primary care clinics. Womens Health Issues. 2004;14: 19-29.
Iyengar R, Sabik L. The dangerous shortage of domestic violence services. Health Aff (Millwood). 2009;28: w1052-w1065.
Evaluating Domestic Violence Programs. Available at: http://www.ahrq.gov/research/domesticviol/.
American Congress of Obstetricians and Gynecologists: Screening Tools–Domestic Violence. Available at: http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585.
Family Violence Prevention Fund: Health Practitioner Tools. Available at: http://fvpfstore.stores.yahoo.net/healpractool.html.
Illinois Family Violence Coordinating Councils. Available at: http://www.ifvcc.org/.
Thomas CR, Miller G, Hartshorn JC, et al. Telepsychiatry program for rural victims of domestic violence. Telemed J E Health. 2005;11: 567-573.
Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women: incidence and prevalence in an emergency department population. JAMA. 1995;273:1763-1767.