This month's featured interview focuses on intimate partner violence (IPV) throughout COVID-19 and the role the primary care workforce plays in screening, training, and education.
The NCIBH team spoke with Nafisa Halim, PhD a Research Assistant Professor of Global Health at Boston University School of Public Health. Dr. Halim is an applied sociologist with research interests in developing and testing maternal and child health interventions in HIV affected and/or resource-poor settings. Halim’s most current work focuses on intimate partner violence during pregnancy and risk of adverse pregnancy and childbirth outcomes.
Do you think primary care providers should be more attentive in addressing intimate partner violence (IPV) during the COVID-19 pandemic?
Yes, as long as intimate partner violence is addressed in consultation with the consenting survivors. Primary care providers should certainly be cognizant of the fact that IPV is a likely byproduct of the COVID-19 pandemic, potentially affecting many of their patients and comprising their ability to adhere to treatment/lifestyle. The COVID-19 pandemic is a high risk, low protection situation for IPV survivors. High risk because many risk factors for IPV including financial stress, relationship strains, service disruptions are well underway, making it likely for IPV to break out among couples. Low protection since IPV survivors are socially distant from family, friends, neighbors, coworkers, and they worried about safety in IPV service facilities.
All involved in IPV practice are aware by now that the lockdown due to the COVID-19 pandemic, although necessary, comprised the safety and security of women having to stay at home 24/7 with their potential abusers. I would argue the extent of the problem may be greater than we know. This is because police reports and hotline records during the months of lockdown were compared with those months in the prior year. And, we saw relatively more calls and reports during the months of lockdown and attributed the change in rates due to the pandemic. This is all good. However, oftentimes, IPV remains underreported, making me worry about those experiencing IPV during these stressful times but not making phone calls or filing police reports. So, yes, I think primary care providers should be more attentive in creating an avenue for disclosure and a safe environment for intimate partner violence survivors during the COVID-19 pandemic should survivors choose to tell the providers about the experiences they are going through.
How can we best prepare the primary care workforce to assess and screen for intimate partner violence needs? How can these strategies be translated to telehealth?
Let me comment on a more fundamental issue, which may be impacting or could impact the fidelity of implementation of intimate partner violence screening. I think for the primary care workforce, it’s imperative that they are aware of why, how, and to what extent IPV matters for overall health. When IPV is perceived as a barrier to treatment adherence, the providers committed to patient well-being would likely be more motivated to IPV screening upholding the highest ethical standards. Also, it’s important that the primary care workforce, like many in society, are aware of any preconceived IPV myths--why IPV happens at the first place, who are at risk, why do IPV survivors not leave a relationship, etc.—getting in the way of provider-patient interactions. Once those fundamental issues are in place, there are increasing more resources out there including the 2013 World Health Organization (WHO) report providing recommendations of IPV assessment and screening for primary care providers. The report includes recommendations on “facilitating disclosure, checking their safety, offering support and referral, and providing the appropriate medical services and follow-up care.” All this to be done without intruding the autonomy of the survivors.
Could you describe any barriers or challenges that you’ve noted in implementing intimate partner violence screening and education in healthcare settings and/or in medical training?
Intimate partner survivors can simply deny follow-up behavioral health referrals or services. This could discourage primary care providers from screening patients for experience of IPV. Also, what is to be considered as public needing attention and what is to be considered as private needing protection is an inherent challenge. In my work as an IPV researcher assessing experience of IPV among women of reproductive ages in global community health settings. I often sense that screening providers are not comfortable implementing an IPV assessment tool if it includes questions about acts considered to be inappropriate to discuss publicly. For example, in my recent study on IPV among pregnant women following prenatal screening for sickle cell disease in Nagpur India, the screening providers were hesitant to ask women about their experience of involuntary anal sex or about their consumption of pornographic materials.
Do you have any recommendations for providers and educators who suspect that a patient or colleague may be an intimate partner violence survivor?
I generally agree with the World Health Organization recommendations on intimate partner violence situations. That is, providers/educators ought to know how best to receive the information about IPV experience and what the follow up steps are before any such conversation should take place. It’s important that institutions in which providers/educators work meet the minimum requirements. The institution should coordinate services with low enforcement or partner with IPV service agencies and organizations. Additionally, providers/educators should have basic training in conducting a difficult conversation (empathetic listening, validation, no overt/covert pressure for disclosure, etc.) with individuals experiencing IPV. My primary recommendation would be for institutions to puts systems and processes in place prior to providers/educators making an attempt to intervene, albeit informally.
Do you know of any resources specific to intimate partner violence education, curricula, or training you can share with our primary care audience?
Anything additional you would like to share about this topic?
As an intimate partner violence researcher, I am quite disturbed by how common IPV is among pregnant women. Like many, I assumed for a long time that pregnancy experiences immune women from IPV experiences, which it does for some but not for all. In the global health setting, we saw women making fewer visits to ANC clinics during COVID-19, making at-risk pregnant women more isolated and vulnerable to IPV. It’s high time for clinics to invest in creative solutions to make sure that at-risk patients are retained in care and that they have the opportunity to seek out help as and when needed.