Assessing the Veterans Health Administration’s response to intimate partner violence among women: protocol for a randomized hybrid type 2 implementation-effectiveness trial

Abstract

Background: Intimate partner violence (IPV) against women in the United States (US) remains a complex public health crisis. Women who experience IPV are among the most vulnerable patients seen in primary care. Screening increases the detection of IPV and, when paired with appropriate response interventions, can mitigate the health effects of IPV. The Department of Veterans Affairs (VA) has encouraged evidence-based IPV screening programs since 2014, yet adoption is modest and questions remain regarding the optimal ways to implement these practices, which are not yet available within the majority of VA primary care clinics. Methods/design: This paper describes the planned evaluation of VA's nationwide implementation of IPV screening programs in primary care clinics through a randomized implementation-effectiveness hybrid type 2 trial. With the support of our VA operational partners, we propose a stepped wedge design to compare the impact of two implementation strategies of differing intensities (toolkit + implementation as usual vs. toolkit + implementation facilitation) and investigate the clinical effectiveness of IPV screening programs. Using balanced randomization, 16-20 VA Medical Centers will be assigned to receive implementation facilitation in one of three waves, with implementation support lasting 6 months. Implementation facilitation in this effort consists of the coordinated efforts of the two types of facilitators, external and internal. Implementation facilitation is compared to dissemination of a toolkit plus implementation as usual. We propose a mixed methods approach to collect quantitative (clinical records data) and qualitative (key informant interviews) implementation outcomes, as well as quantitative (clinical records data) clinical effectiveness outcomes. We will supplement these data collection methods with provider surveys to assess discrete implementation strategies used before, during, and following implementation facilitation. The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will guide the qualitative data collection and analysis. Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

A Process to Identify and Address Barriers to Providing Financial Capability Programming to Survivors of Intimate Partner Violence

“…The process described here highlights what implementation research looks like in a real-world agency setting where program activities, staffing, and even a global pandemic (COVID-19) may affect research activities. The nascent application of implementation science to work with IPV survivors has largely been in large, institutional settings (Iverson et al, 2019, 2020), yet we demonstrate that it is possible to develop an action plan, tailored to a small agency setting, which addresses the barriers to implementation specific and unique to the context. Similarly, we show that it is possible to adapt the QUERI process to respond to real-world challenges (Curran et al, 2008).…”

“…Implementation science is the systematic study of methods that promote the implementation into practice of research-tested interventions and has been used to improve professional practice in health care settings (Baker et al, 2015; Eccles et al, 2009). However, there has been little effort to date to employ implementation science to improve DSV service provision (Edmond & Voth Schrag, 2017; Iverson et al, 2020). .…”

Health Service Interventions for Intimate Partner Violence among Military Personnel and Veterans: A Framework and Scoping Review

“…There were five studies describing elements of case identification strategies in military and veteran-specific health services, encompassing tools and protocols for improving recognition of service users who have experienced IPV. Four studies described performance or implementation of brief IPV screening tools, including the 4-item Hurt-Insult-Threatens-Scream (HITS) [ 23 , 24 ], and an extended version called the E-HITS [ 25 , 26 ]. Published reports addressed accuracy and sensitivity when using the CTS-2 as the reference standard among women veterans.…”

“…One publication also reported data supporting feasibility and acceptability [ 24 ]. The implementation of routine screening using the E-HITS in VHA primary care clinics is currently under evaluation in an ongoing implementation-effectiveness trial [ 26 ]. The search also returned one study which reported on the 10-item Trauma Questionnaire, which includes 2 items about threatened and actual IPV [ 27 ].…”

Patient and provider barriers, facilitators, and implementation preferences of intimate partner violence perpetration screening

“…Certainly, a primary care setting sees more patients and thus would be able to screen a larger number of people. However, primary care providers also often report being overburdened by screening, having a large volume of patients, being under-staffed, and not have enough time with each patient to conduct the many screenings that are already currently required [44][45][46][47][48]. Future research should formally evaluate the feasibility and effectiveness of screening for IPV use in these settings.…”