Implementation of intimate partner violence education for adolescents with spina bifida

2.1Design

Materials and methods for this quality improvement study were adapted from an adolescent IPV educational training program created for adolescent health settings [5] utilizing the Futures Without Violence training materials [6]. For one month prior to an educational training session, baseline data were collected from patients after their clinic visit about whether they discussed IPV during that visit. Following this, all interested Physical Medicine and Rehabilitation (PM&R) staff (n= 8) attended an educational training session based on this previously tested, publicly available training. Attendees completed pre and post-training questionnaires. The training session reviewed the use of an educational safety card to provide patients with information regarding both IPV and referral resources [2]. For two months following the training, adolescent patients were asked to complete a brief survey about their visit. Providers and staff also completed a follow-up survey two months after the training. University of Pittsburgh Institutional Review Board approval was obtained for this study, which included a waiver of parental permission.

2.2Sample and setting

The spina bifida clinic at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center is a specialized clinic staffed by a multidisciplinary health care team. The clinic staff was consistent during the entirety of this QI project, and was comprised of nurses, medical students, trainees, and attending physicians. All English-speaking patients between the ages of 12–21 were eligible to complete the patient feedback surveys and no demographic information was obtained.

2.3Procedures

Education session materials were adapted from Futures Without Violence clinical guidelines on IPV among adolescents [6], and were modified to include information regarding IPV in individuals with disabilities, in particular those with spina bifida. Surveys for providers were modified from previous IPV studies and assessed their confidence with and frequency of discussing IPV during clinic visits. Patient feedback surveys, modified from previous studies [5, 7], were completed anonymously after clinical encounters, both prior to the education session to establish a baseline, as well as for two months after the education session. Patients were given their survey during their clinic visit and were instructed to complete it at the completion of their visit. No patient completed the survey more than once. All data collected were anonymous and surveys were stored in a locked box.

Data were analyzed using SPSS. In addition to descriptive statistics for clinician surveys, changes from before and after training in patient feedback were assessed using descriptive statistics, Fisher’s Exact Tests (analysis of safety card distribution frequency), or Chi-square tests. Responses to patient surveys were compared from pre-training to one-month post, two-months post, as well as across the two months following the training.

3.1Patient surveys

For baseline data there were 15 eligible adolescent patients, of which 13 (87%) completed the surveys. Fifteen percent of these patients responded that providers discussed healthy/unhealthy relationships with them, and 31% stated providers reviewed confidentiality with them (Table 1). About one third stated that discussing relationships was somewhat or very helpful.

During the first month following the education session, patient safety cards were placed among other education materials provided in the clinic. Of the 16 eligible adolescent patients who presented to clinic, eight completed surveys (50%). Patient reports indicated that the frequency of discussion of healthy/unhealthy relationships had significantly increased with 88% of respondents stating that such conversations occurred (p= 0.005, Table 1), although no safety cards were distributed. There was no significant difference between this time point and baseline regarding discussion of confidentiality (p> 0.05).

Thirteen of the 18 adolescent patients seen in clinic during the second month returned surveys (72%). To remind providers to distribute the patient safety cards, these were attached to the charts of all eligible patients. This increased the use of the cards from 0% to 62% of survey respondents (p= 0.005). In the second month, 88% of respondents stated this increased their understanding of how to help someone affected by IPV. However, rate of discussion of healthy/unhealthy relationships fell to 54%, which was not significantly different from baseline (p> 0.05) or the first month (p> 0.05).

Following the education session, the frequency of discussion about healthy/unhealthy relationships over the next two months increased significantly (p= 0.03, Table 1). There was no significant difference across the time points related to frequency of discussion of confidentiality. A majority of patients who received the informational cards found them to be useful, although to promote provider discussion of the cards these had to be prominently placed.

3.2Provider training

The education session was attended by eight spina bifida clinic staff during a departmental meeting: an administrator, two nurses, and five physicians. Six of the attendees completed pre-education surveys, and all eight attendees completed a post-training survey immediately after the training session. In the pre-training survey, for questions regarding frequency of discussion of IPV, confidentiality as well as assessing a patient’s safety in a relationship, most individuals stated they had such discussions “not so often” or “rarely” (see Table 2). The most often cited reasons for not addressing such issues included not having enough time, not being sure how to ask, and only asking if the patient raises the concern. Of the six providers, one suggested that prompts in the electronic record would be helpful. Five noted that the clinic had no materials related to IPV or reproductive coercion.

All respondents to the post-training either agreed or strongly agreed with the following statements: the education session was effective in increasing understanding of domestic and sexual violence, discussion of confidentiality with patients, ways to provide education, and how to obtain access to resources. In addition, all respondents either agreed or strongly agreed that they would be more likely to provide education regarding IPV and to discuss confidentiality. Two months later, four physicians in the spina bifida clinic completed a self-assessment survey. Most reported that they discussed IPV and confidentiality, and were more likely to assess safety of their patients. All respondents either agreed or strongly agreed that they were more comfortable responding to clients who disclose abuse and were either somewhat or completely confident in referring a patient to a partner IPV organization (Table 3).