A Pilot Project Exploring Medical Students’ Barriers to Screening for Intimate Partner Violence and Reproductive Coercion

Intimate partner violence (IPV) encompasses any form of assault intended to isolate and/or intimidate, including physical and psychological abuse, reproductive coercion, and stalking.¹ Reproductive coercion refers to any behavior that manipulates reproductive health outcomes, such as sabotaging birth control methods, pressuring a woman to get pregnant or a man to father a child, or exerting control over the outcome of a pregnancy.^2,3 Multiple studies have examined the prevalence of reproductive coercion in different populations of women, with reported prevalence ranging from 16% to 54%.^4-6

While research suggests that most health care practitioners do not routinely screen patients for IPV, data on screening practices for reproductive coercion are scant.^7,8 An often-cited barrier to IPV screening is the lack of provider education.^7,9 One study conducted interviews with 15 medical students to elucidate their barriers to screening, with fear of offending the patient, lack of training and knowledge, and time constraints frequently reported as concerns.¹⁰

As studies have shown that health care practitioners are more likely to screen if they have received IPV training, the Society of Teachers of Family Medicine (STFM) National Clerkship Curriculum supports the inclusion of this material in clerkships.¹¹ The extent of IPV education directly correlates with comfort and knowledge regarding the topic.^7,9,12 While nearly all US medical schools have required coursework on domestic violence, the quality of this course content is highly variable.^13,14 Recent reports have described specific interventions aimed at improving medical students’ knowledge of IPV, but have not looked specifically at reproductive coercion.^15,16

In order to optimize educational interventions, the objectives of our study were to further elucidate the internal barriers that medical students face when presented with the opportunity to screen for IPV and reproductive coercion, and to describe how our curriculum on this topic could be improved to better address these barriers.

During the 2016 academic year, immediately after the pregnancy options counseling OSCE, students completed an optional, anonymous survey with Likert-type and open-ended questions evaluating the self-perceived impact of this session on their IPV and reproductive coercion screening practices.

We completed an exploratory thematic analysis of responses to the open-ended survey questions using an iterative process. First, two coders independently coded the responses. We developed a final codebook through consensus, and responses were then recoded using this codebook. We used NVivo 11 (QSR International, Melbourne, Australia) for data management and to compute measures of interrater reliability (including kappa). We quantified the occurances of identified themes in order to identify their relative importance. Descriptive statistics for the quantitative items were computed using Stata 14 (College Station, Texas). The Florida International University Institutional Review Board granted exemption for this study.

All students (n=118) on the family medicine clerkship completed the pregnancy options counseling OSCE; 87% (n=103) answered all quantitative survey questions. Table 1 shows quantitative results.

Of the 118 students who completed the OSCE, 100 (85%) provided qualitative comments. Of those, 88 students reported barriers to screening for reproductive coercion, while 12 students explicitly noted no barriers to screening. Ninety students reported a barrier to screening for IPV, while 10 students stated that they had no barriers. The identified themes related to student barriers to screening for IPV and reproductive coercion, along with selected supportive quotes, are reported in Tables 2 and 3, respectively.

Overall, the kappa coefficient for interrater reliability was moderate at 0.58, and absolute agreement was high at 98%.¹⁹

Our findings build on the previous work of Aluko et al by looking at barriers to screening specific to reproductive coercion and by nesting our study within an evaluation of an existing curricular intervention.¹⁰ Students reported a variety of barriers to screening for intimate partner violence (IPV) and reproductive coercion that involved both asking the questions and dealing with patients’ potential responses. The reported barriers to screening for IPV and reproductive coercion were similar. Reproductive coercion had the added barriers of confusion about its relationship to IPV and the necessity of screening for it if questions about IPV have already been asked.

Even though the educational module included scripted screening questions, students reported another major barrier to screening was difficulty finding the words with which to ask the questions, thereby suggesting that simply providing scripted questions was insufficient. A taped role-play encounter may be more effective, offering a performance model that can support skills acquisition.²⁰

Many students reported not screening for IPV or reproductive coercion because of their lack of training in how to respond to a positive screen. Our analysis of students’ reported internal barriers suggests that equipping them to provide initial management is an important component of promoting screening behavior. STFM also supports the incorporation of objectives related to both screening and management.¹¹

Our study has several limitations. First, students who found this to be a useful session and a more pertinent or interesting topic may have been more likely to complete the post-OSCE assessment. Another limitation is that students self-reported whether they screened the standardized patient for IPV and reproductive coercion. Ideally, this self-reported data should have been corroborated by the standardized patient’s record of whether a student effectively screened. Due to session logistics, we were unable to incorporate this into the OSCE. Additionally, we performed the study at a single medical school and did not involve a control group of students that was not exposed to the educational intervention being examined. Finally, our study did not allow for long-term follow-up to assess whether students did in fact screen future patients for IPV and reproductive coercion.

Despite these limitations, our preliminary findings support the need for a longitudinal curriculum in IPV and reproductive coercion, during which an appropriate emotional context could be built as a foundation for skills acquisition. This longitudinal approach is also supported by the literature correlating the extent of training with the likelihood to screen.¹² Future research should examine the ideal content and structure of curricula addressing IPV and reproductive coercion, and aim to provide more specific correlations between training interventions and screening practices. Additionally, future research should consider the impact of training on long-term IPV and reproductive coercion screening behaviors.