Transcript Intimate Partner Violence and Preconception Care Risk

Assessing Intimate Partner Violence
(IPV) & Preconception Health &
Healthcare Risk (PHHC) via Virtual
Patient Advocate (VPA) Technology
Brian Penti MD
Academic Research Fellow, Department of Family Medicine
Data & support from Gabby Preconception Care System team
Academy on Violence & Abuse, October 17, 2014
Controversies & Challenges in Addressing Violence & Abuse
Across the Lifespan
Objectives Today
• Background information on:
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Preconception Care
Health Disparities
Virtual Patient Advocate
Intimate Partner Violence
• Objectives/Hypothesis
• Methods
• Limitations
• Results
• Conclusions
• Recommendations/Future research
Health Disparities AA women
Preconception care is:
“a set of interventions that aim to identify and modify
biomedical, behavioral and social risks to a woman’s health or
pregnancy outcome through prevention and management”
CDC, Johnson K, Posner SF, Biermann J, Cordero JF, et al. (2006) CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care.
Recommendations to improve preconception health and health care: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on
Preconception Care. MMWR Recomm Rep 55: 23
At birth
Smoked during pregnancy
11.0%
Consumed alcohol in pregnancy
10.1%
Had preexisting medical conditions
4.1%
Rubella sero-negative
7.1%
Received inadequate prenatal care
At risk of
getting
pregnant
15.9%
Cardiac Disease
3%
Hypertension
3%
Asthma
6%
Dental caries or oral disease (women 20-39)
Diabetic
>80%
9%
On teratogenic drugs
2.6%
Overweight or Obese
50%
Not taking Folic Acid
69.0%
Preconception Health & Health Care
Although most women understand optimizing health before
pregnancy is important & most physicians think PCC is
important, few obstetricians/gynecologist or family
physicians provide comprehensive PCC to their patients…
Hence we need to create tools to assist busy clinicians in
providing this care
Using Health IT to Overcome
Challenge of Clinician Time
Virtual Patient Advocates (VPA’s): computerized, animated
character designed to integrate best practices from providerpatient communication theory
VPA’s may be ideal for delivering PCC because:
•can reach large # of patients
•Alleviate clinician time restraints
•Can control costs
•High patient acceptability:
•Culturally appropriate
•Provide understandable info
for those with low Health literacy
Characters: Louise (L) and Elizabeth (R)
Now Introducing: Gabby
Gabby Version 2
1. Meet Gabby
2. Take Risk
Assessment (RA)
Achieve Goal
8b. Choose new risk to
discuss from
“My Survey Results”
OR “My Health To-Do List”
3. Review results
(“My Survey
Results”)
6. Listen to first
stage-appropriate
script(s) from Gabby
7a. Add to risk to
MHTDL
7b. Don’t Add to
MHTDL
Precontemplation
4. Answer Stage of
Change question for
each triggered risk
5. Choose risk to
learn about with
Gabby
8a. Longitudinal
behavior change
scripts
Motivational Interviewing
Contemplation &
Planning
- Shared Decision Making
(Family Planning)
- Sequential Discrete
(“Go to the Doctor” risks)
Contemplation,
Planning, Action,
Maintenance
- Problem Solving/Tips
- Homework
- Goal Setting
- Educational Info
(Nutrition, Activity, and
Stress Management)
Intimate Partner Violence (IPV)
• IPV is associated with:
– unwanted pregnancy and abortion (x2)
– maternal death in pregnancy
– Adverse birth outcomes:
• low birth weight (16%)
• preterm delivery
• neonatal death
• Prevalence of IPV during pregnancy ranges
from 1-20%, although studies that asked
about violence more than once or asked
during the 3rd trimester reported prevalence
rates of 7-20%.
• Research suggests IPV screening and
intervening during pregnancy may improve
birth outcomes.
Hypothesis
• Young African-American women would be
willing to disclose IPV during anonymous PHHC
screening.
• For those women who report a history of IPV,
they will have increased number of
preconception care risks compared to women
who do not have history of IPV.
• Gabby, in context of providing PHHC education,
will help women to address IPV.
Methods -1
Analysis of Data from a RCT (HRSA B-MCH R40
MC21510)
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100 African-American women between the ages of 18-34
from 20 States from a cohort of women trained in the
Office of Minority Health PCC Peer Educator Program &
attending HRSA Healthy Start sites
Intervention participants will use system for 6 months
Primary outcome: reduction in number of preconception
risks
Secondary outcomes: progress in stage of change; system
usage and satisfaction, etc.
Will stratify by health literacy, education, income,
technology use, etc.
Methods -2
Dependent Variable: women considered to have history
of IPV if answered yes to any of following 6 questions:
**these are non-validated screening questions, newer version is using WAST questionnaire**
Have you ever been hit, slapped, kicked, or physically hurt in any
way?
Has anyone ever made you do something sexual that you didn’t
want to do?
Have you ever felt nervous or scared because of the things that
someone said to you?
Has anyone ever told you that you are a bad person, that you are
useless or that you are worth nothing?
Are you afraid that someone you know may hurt you?
Are you ever afraid or nervous to go home?
Methods -3
• Independent Variable: number of PCC risks (103
risks)
4%
3%
4%
21%
Nutrition
4%
Infectious
Genetic
5%
Environmental
Reproductive
Immunization
7%
Health Conditions/ Meds
17%
7%
Healthcare/ Programs
Emotional
Substance
Men
7%
10%
11%
Jack B et al. Am J Obstet Gyn
2008
Relationships
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Results
90 out of 100 women enrolled in study completed
the risk assessment on-line:
– 57% reported yes of at least 1 of 6 IPV questions
– 52% reported emotional or verbal abuse
– 37% reported history of physical or sexual abuse
• Women with history of any IPV had more PHHC
risk than women with no history of IPV (25.9 vs
20.9; p<0.0001)
• Women with history of physical/sexual IPV had
26.8 PHHC risks compared to 22 PCC risks in
women without.
Results
• **Gabby V2 System effective in reducing total
number of PHHC risks, but not powered to
assess effectiveness in reducing risk for women
with history of IPV
Results: all IPV
+IPV (n=51)
(-) IPV (n=39)
P-Value
Total # of
Preconception Care
Risk
Mean
(SD)
25.94 (5.9)
20.97 (4.5)
0.0001
Multidimensional
Scale of Perceived
Social Support
Mean
(SD)
68.6 (9.6)
73.1 (8.6)
0.02
Everyday
Discrimination scale
Mean
(SD)
14.59 (7.8)
10.54 (7.5)
0.0156
Stress
N(%)
10 (19.6%)
2 (5.3%)
0.0419
Trouble paying bills
N(%)
22 (43.1%)
6 (15%)
0.0048
Anxiety/ Depression
N(%)
13 (25.5%)
5 (12.8%)
0.1365
No Health Insurance
N(%)
7 (13.73%)
1 (2.56%)
0.1310
Results: Limited to Physical or
Sexual Abuse
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Physical/Sexual Abuse
P-value
Yes
(n=33, 36%)
No
(n=58; 64%)
Number of PHHC risks
26.8 (6.7)
22 (4.6)
0.0001
Multidim Scale of
Perceived Social
Support
67.9 (10.3)
72.1 (8.2)
0.03
14.8 (8)
11.5 (7.7)
0.06
45.5%
22.4%
0.02
Everyday Discr. Scale
Trouble paying bills
Social Support, IPV, & PHHC Risks:
• higher social support scores (X axis) are associated with
lower PHHC risks (Y axis) amongst women w/ hx IPV,
but not for women without IPV
Conclusions:
• Initial data suggests the Gabby PHHC system can
identify PHHC risks & reduce total number of
PHHC risks, although our study was not powered
to assess if Gabby can intervene in cases of IPV.
• Women with history of IPV have more
preconception care risks compared to women with
no reported hx of IPV.
• Social Support appears to be protective in
reducing number of PHHC risks for women who
have a history of IPV.
Limitations
• Not able to assess birth outcomes yet
• Use of non-validated IPV screening questions
• Unclear if women who report history of IPV are
currently in abusive relationship
• Limited number of test subjects
• Not powered to assess if Gabby PHHC system
effective in decreasing IPV risk
• Information is self-reported
Moving Forwards
• Study to enroll 500 AA women to use Gabby system, using
WAST screening questions (currently >150 women enrolled)
• For women answer +IPV, what is the impact of the Gabby PHHC
System? (ie Klevins Study published in JAMA)
• Does framing discussions regarding IPV and pregnancy
outcomes increase motivation to intervene?
• Can men be potentially screened for perpetration of IPV using
such a system (ie Gabe)?
• Does the Gabby system improve birth outcomes for AA women?
Could this system be effective in general population?
• PCORI study regards Integrative Medicine Group Visits to
address chronic pain exploring relations to IPV & ACE’s
Acknowledgement
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Megan Hempstead MPH1
Suzanne Mitchell MD, MS1
Paula Gardiner MD, MPH1
Karla Damus PhD, MSPH, RN1
Ekaterina Sadikova MPH
Leanne Yinusa-Nyahkoon, ScD, OTR/L 3
Larry Culpepper MD1
Tim Bickmore PhD 2
Brian Jack MD1
Affiliations:
– Boston University School of Medicine Department of Family
Medicine
– Northeastern University Department of Computer Science
– Boston University Sargent College
Questions?
My Questions to the Audience:
• Any insights about how to best get someone to
actually start to talk about their experience (of
IPV) with VPA? How do you get people to take
that step?
• What concerns would you have of a computer
program eliciting a person’s exposure or
experience with IPV? (thinking of both victim
AND perpetrator). For example, what if someone
becomes severely distressed while using the
program?