Intimate Partner Violence Training and Readiness to Respond among Students,Staff,and Faculty in Three Institutions in the United States

Abstract

Intimate partner violence (IPV) is a significant public health concern; however, limited studies have explored perceptions and experiences towards IPV among students, staff, administrators, and faculty across diverse disciplines at institutions of higher education. The purposes of this study were to (1) assess experiences of IPV among a sample of students, staff/administrators, and faculty and (2) examine the relationship among attitudes, actual and perceived knowledge, awareness, training, readiness, and personal experiences with IPV in this sample. Participants were recruited from an urban university and two university-affiliated medical institutions to participate in an online survey. Bivariate and multivariate associations were assessed. Structural Equation Modeling (SEM) was used to examine direct and indirect effects of perceived and actual knowledge and personal experiences with IPV. Of the 216 respondents, 42.6% reported personally experiencing IPV and 34.3% reported having witnessed IPV. Over 34% of participants never received training on IPV. The sub-sample with training received between one and more than 15 hours of training. Standardized total effect of training on attitudes and awareness was β = 0.42 (95% confidence interval [CI] = 0.30–0.51), the combined indirect effects was β = 0.18 (95% CI = 0.10–0.27) and the direct effects of β=0.23 (95% CI = 0.12–0.34), indicating that hours of training was highly associated with the participants’ perceived knowledge and actual knowledge, which improved their attitudes and awareness towards IPV survivors. Our findings suggest the need for campus-wide formal training on IPV to better prepare members in higher education to accurately identify, assess, and intervene to protect victims of abuse. Interprofessional approaches are needed that focus on the multiple and intersecting needs of victims of violence and should also enhance professional self-efficacy and increase readiness to respond to IPV survivors.

Keywords

intimate partner violence higher education perceived knowledge self-efficacy training attitudes

Characterized by physical violence, sexual violence, psychological abuse, and stalking, intimate partner violence (IPV) is a significant public health and public safety concern in the United States (U.S.) (Smith et al., 2017). The Centers for Disease Control and Prevention (CDC) estimates that 1 in 3 women (36.4% or 43.6 million) and 1 in 3 men (33.6% or 37.3 million) have experienced sexual violence, physical violence, and/or stalking by an intimate partner (Smith et al., 2018). IPV has been linked to a number of acute and chronic health consequences, primarily among female victims, including unwanted pregnancy, sexually transmitted infections, asthma, diabetes, depression, and suicidality (Black, 2011; Campbell, 2002; McLaughlin et al., 2012). In addition to its impacts on health, IPV has extensive social and economic costs to victims, including losses in wages, work productivity, employment, and housing (Daoud et al., 2012; Peterson et al., 2018). The lifetime economic population burden of IPV is $3.6 trillion in the U.S., with individual costs estimated at $103,767 for female victims and $23,414 for male victims (Peterson et al., 2018). IPV is also a leading cause of morbidity in the U.S., where 1 in 3 female homicide victims in the U.S. are killed by former or current intimate partners (Bridges et al., 2008; Cronholm et al., 2011).

In addition to the general population, IPV also affects a large proportion of students on university campuses in the U.S.; estimates on the prevalence of IPV among college students range from 21% to 32% (Anasuri, 2016). Studies on IPV among students have also assessed attitudes and awareness related to IPV professional practice, particularly among students in the healthcare-related fields of nursing, medicine, social work, dentistry, and pharmacy (Conn et al., 2014; Connor et al., 2012; Fedina et al., 2018; Moskovic et al., 2009; Sawyer et al., 2017). These studies have highlighted the need for the adequate education and training of students in health fields to prepare them to intervene when appropriate. As part of the educational community, with adequate training, students, faculty and staff are well-positioned to intervene and support peers and colleagues in academic institutions and health care facilities who may be experiencing IPV. Additionally, many faculty and staff members from the different professions are in clinical practice in a variety of settings (e.g., medicine, nursing, social work, law, dentistry, and pharmacy), where they are likely to encounter victims of IPV and should be able to identify and respond to those experiencing IPV. However, prior studies have not fully explored the attitudes, knowledge, training, and personal experiences with IPV among members of a campus community with diverse roles (administrative, faculty, and staff) and their readiness to respond to IPV. Findings from such studies could inform us on the training and educational needs for all members within campus communities and provide knowledge for university-wide interprofessional responses to IPV.

Attitudes and Knowledge Related to Intimate Partner Violence

A growing body of research has examined attitudes, beliefs, and perceived preparedness to screen and respond to IPV in healthcare settings, particularly among physicians, nurses, dental professionals, and social workers (Clark et al., 2020; Cowan et al., 2019; Daoud et al., 2012; LeMich et al., 2018; Ramsey et al., 2012). Indeed, individual attitudes, knowledge, beliefs, and perceptions towards IPV can be a barrier to screening and delivering effective responses in clinical practice (Alvarez et al., 2018; Roark, 2010; Warrener et al., 2013). Findings from existing research highlight that providers’ negative attitudes and common misconceptions of IPV have been barriers to screening for IPV. For example, in one study, approximately one-fourth of physicians (25.2%) and nurses (19.9%) described being frustrated by IPV victims’ behaviors and decisions (e.g., remaining in abusive relationships, expressing feelings of love towards their abuser, issues around victims’ children), attitudes which prevented providers from screening for IPV (Daoud et al., 2012). In a study of oral health professionals, 61.5% of participants reported being unprepared to appropriately screen for IPV and 64% felt they could not correctly refer patients to local social services (Harris et al., 2016). Also, practitioners’ lack of knowledge of IPV can act as a barrier to screening and response, including how to identify and respond to more nuanced or hidden forms of IPV. Findings from a study of social work practitioners suggests that physical violence may often be more easily identified in clinical settings than psychological and sexual abuse, including coercive control, sexual coercion, and reproductive coercion (Fedina et al., 2018). Despite the recognition that understanding IPV is essential for professionals across the health spectrum, schools have not fully integrated content on IPV into their core courses (Cronholm et al., 2014; Forgey & Colarossi, 2003; Moskovic et al., 2009). To our knowledge, the extent to which campus communities offer training on identifying and responding to IPV for staff and faculty members is unknown, specifically, trainings that utilize interprofessional frameworks. Importantly, the difference between perceived and actual knowledge will provide information to strategically target content for IPV training. In our study, perceived knowledge is conceptualized as the participants’ perceptions of the manifestations of IPV, referral sources, questions to ask a victim, and role in identifying a victim. Actual knowledge is conceptualized as participants’ actual knowledge regarding risk factors of IPV victimization, facts about perpetrators, warning signs, reasons victims may not leave a relationship, and appropriate ways to ask about IPV experiences.

Personal Experiences With Intimate Partner Violence

Although attitudes and knowledge on IPV can influence clinical responses, direct experience with IPV is also likely to contribute to individual attitudes and beliefs towards IPV (Ramsay et al., 2012). However, limited studies have explored how personal experiences influence attitudes and knowledge of IPV, particularly in healthcare settings. Some studies have explored the relationship between personal experiences with IPV, attitudes, and knowledge among students in healthcare-related programs (Sprague et al., 2012). Findings from these studies suggest concerning rates of IPV (ranging from approximately 40%–70%) among students in these fields of study, including both direct and indirect (i.e., witnessing IPV) experience with IPV (Connor et al., 2011, 2012). Mixed results are presented on the relationship between personal experiences with IPV and attitudes, knowledge and clinical practice, particularly after controlling for training experience in IPV (Connor et al., 2013; McLindon et al., 2019; Postmus et al., 2011).

Current Study

No studies were found that explored the relationship among attitudes, knowledge, training, and personal experiences with IPV among members of a campus community (i.e., students, staff/administrators, and faculty), including potential differences within the sub-groups. Such research can inform the development of effective and coordinated responses for patients who may be experiencing IPV served by student interns, staff, and faculty practicing in healthcare settings. The purpose of this study is two-fold: (1) to assess experiences of IPV among a diverse sample of members of a campus community that included students, staff/administrators, and faculty, and (2) to examine the relationships among attitudes, knowledge, training, and personal experiences with IPV in the sample including students, staff/administrators, and faculty. Level of perceived knowledge, actual knowledge, and preparedness to screen, as well as attitudes and awareness of IPV were examined. Additionally, training experiences (e.g., number of hours) were assessed and comparisons were made by participants’ characteristics (e.g., race/ethnicity, role/position). The following hypotheses were tested:

H_1: Perceived IPV knowledge is associated with IPV actual knowledge and screening knowledge.

H_2: IPV hours of training is associated with IPV awareness, attitudes and screening knowledge.

H₃: Perceived knowledge and actual knowledge mediates the effects of hours of IPV training on awareness and attitudes toward IPV.

H₄: Personal IPV experience (experiencing and witnessing) moderates the mediation effects of perceived knowledge and actual knowledge on the association between hours of IPV training and IPV awareness and attitudes.

Method

Study Procedures and Recruitment

A cross-sectional, online survey was administered via Qualtrics in October 2017 to a convenience sample of participants from one academic institution and two medical institutions on the same graduate school campus in the northeast U.S.; participants were comprised of faculty, students, staff, and administrators (from Schools of Medicine, Nursing, Dentistry, Pharmacy and Social Work) and inclusion criteria were as follows: (a) 18 years and older, (b) identified as student, faculty, staff, or administrator at the participating institutions. Participants were recruited through posted flyers at the institutions, email blasts, and newsletter advertisements. Specifically, email messages were sent to individual inboxes by utilizing the institutions’ global address book. Flyers were distributed and posted through a university-wide electronic newsletter and similar e-newsletters were distributed within the schools. School deans and department heads at the university and hospitals were also contacted via email to inform them of the study and to distribute the survey to potential participants in their schools and departments. Study participants were informed that consent was given upon clicking “yes” to proceed to the survey platform. All responses were collected anonymously; the survey took approximately ten minutes to complete. Hotline information and local resources and services for IPV were provided at the end of the survey to minimize participant potential distress. All study procedures were approved by the University’s Institutional Review Board prior to the study.

Measures

Modified measures from the Physicians Readiness to Respond to Intimate Partner Violence Survey tool (PREMIS) were used (Connor et al., 2011; Short et al., 2006). Six sub-scales were utilized in the current analysis. Reliability assessments were computed for each sub-scale and are described below.

Demographic Characteristics

An investigator-developed form was used to collect data related to participants’ attributes (e.g., age, gender, race/ethnicity, sexual orientation, relationship status, institutional affiliation), IPV training experiences (e.g. type of training received, reason(s) for training, location of training, and the number of hours of training received).

Perceived Knowledge Scale

Measured participants’ perception of IPV knowledge (for example, manifestations of IPV, referral sources, questions to ask a victim, role in identifying a victim, etc.). A composite score for the 11 items ranged from 11–55 in a Likert Scale (Likert scale: 1 = Nothing, to 5 = A Great Deal). Internal consistency was α = 0.97.

Screening Knowledge Scale

Measured how prepared and skilled participants were in assessing people experiencing IPV (for example, can ask the appropriate questions, appropriately respond to IPV disclosures, can identify signs of abuse, etc.). A sum score of the six items ranged from 6−30 in a Likert scale (1 = Not at All Prepared, 5 = Very Much Prepared). Internal consistency was α = 0.96.

Actual Knowledge

Measured participants’ knowledge regarding risk factors of IPV victimization, facts about perpetrators, warning signs, reasons victims may not leave a relationship, and appropriate ways to ask about IPV experiences. A composite score of the 17 items was computed ranging from range 0–17 in a dichotomous scale. Some items were reverse coded as appropriate. The higher the score, the more knowledgeable of IPV. The Kuder–Richardson 20 reliability measure was α = 0.56.

Attitudes and Awareness

Measured participants’ attitudes and understanding of IPV (for example, there is little help that I can provide, victims have the right to make their own decisions, etc.). Sum of the 13 items with some items that were reverse coded ranged from 13 to 65. (1 = strongly disagree, 5 = strongly agree). Internal consistency was α = 0.51.

Personal Experience

Measured participants’ history of experiencing IPV and history of witnessing IPV. Two dichotomous (yes/no) questions were used: (1) “have you ever experienced physical violence, sexual abuse, emotional abuse, intimidation, economic deprivation or threats of violence in an intimate partner relationship?” and (2) “have you ever witnessed intimate partner violence in the form of physical abuse, sexual abuse, or psychological abuse directed toward a family member?”

Data Analysis

Data were exported from Qualtrics into SPSS V25 and Mplus and analyzed using descriptive statistics, correlations, and structural equation modeling (SEM). Univariate descriptive statistics are presented as frequencies and percentages for categorical variables, and means and standard deviations for continuous variables. Demographic items included categories with small cell sizes (n < 10); therefore, where feasible, the cells were collapsed with related categories. We collapsed gender, relationship status, primary affiliation, and sexual orientation in this fashion. All outcomes were assessed for normality; while Actual Knowledge was found to be left skewed, all other outcomes were normally distributed. After cube transformation, Actual Knowledge was normally distributed, and this cubed value was used in analyses. Bivariate analyses were performed examining the associations among participant characteristics: demographics, IPV training, and different domains of knowledge with the outcomes: Attitudes and Awareness, Screening Knowledge, and Actual Knowledge. When examining the associations between continuous outcomes with continuous participant characteristics, we performed Pearson’s Product-Moment correlations. When examining outcomes and categorical participant characteristics, we tested the association with ANOVAs and presented the mean and standard deviation of the outcomes.

Structural equation modeling (SEM) was employed to estimate the complex interrelationships among knowledge, personal experiences, hours of training, and awareness and attitude simultaneously. SEM was conducted in Mplus with full information maximum likelihood (FIML) to account for the missing values. The comparative fit index (NFI), Root Mean Square Error of Approximation (RMSEA) and the standardized root mean square residual (SRMR) were used to estimate model fit (Hu & Bentler, 1999). A RMSEA below .05 and CFI greater than .95 indicates good fit (Hoyle, 2012). RMSEA below .08 and CFI greater than .90 indicate adequate fit, and SRMR below 0.08 indicate good fit. Each model met all of these criteria. Biased-adjusted 95% Bootstrapped confidence interval (95% BCI) was used to assess the mediation effects.

Results

Demographic Characteristics of the Participants

The sample included 216 participants with a median age of 38.9 years (SD = 13.5). The youngest participant was 21 years old and the oldest 70 years old. The sample was mostly female (n = 192, 88.9%). Participants were largely non-Hispanic/Latino (n = 203, 94.0%) and White (n = 170, 78.7%), followed by Black or African American (11.1%), Asian (5.1%), and Other (3.2%). The majority of participants were heterosexual (n = 177, 81.9%) and married (n = 105, 48.6%). In addition, 36.6% were staff or administrators, 32.4% students, 22.2% faculty, and 7.9% VA employees. Table 1 provides details of participants’ demographic characteristics.

Table 1.

Demographic Characteristics of the Participants (N = 216).

Demographics	n	(%)	Mean	SD
Age (years)	216		38.9	13.5
Gender
Female	192	(88.9)
Male	17	(7.9)
Other or missing	7	(3.2)
Hispanic or Latino Ethnicity
Yes	10	(4.6)
No	203	(94.0)
Missing	3	(1.4)
Race
White	170	(78.7)
Black or African American	24	(11.1)
Asian	11	(5.1)
Other	7	(3.2)
Missing	4	(1.9)
Sexual orientation
Heterosexual	177	(81.9)
Sexual minority (lesbian/gay/bisexual)	36	(16.7)
Missing	3	(1.4)
Relationship status
Single	58	(26.9)
Married	105	(48.6)
Partnered/Coupled	47	(21.8)
Other	6	(2.8)
Roles
Primary Affiliation
UMB	194	(89.8)
UMMC	5	(2.3)
VA medical center	17	(7.9)
School Affiliation
Nursing	56	(28.9)
Medicine	37	(19.1)
Pharmacy	4	(2.1)
Law	29	(14.9)
Social work	48	(24.7)
Dentistry	4	(2.1)
Graduate	6	(3.1)
Missing	10	(5.2)
Role Identification Student	70	(32.4)
Faculty	48	(22.2)
Staff or administrator	79	(36.6)
VA employee	17	(7.9)
Missing	2	(1.0)
IPV training
None	74	(34.3)
1–5 hours	81	(37.5)
6–15 hours	25	(11.6)
More than 15 hours	36	(16.7)
Knowledge and attitudes
Perceived Knowledge	216		34.6	11.5
Screening Knowledge	216		19.7	5.7
Attitudes and Awareness	216		48.3	4.4
Actual Knowledge	216		13.8	2.2
Personal Experience
Have you experienced IPV
Yes	92	(42.6)
No	116	(53.7)
Missing	8	(3.7)
Have you witnessed IPV
Yes	74	(34.3)
No	134	(62.0)
Missing	8	(3.7)

**SD – standard deviation.

Over 40% (42.6%, n = 92) reported personally experiencing IPV and 34.3% (n = 74) reported having witnessed IPV. Over 34% (n = 74) of participants never received training on IPV. The analysis included 37.5% that had received between one and five hours of training, 11.6% that received 6–15 hours of training, and 16.7% that had more than 15 hours of training. The type of training most frequently reported was classroom/lecture (50.5%), followed by online training (38%) and skills based/clinical training (28.7%). Reasons for attending IPV training included personal interest (60.6%), school requirement (38%), workplace requirement (34.5%), licensing or continuing education (14.8%) and other (6.3%). The most frequently endorsed location for receiving training was in an institution of higher education. Participants who did not receive any training (n = 74) reported the following reasons: training was not required (60.8%), no training was available (52.7%), lack of time (13.5%), and no interest (12.2%), which were not mutually exclusive. Participants who received training had a mean Perceived Knowledge score of 37.8 (SD = 9.8), a mean Screening Knowledge score of 21.5 (SD = 4.8), a mean Attitudes and Awareness score of 49.3 (SD = 4.2), and an Actual Knowledge score of 14.1 (SD = 2.1). Participants who did not receive training had a mean Perceived Knowledge score of 28.4 (SD = 12.0), a mean Screening Knowledge score of 16.3 (SD = 5.7), a mean Attitudes and Awareness score of 46.6 (SD = 4.3), and an Actual Knowledge score of 13.2 (SD = 2.3).

Bivariate analyses demonstrated that a history of IPV experience was associated with sexual minority status, single relationship status, university affiliation, staff or administrator roles, 0 to over 15 hours of IPV training, and witnessing IPV. History of witnessing IPV was associated with older age, Black/African American or Asian racial/ethnic identity, university affiliation, staff or administrator roles, and history of experience of IPV (all p ≤ 0.05). Additionally, higher perceived Knowledge scores were associated with sexual minority status, more hours of IPV training, and higher Attitudes and Awareness, Screening Knowledge, and Actual knowledge scores (H₁ was supported). Higher Attitudes and Awareness scores were associated with White or Other race (as compared to Black/African American and Asian American), sexual minority status, more IPV training, and higher Perceived Knowledge, Screening Knowledge, and Actual knowledge scores (H₂ was supported). Higher Screening Knowledge scores were associated with the hospital’s primary affiliations (as compared to the university), more IPV training, and higher Perceived Knowledge, Attitudes and Awareness, and Screening Knowledge scores. Actual Knowledge scores were associated with White or Other race (as compared to Black/African American or Asian American), student role (as compared to staff or administrator), more IPV training, and higher Perceived Knowledge, Attitudes and Awareness, and Screening Knowledge scores. See Table 2 for details including the direction and magnitude of the associations and test statistics.

Table 2.

Bivariate Results of Key Study Variables (N = 216).

	Perceived knowledge (Range 11–55)			Attitudes and awareness (Range 13–65)			Screening knowledge (Range 6–30)			Actual knowledge (Range 0–17)
Characteristic	n	Mean (SD) or r	p	n	Mean (SD) or r	p	n	Mean (SD) or r	p	n	Mean (SD) or r	p
Demographics
Age, r^a	216	0.001	0.99	216	−0.11	0.09	216	−0.02	0.78	216	−0.12	0.07
Gender, m (SD)^b	209		0.68	209		0.77	209		0.34	209		0.48
Male		33.4 (10.0)			48.6 (4.5)			20.9 (4.7)			13.5 (3.0)
Female		34.6 (11.7)			48.3 (4.5)			19.6 (5.7)			13.8 (2.0)
Hispanic, m (SD)^b	213		0.56	213		0.91	213		0.77	213		0.83
Yes		36.6 (15.2)			48.2 (4.0)			19.2 (7.7)			13.7 (1.3)
No		34.4 (11.3)			48.4 (4.5)			19.7 (5.5)			13.8 (2.1)
Race, m (SD)^b	212		0.79	212		< 0.001	212		0.97	212		< 0.001
White		34.3 (11.6)			48.9 (4.2)			19.7 (5.6)			14.1 (1.8)
Black		35.9 (12.1)			45.8 (4.6)			19.2 (6.4)			12.0 (2.8)
Asian		35.8 (8.7)			44.8 (4.2)			20.1 (3.8)			12.8 (3.3)
Other		31.4 (30.3)			48.4 (1.3)			19.6 (5.1)			14.4 (0.8)
Sexual orientation, m (SD)^b	213		0.02	213		0.004	213		0.18	213		0.31
Heterosexual		33.8 (11.3)			48.1 (4.4)			19.5 (5.7)			13.8 (2.0)
Sexual minority		38.6 (11.4)			50.3 (3.8)			20.9 (5.5)			14.2 (2.1)
Relationship status, m (SD)^b	210		0.22	210		0.99	210		0.60	210		0.18
Single		36.5 (11.1)			48.4 (4.6)			20.1 (5.9)			13.7 (2.2)
Married		33.3 (11.2)			48.3 (4.8)			19.7 (5.5)			13.7 (2.2)
Partnered/Coupled		33.7 (12.0)			48.3 (2.8)			19.0 (5.5)			14.4 (1.5)
Roles
Primary Affiliation, m (SD)^b	216		0.75	216		0.98	216		0.04	216		0.17
UMB		34.5 (11.7)			48.3 (4.5)			19.5 (5.8)			13.7 (2.2)
UMMC or VA medical center		35.3 (9.0)			48.3 (4.2)			22.0 (3.4)			14.4 (2.0)
Role, m (SD)^b	214		0.48	214		0.39	214		0.12	214		0.01
Student		36.0 (11.3)			48.8 (4.8)			20.3 (5.5)			14.3 (2.2)
Faculty		34.6 (10.7)			48.5 (4.4)			19.9 (5.8)			13.6 (2.9)
Staff or Administrator		33.1 (12.5)			47.7 (4.1)			18.7 (6.0)			13.3 (1.8)
VA employee		35.5 (9.9)			49.1 (4.3)			21.9 (3.7)			14.8 (0.9)
IPV training, m (SD)^b	216		< 0.001	216		< 0.001	216		< 0.001	216		0.01
None		28.4 (12.0)			46.6 (4.3)			16.3 (5.7)			13.2 (2.3)
1–5 hours		33.6 (8.2)			47.6 (3.5)			20.1 (4.5)			13.8 (2.3)
6–15 hours		39.1 (8.7)			52.4 (4.3)			21.0 (4.9)			14.7 (1.0)
More than 15 hours		46.3 (7.8)			50.9 (3.8)			25.0 (3.6)			14.3 (2.2)
Knowledge and attitudes
Attitudes and Awareness, r^a	216	0.39	< 0.001	216	1.00	-	216	0.39	< 0.001	216	0.38	< 0.001
Screening knowledge, r^a	216	0.74	< 0.001	216	0.39	< 0.001	216	1.00	-	216	0.25	< 0.001
Actual knowledge, r^a	216	0.16	0.02	216	0.38	< 0.001	216	0.25	0.001	216	1.00	-
Personal experience
Experienced IPV, m (SD)^b	208		0.038	208		0.65	208		0.78	208		0.76
Yes		35.3 (12.8)			48.3 (4.7)			19.6 (6.1)			13.9 (1.7)
No		33.9 (9.9)			48.6 (3.4)			19.8 (5.2)			13.8 (2.4)
Witnessed IPV, m (SD)^b	208		0.91	208		0.56	208		0.52	208		0.75
Yes		34.5 (12.1)			48.1 (4.8)			19.4 (5.4)			13.8 (1.9)
No		34.7 (11.1)			48.5 (4.3)			19.9 (5.6)			13.9 (2.3)

^aPearson correlation

^bLinear regression

In the SEM, we initially included all three knowledge measures as mediators in the model. Though the path from hours of training to screening knowledge was significant (β = .52, p < .001) (H₂ was supported), the path from screening knowledge to attitudes and awareness was not significant (β = .08, p = .28), and the indirect effects through screening knowledge was non-significant (β = .18, p = .29). Thus, we removed screening knowledge from the mediation modeling. As seen in Figure 1, perceived knowledge and actual knowledge played mediating roles between the hours of training and attitudes and awareness (H₃ was supported). The standardized total effect of training hours on attitudes and awareness was β = 0.42 (95% bootstrapped confidence interval [BCI] [0.30, 0.51]), the combined indirect effects was β = 0.18 (95% BCI [0.10, 0.27]) and the direct effects of β = 0.23 (95% BCI [0.12, 0.34]), indicating that hours of training was highly associated with the participants’ perceived knowledge and actual knowledge, which improved their attitudes and awareness towards IPV victims. We further explored whether the mediation effects were moderated by participants having witnessed or experienced IPV using the moderated mediation modeling, assuming the moderation effects occur on “a” path and “b” path. Results demonstrated that the mediation effect did not differ by either “witness” (β = −0.301, 95 BCI [−1.17, 0.62]) or by “experience” ([β = −0.259, 95% BCI [−1.0, 0.52]; hence, the data were not shown) (H₄ was not supported). See Figure 1.

Figure 1.

Actual knowledge and perceived knowledge mediated the effects of hours of training on attitude. Total effect .417, 95% BCI [.303, .513]; total indirect effect .183, 95% BCI [.099, .258]; total direct effect .234, 95% BCI [.115, .344]. BCI – bootstrapped.

Discussion

Characteristics of IPV Experiences and Training

Overall, a large proportion of participants in this study (42.6%) reported a personal experience of IPV, suggesting the need for institutions of higher education and hospitals to provide greater support and resources related to IPV for their campus community members. This is particularly important for members that may be at heightened risk of experiencing and witnessing IPV, belonging to communities of color, and sexual and gender minority groups (Capaldi et al., 2012; National Criminal Justice Reference Service [NCJRS], 2018; Whitton et al., 2019).

Our current findings support prior research in that populations more at risk of experiencing IPV include those from sexual minority groups who may experience additional stressors unique to their relationships (NCJRS, 2018; Whitton et al., 2019). In addition, stigma and discrimination may increase the challenge in help-seeking and accessing limited resources for this group (Gehring & Vaske, 2017; Rolle et al., 2018). Having a single relationship status was also associated with experiencing IPV, while increasing age was only associated with witnessing, but not experiencing IPV in our study. Age has been negatively correlated with IPV with being younger aged a risk factor (Capaldi et al., 2012; Peterman et al., 2015). Studies examining the connection between IPV, and relationship status have indicated that single, divorced or cohabiting women were more likely to experience IPV (Bernards & Graham, 2013; Huang et al., 2010; Hyman et al., 2006) compared with married individuals.

Regarding institutional affiliation, we found that university (as opposed to hospital) affiliation and having a staff or an administrator status were associated with experiencing and witnessing IPV. There may be several explanations why these groups were more likely to experience and witness IPV. First, university participants in this study may have been exposed to more training (e.g., Title IX) on IPV than hospital participants and may have been more likely to label their experiences as IPV. This explanation may also be related to the study’s measure of IPV, which included single items asking the respondent whether they had personally experienced or witnessed IPV, rather than the use of a behaviorally specific measure. . Other factors, such as age and socioeconomic factors, may also influence these associations. Hospital and university administrators may have also been exposed to more training given their status, may have been older, and may have had longer relationships. Further study is needed with larger samples for test interaction effects among these variables to better understand congruent links among group characteristics and known risk factors (e.g., age, relationships, socioeconomic status) associated with IPV.

As expected, witnessing and experiencing IPV were strongly associated and is consistent with previous research that clearly demonstrates this bidirectional association (Breiding et al., 2014; Capaldi et al., 2012). Having no training or having 15 or more hours of IPV training were associated with experiencing IPV. While the current study did not ask when the IPV trainings occurred, it is possible that those with no training had no knowledge of risk factors or awareness of danger signs in a relationship, leading to experiences of IPV. It is equally possible that those who experienced IPV will subsequently have sought out additional training specifically to understand their experiences and to prevent future ones. Additionally, while role (e.g., social work, law, medicine) was not associated with experiencing or witnessing IPV, it is possible that sub-groups of participants may have been more or less likely to receive training, and to have received certain types of training (e.g., law participants receiving training on legal issues related to IPV; nursing participants receiving training on clinical screening), which may have influenced their reports of witnessing and experiencing IPV. In a study using data from the International Dating Violence Study, Paat and Markham (2019) explored underlying mechanisms influencing IPV among college students from 32 countries and found that early socialization (e.g., childhood neglect, witnessing domestic violence), was associated with later IPV victimization among college students. As such, there are likely other factors related to socialization, childhood trauma, family social structure, and relationship dynamics that influence IPV experiences among university and hospital students, staff, and faculty.

Approximately two-thirds of participants indicated having had some type of IPV training. The remaining 34.3% did not, and their qualitative responses indicated lack of requirement and lack of opportunity as major reasons for not being trained. Participants who received training reported reasons for training as workplace and academic requirements as well as for personal interest. These results suggest the need to provide readily accessible ongoing training using interprofessional approaches to counter the influence of factors known to discourage effective IPV responses by clinicians and other professionals, for example, personal discomfort, lack of consistent training, lack of role clarity among professionals, and lack of clear protocols on how to proceed when IPV is disclosed (Alvarez et al., 2018; Conn et al., 2014; Jenner et al., 2016).

Attitudes, Knowledge, Training, and Personal Experiences of Intimate Partner Violence

In addition to examining IPV among members of an academic institution and two hospitals, our study investigated the relationship among attitudes, knowledge, training, and personal experiences with IPV among staff/administrators, faculty, and students. Our results demonstrate that even though hypothesis four was not supported (personal IPV experience [actual experience and witnessing] mediates the positive effects of perceived knowledge and hours of IPV training on IPV awareness and attitudes, and actual and screening knowledge), hypotheses one to three were supported.

Specifically, perceived IPV knowledge was associated with IPV actual knowledge and screening knowledge (hypothesis 1). The lowest scores reported by participants were in the area of screening knowledge. This suggests that despite moderate to high scores in the other domains (perceived knowledge and actual knowledge, and attitudes and awareness of IPV), actual preparedness in terms of how to screen for IPV was not high among participants. Overall, participants were “not ready” or were only “somewhat prepared” to ask screening questions and to respond to patients or clients experiencing IPV. Prior research with students and health care professionals also found that theoretical knowledge or understanding of IPV did not readily translate into actual screening behaviors (Aluko et al., 2015; LeMich et al., 2018; Sawyer et al., 2017). This indicates the need for more intentional implementation of opportunities for students and clinicians to practice IPV screenings in situations such as in classroom role plays, internships, and/or simulation laboratories (SIM labs). SIM labs have the advantage of providing provider-patient interactions in a safe environment and mitigating the fear that patients will be harmed during the encounter. Therefore, the use of standardized patients in SIM laboratories will facilitate the practice of IPV screening skills and should be explored and evaluated.

Training was significantly associated with greater awareness and positive attitudes, and screening skills (hypothesis 2). Hypothesis 3 was also supported in that perceived knowledge and actual knowledge mediated the effects of hours of training on awareness and attitudes with hours of training being highly associated with the participants’ perceived knowledge and actual knowledge, and improved their attitude and awareness towards those who experienced IPV. While any training is likely to result in better understanding and services, the amount and quality of the training are also critical elements to consider. The number of hours of training was consistently associated with all the outcomes in terms of increased perceived knowledge, and screening knowledge, and with greater increases in actual knowledge and preparedness to screen. Such findings would suggest the need for repeated trainings, indicating that learning skills, increasing knowledge, and professional interventions to identify IPV do not occur through one-time exposure. The frequency and length of trainings necessary to develop proficiency need to be empirically substantiated and are likely to require resources and commitment over time from organizations (O’Campo et al., 2011). As noted earlier, it is possible that participant role (e.g., social work, law, medicine) or certain sub-groups of participants may have received content-specific training (e.g., legal issues, screening, counseling and case management) or to have a greater desire to receive training, which could also affect the relationship among perceived and actual knowledge and lead to differences in these outcomes.

Racial/ethnic identity was also associated with actual knowledge and attitudes and awareness. Specifically, African American and Asian American participants reported lower levels of actual knowledge and awareness of IPV and more negative attitudes towards those experiencing IPV. These findings are supported in some studies suggesting greater acceptance of IPV that may potentially be justified by more traditional gender or patriarchal cultural norms (Crittenden et al., 2017; Hayes & Boyd, 2017; Joshi & Childress, 2017; Love & Richards, 2013). Additional factors need further exploration as minority status is also often associated with economic factors (e.g., education, income, employment status) as well as cultural differences and gender role inequalities, which may lead to increased IPV exposure and risk (Capaldi et al., 2012; Njie-Carr, 2014). In addition, IPV may be defined as only physical violence in certain cultures with less recognition of psychological abuse and limited acknowledgment of other forms of IPV. In particular, issues of acculturation and enculturation are known to impact attitudes and help-seeking behaviors among minority immigrant populations (Sabri et al., 2018; Njie-Carr et al., 2021; Yoshihama et al., 2014). Therefore, training should be tailored to address diverse cultural attitudes on IPV among health and human service providers, and also focus on how to screen patients appropriately using culturally sensitive approaches.

Our findings also indicated that sexual minority participants were more likely to have positive attitudes and awareness as well as higher screening knowledge than heterosexual participants. Jacobson and colleagues (2015) found a significant association between sexual orientation and sexism with sexual minority students reporting more non-sexist attitudes. However, gender was a more significant predictor of attitudes towards IPV than sexual orientation. Further research is needed to parse out differences between gender, sexual orientation, and attitudes towards IPV, as well as identifying best practices working with patients from diverse populations.

Public awareness campaigns on campuses and in workplaces would be helpful in highlighting the pervasiveness of IPV to increase interest and garner awareness. These results also indicate a need for educators and clinical supervisors in work settings to focus on the importance of understanding IPV and its impact on the patients served in order to accurately identify perpetrators and victims and to intervene promptly or mobilize prevention efforts. While mandatory training may not be feasible in all work settings, in light of university campuses’ requirement to provide Title IX training (to end sexual discrimination, sexual harassment and violence in educational facilities under a federal mandate), information on IPV may be incorporated as part of, or as, supplemental training to faculty, staff/administrators, and students.

Study Limitations and Future Recommendations

The study is a cross-sectional design and precludes causal inferences. Additionally, we relied on self-report for the completion of the surveys. While it is a strength of the study to include diverse members of the university community, future studies should include a larger sample size and oversample certain sub-groups to increase overall representativeness and the ability to generalize results. Given that this study used a convenience sample, findings may not be generalizable to the population of higher education students, staff, faculty, and hospital employees. Relatedly, results reporting on group differences in attitudes, awareness, and knowledge reflect bivariate associations and small sample sizes prevented additional confounding variables to be included in the SEM. Future studies with larger samples are needed to conduct SEM analyses with additional confounders. Still, results from the SEM in this study yields important contributions on the relationship between key latent constructs that should be targeted in university-based training and education to address and prevent IPV. A future national cluster sampling study with a larger sample size from the different institutions would allow for participant characteristics, school, and institution analyses, which were not addressed in this study. It is also possible that self-reporting is responsible for the high reported rates of experiencing intimate partner violence; those who have already experienced such violence may be more likely to respond to a survey of this kind. Additionally, the instrument used to measure “experiences of IPV,” was limited in its scope of the different types of violence. This may have also influenced the characteristics associated with experiencing and witnessing IPV in this study and help explain why administrators and university participants were more likely to report experiences of IPV, compared to students and hospital employees.

Current findings highlight areas for future research and implications for practice as noted throughout the discussion section. Given our findings, the main areas that need to be addressed are the importance of increasing the institution-wide awareness of IPV, as well as providing training. In order to appropriately serve patients and community members experiencing IPV with coordinated, interprofessional responses, it is imperative to provide evidence based, culturally appropriate trainings that will increase health care providers’ skills, knowledge, and acceptance of IPV as a pervasive and critical problem that needs to be addressed. In turn, providers will be better prepared to screen, assess, and intervene early with the needed support, resources, and services to IPV victims encountered in all practice settings.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Lisa Fedina

Veronica P. S. Njie-Carr

Author Biographies

Lisa Fedina, MSW, Ph.D. is an Assistant Professor in the School of Social Work at the University of Michigan, Ann Arbor. Her research interests include sexual violence, intimate partner violence, and health outcomes.

Eric Barr, MS is a Statistician at the University of Maryland School of Nursing.

Laura Ting, PhD is an Associate Professor in the Department of Social Work at the University of Maryland Baltimore County. Her research interests include intimate partner violence, batterer intervention programs, and alcohol and substance misuse.

Roma Shah, MPH, MSW is a Staff Associate at the State University of New York in the Got Your Back program.

Mattison Chayhitz, BS, is a registered nurse at Avevanna Healthcare in Baltimore, MD.

Leigh Goodmark, JD is Marjorie Cook Professor of Law and Director of the Gender Violence Clinic at the University of Maryland Carey School of Law. Her scholarship has appeared in numerous journals and law reviews, including the Harvard Civil Rights-Civil Liberties Law Review, Violence Against Women, and the Yale Journal on Law and Feminism.

Richard P. Barth, MSW, PhD is a Professor in the School of Social Work at the University of Maryland, Baltimore. He has directed more than 50 studies and served as Principal Investigator of Berkeley’s Child Welfare Research Center from 1990 to 1996 and as Co-Principal Investigator of the National Survey of Child and Adolescent Well-Being, the first national study of child welfare services in the US.

Veronica P. Njie-Carr, PhD, RN, ACNS-BC, FWACN is an Associate Professor at the University of Maryland School of Nursing. Her research includes cross-cultural investigations to reduce contextual and structural health disparities among women of African descent who are at risk or living with HIV, including women experiencing intimate partner violence.

References

Aluko

Beck

Howard

(2015). Medical students’ beliefs about screening for intimate partner violence: A qualitative study. Health Promotion Practice, 16(4), 540–549. https://doi.org/10.1177/1524839915571183

Alvarez

Debnam

Clough

Alexander

Glass

N. E.

(2018). Responding to intimate partner violence: Healthcare providers’ current practices and views on integrating a safety decision aid into primary care settings. Research in Nursing & Health, 41(2), 145–155. https://doi.org/10.1002/nur.21853

Anasuri

(2016). Intimate partner violence on college campuses: An appraisal of emerging perspectives. Journal of Education and Human Development, 5(2), 74–80, https://doi.org/10.15640/jehd.v5n2a9

Bernards

Graham

(2013). The cross-cultural association between marital status and physical aggression between intimate partners. Journal of Family Violence, 28(4), 403–418. http://doi.org/10.1007/s10896-013-9505-1

Black

M. C.

(2011). Intimate partner violence and adverse health consequences: Implications for clinicians. American Journal of Lifestyle Medicine, 5(September-October), 428–439. https://doi.org/10.1177/1559827611410265

Breiding

M. J.

Chen

Black

M. C.

(2014). Intimate partner violence in the United States — 2010. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Bridges

F. S.

Tatum

K. M.

Kunselman

J. C.

(2008). Domestic violence statutes and rates of intimate partner and family homicide. Criminal Justice Policy Review, 19(1), 117–130, https://doi.org/10.1177/0887403407309038

Campbell

J. C.

(2002). Health consequences of intimate partner violence. Lancet, 359(9314), 1331–1336, https://doi.org/10.1016/s0140-6736(02)08336-8

Capaldi

D. M.

Knoble

N. B.

Shortt

J. W.

Kim

H. K.

(2012). A systemic review of risk factors for intimate partner violence. Partner Abuse, 3(2), 231–280. https://doi.org/10.1891/1946-6560.3.2.231

10.

Clark

C. J.

Renner

L. M.

Logeais

M. E.

(2020). Intimate partner violence screening and referral practices in an outpatient care setting. Journal of Interpersonal Violence, 35(23-24), 5877–5888, https://doi.org/10.1177/0886260517724253

11.

Connor

P. D.

Nouer

S. S.

Mackey

S. N.

Banet

M. S.

Tipton

N. G.

(2012). Overcoming barriers in intimate partner violence education and training of graduate social work students. Journal of Teaching in Social Work, 32(1), 29–45, https://doi.org/10.1080/08841233.2012.641893

12.

Connor

P. D.

Nouer

S. S.

Mackey

S. N.

Tipton

N. G.

Lloyd

A. K.

(2011). Psychometric properties of an intimate partner violence tool for healthcare students. Journal of Interpersonal Violence, 26(5), 1012–1035, https://doi.org/10.1177/0886260510365872

13.

Connor

P. D.

Nouer

S. S.

Speck

P. M.

Mackey

S. N.

Tipton

N. G.

(2013). Nursing students and intimate partner violence education: Improving and integrating knowledge into health care curricula. Journal of Professional Nursing, 29(4), 233–239, https://doi.org/10.1016/j.profnurs.2012.05.011

14.

Conn

Young

Rotstein

Schemitsch

(2014). “I’ve” never asked one question Understanding the barriers among orthopedic surgery residents to screening female patients for intimate partner violence. Canadian Journal of Surgery, 57(6), 371–378. https://doi.org/10.1503/cjs.000714

15.

Cowan

El-Hage

Green

Rice

Young

Whiteside

(2019). Investigating the readiness of hospital social workers to respond to domestic and family violence. Australian Social Work, 73(3), 357–367. https://doi-org/10.1080/0312407X.2019.1675735

16.

Crittenden

Policastro

Eigenberg

(2017). Attitudes toward dating violence: How does sexual identity influence perceptions among college students? Journal of Aggression, Maltreatment & Trauma, 26(7), 804–824. https://doi.org/10.1080/10926771.2017.1328473

17.

Cronholm

P. F.

Fogarty

C. T.

Ambuel

Harrison

S. L.

(2011). Intimate partner violence. American Family Physician, 83(10), 1165–1172. https://www.aafp.org/afp/2011/0515/afp20110515p1165.pdf

18.

Cronholm

P. F.

Singh

Fogarty

C. T.

Ambuel

(2014). Trends in violence education in family medicine residency curricula. Family Medicine, 46(8), 620–625.

19.

Daoud

Matheson

F. I.

Pedersen

Hamilton-Wright

Minh

Zhang

Beynon

C. E.

Gutmanis

I. A.

Tutty

L. M.

Wathen

C. N.

MacMillan

H. L.

(2012). Why physicians and nurses ask (or don’t) about partner violence: A qualitative analysis. BMC Public Health, 12(1), 473. https://doi.org/10.1186/1471-2458-12-473

20.

Fedina

Lee

de Tablan

(2018). MSW graduates’ readiness to respond to intimate partner violence. Journal of Social Work Education, 54(1), 33–48. https://doi.org/10.1080/10437797.2017.1307150

21.

Forgey

M. A.

Colarossi

(2003). Interdisciplinary social work and law: A model domestic violence curriculum. Journal of Social Work Education, 39(3), 459–476, https://doi.org/10.1080/10437797.2003.10779149

22.

Gehring

Vaske

(2017). Out in the open: The consequences of intimate partner violence for victims in same-sex and opposite-sex relationships. Journal of Interpersonal Violence, 32(23), 3669–3692. http://doi.org/10.1177/0886260515600877

23.

Harris

C. M.

Boyd

Rainchuso

Rothman

(2016). Oral health care providers’ knowledge and attitudes about intimate partner violence. Journal of Dental Hygiene, 90(5), 283–296. https://jdh.adha.org/content/90/5/283.short

24.

Hayes

Boyd

(2017). Influence of individual- and national-level factors on attitudes toward intimate partner violence. Sociological Perspectives, 60(4), 685–701. http://doi.org/10.1177/0731121416662028

25.

Hoyle

R. H.

(Ed.). (2012). Handbook of structural equation modeling. Guilford press.

26.

Huang

Son

Wang

L. R.

(2010). Prevalence and factors of domestic violence among unmarried mothers with a young child. Families in Society, 91(2), 171–177, https://doi.org/10.1606/1044-3894.3978

27.

Bentler

P. M.

(1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6(1), 1–55, https://doi.org/10.1080/10705519909540118

28.

Hyman

Forte

Mont

J. D.

Romans

Cohen

M. M.

(2006). The association between length of stay in Canada and intimate partner violence among immigrant women. American Journal of Public Health, 96(4), 654–659, https://doi.org/10.2105/ajph.2004.046409

29.

Jacobson

Daire

Abel

Lambie

(2015). Gender expression differences in same- sex intimate partner violence victimization, perpetration, and attitudes among LGBTQ college students. Journal of LGBT Issues in Counseling. 9(3), 199–216. https://doi.org/10.1080/15538605.2015.1068144

30.

Jenner

Etzold

Oesterhelweg

Stickel

Kurmeyer

Reinemann

Oertelt- Prigione

(2016). Barriers to active inquiry about intimate partner violence among German physicians participating in a mandatory training. Journal of Family Violence, 31, 109–117. https://doi.org/10.1007/s10896-015-9754-2

31.

Joshi

Childress

(2017). A national survey of attitudes toward intimate partner violence among married women in Kazakhstan, Kyrgyzstan, and Tajikistan: Implications for health prevention and intervention. Social Work in Health Care, 56(4), 294–319. https://doi.org/10.1080/00981389.2016.1268660

32.

Lemich

Freudenthal

Neill

Bowen

(2018). Dental hygienists’ readiness to screen for intimate partner violence in the state of Texas. Journal of Dental Hygiene, 92(3), 47–55. https://jdh.adha.org/content/jdenthyg/92/3/47.full.pdf

33.

Love Richards

, (2013). An exploratory investigation of adolescent intimate partner violence among African American youth: A gendered analysis. Journal of Interpersonal Violence, 28(17), 3342–3366. https://doi.org/10.1177/0886260513496898

34.

McLaughlin

O’Carroll

R.E.

O’Connor

R.C.

(2012). Intimate partner abuse and suicidality: A systematic review. Clinical Psychology Review, 32(8), 677–689. https://doi.org/10.1016/j.cpr.2012.08.002

35.

McLindon

Humphreys

Hagerty

(2019). Is a clinician's personal history of domestic violence associated with their clinical care of patients: A cross-sectional study. BMJ Open, 9 (7), Article e029276. https://doi.org/10.1136/bmjopen-2019-029276

36.

Moskovic

Wyatt

Chirra

Guiton

Sachs

C. J.

Schubmehl

Sevilla

Pregler

J. P.

(2009). Intimate partner violence in the medical school curriculum: approaches and lessons learned. AMA Journal of Ethics, 11(2), 130–136, https://doi.org/10.1001/virtualmentor.2009.11.2.medu2-0902

37.

National Criminal Justice Reference Service . (2018). Intimate partner violence fact sheet. https://ovc.ncjrs.gov/ncvrw2018/info_flyers/fact_sheets/2018NCVRW_IPV_508_QC.pdf

38.

Njie-Carr

(2014). Abused experiences of HIV-positive women and perceptions of maleperpetrators’ role: A concurrent mixed methods study. Journal of the Association of Nurses in AIDS Care, 25(5), 376–391. http://doi.org/10.1016/j.jana.2013.11.002

39.

Njie-Carr

V. P. S.

Sabri

Messing

J. T.

Ward-Lasher

Marea

Wachter

Campbell

(2021). Understanding intimate partner violence among immigrant and refugee women: A grounded theory analysis. Journal of Aggression, Maltreatment, & Trauma, 30(6), pp.792–810. https://doi.org/10.1080/10926771.2020.1796870

40.

O’Campo

Kirst

Tsamis

Chambers

Ahmad

(2011). Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review. Social Science & Medicine, 72, 855–866. https://doi.org/10.1016/j.socscimed.2010.12.019

41.

Paat

Y-F

Markham

. (2019). The roles of family factors and relationship dynamics on dating violence victimization and perpetration among college men and women in emerging adulthood. Journal of Interpersonal Violence, 34(1), 81–114. https://doi.org/10.1177/0886260516640544

42.

Peterman

Bleck

Palermo

(2015). Age and intimate partner violence: An analysis of global trends among women experiencing victimization in 30 developing countries. Journal of Adolescent Health, 57(6), 624–630. https://doi.org/10.1016/j.jadohealth.2015.08.008

43.

Peterson

Kearns

M. C.

MacIntosh

W. L.

Estefan

L. F.

Nicolaidis

McCollister

K. E.

Gordon

Florence

(2018). Lifetime economic burden of intimate partner violence among U.S. adults. American Journal of Preventive Medicine, 55(4), 433–444. https://doi.org/10.1016/j.amepre.2018.04.049

44.

Postmus

J. L.

McMahon

Warrener

Macri

(2011). Factors that influence attitudes, beliefs, and behaviors of students toward victims of violence. Journal of Social Work Education, 47(2), 303–319. https://doi.org/10.5175/jswe.2011.200900122

45.

Ramsay

Rutterford

Gregory

Dunne

Eldridge

Sharp

Feder

(2012). Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians. British Journal of General Practice, 62(602), e647–e655. https://doi.org/10.3399/bjgp12x654623

46.

Roark

(2010). Intimate partner violence: Screening and intervention in the health care setting. The Journal of Continuing Education in Nursing, 41(11), 490–495. https://doi.org/10.3928/00220124-20100601-02

47.

Rolle

Giardina

Caldarera

Gerino

Brustia

(2018). When intimate partner violence meets same sex couples: A review of same sex intimate partner violence. Frontiers in Psychology, 9(August), 1506–1519. https://doi.org.10.3389/fpsyg.2018.01506

48.

Sabri

Nnawulezi

Njie Carr

V. P. S.

Shah

Messing

Ward-Lasher

Alvarez

Campbell

(2018). Multilevel risk and protective factors for intimate partner violence among immigrant and refugee women: Perceived needs for safety planning interventions. Race & Social Problems, 10(4), 348–365. https://doi.org/10.1007/s12552-018-9247-z

49.

Sawyer

Coles

Williams

Lucas

Williams

(2017). Paramedic Students' Knowledge, Attitudes, and Preparedness to Manage Intimate Partner Violence Patients. Prehospital Emergency Care, 21(6), 750–760. https://doi.org/10.1080/10903127.2017.1332125

50.

Short

L. M.

Alpert

Harris

J. M.

Surprenant

Z. J.,

Jr (2006). A tool for measuring physician readiness to manage intimate partner violence. American Journal of Preventive Medicine, 30(2), 173–180. https://doi.org/10.1016/j.amepre.2005.10.009

51.

Smith

S. G.

Basile

K. C.

Gilbert

L. K.

Merrick

M. T.

Patel

Walling

Jain

(2017). National intimate partner and sexual violence survey (NISVS): 2010-2012 state report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

52.

Smith

S. G.

Zhang

Basile

K. C.

Merrick

M. T.

Wang

Kresnow

Chen

(2018).The national intimate partner and sexual violence survey (NISVS): 2015 data brief – updated release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

53.

Warrener

Postmus

J. L.

McMahon

(2013). Professional efficacy and working with victims of domestic violence or sexual assault. Affilia: Journal of Women & Social Work, 28(2), 194–206. https://doi.org/10.1177/0886109913485709

54.

Whitton

Newcomb

M. E.

Messinger

A. M

Byck

Mustanski

(2019). A longitudinal study of IPV victimization among sexual minority youth. Journal of Interpersonal Violence, 34(5), 912–945. http://doi.org.10.1177/088626051

55.

Yoshihama

Blazevski

Bybee

(2014). Enculturation and attitudes toward intimate partner violence and gender roles in an Asian Indian population: implications for community-based prevention. American Journal of Community Psychology, 53(3-4), 249–260. https://doi.org/10.1007/s10464-014-9627-5