Healthcare providers' experiences screening for intimate partner violence among migrant and seasonal farmworking women: A phenomenological study

Abstract Background Migrant and seasonal farmworking (MSFW) women patients experience substantially more intimate partner violence (IPV) than the general population, but few health‐care providers screen patients for IPV. While researchers have examined screening practices in health‐care settings, none have exclusively focused on MSFW women. Objective The aim of this phenomenological study was to explore the experiences of health‐care providers who have screened for and/or addressed IPV with MSFW women patients. Design Researchers utilized descriptive phenomenology to capture the lived experiences of these health‐care providers. Data were analysed using Colaizzi's seven‐stage framework. Setting and participants Interviews were conducted with nine female participants – all of whom: (i) were clinically active health‐care providers within the MSFW community, (ii) were bilingual in English and Spanish or had access to a translator, (iii) had treated MSFW patients who had experienced IPV and (iv) were at least 18 years of age. Results Participants' experiences were reflected in four emergent themes: (i) provider‐centered factors, (ii) patient‐centered factors, (iii) clinic‐centered factors and (iv) community‐centered factors. Participants described barriers to establish routine IPV assessment, decrease patient ambivalence and increase on‐site support and community resources. Discussion and conclusions This study aimed to generate a greater understanding of the experiences of health‐care providers with screening for and addressing IPV with MSFW patients. Implications and recommendations for research, clinical practice and policy are provided.


Introduction
Intimate partner violence (IPV) is a pervasive public health problem 1 with serious consequences for women's health. 2 Migrant and seasonal farmworking (MSFW) women are particularly at risk of experiencing IPV because of cultural beliefs, environmental factors, and health disparities. [3][4][5] Despite previous researchers indicating that IPV screenings in healthcare settings increase IPV identification rates, 6,7 and previous reports that MSFW women report higher rates of IPV than the general population, 8 many providers opt not to screen for various reasons. 9,10 The authors examined providers' experiences screening MSFW women for IPV in healthcare settings.

Literature review
IPV is considered to be the primary cause of injury to all women ages   11 and has resulted in significant inpatient and outpatient health costs (e.g., medical costs incurred from IPV injuries) and devastating social and family intergenerational consequences. 12 Among MSFW women, physical violence victimization ranged from 18.5 8 to 20% 13 within the previous year and between 19 14 and 33.9% 8 over one's lifetime. Hazen and Soriano 8 also identified a 20.9% lifetime prevalence rate of sexual coercion among MSFW women, with 14.4% reporting having experienced it within the previous year alone.

Risk factors for IPV
MSFW are among some of the most disadvantaged and medically underserved populations in the United States. 15 Various factors including poverty, frequent mobility, low literacy, language and cultural barriers impede MSFW access to social services and cost-effective primary health care. 16 Awareness of available resources (e.g., women's shelters, police, domestic violence hotlines) among MSFW women appears to be low, with only 22% of being aware of resources, yet 87% indicating they would seek help if available. 17 Other variables of work stress (i.e., low income, unemployment) 18 and male work status (i.e., 'low-status' jobs) 17 have been associated with IPV as well.

IPV screening
Routine screening for IPV in health-care settings could identify women at risk and lead to interventions that reduce violence and improve health outcomes. 6 Although IPV screening is recommended by the Institute of Medicine 19 and several professional organizations (e.g., American Congress of Obstetricians and Gynecologists 20 ), most providers do not routinely screen for IPV. 21 Providers reported numerous barriers to screening for IPV including training, 21,22 lack of time and referral resources, 21 self-assessed competence in identifying IPV 9 and lack of confidence in the ability to make referrals, discomfort in asking the IPV screening questions and no ready access to mental health specialists. 9 Additional barriers to disclosing IPV among MSFW patients included feeling ashamed or embarrassed, 23 inability to speak English and no access to a translator, 23 fear of being deported or separated from family, 14,24 fear that a perpetrator would find out and make things worse 23 and illiteracy. 25 Given that much of the available data is at least a decade old, it is not known how providers are experiencing screening for IPV and why some continue to screen in the face of seemingly insurmountable barriers. Furthermore, while researchers have recently examined screening practices in healthcare settings, determining that many providers do not screen for IPV 6,21,26 ; none have exclusively focused on MSFW women, a highly atrisk population for IPV. 8 The purpose of this study was to examine health-care providers' experiences screening for and treating IPV among MSFW women patients.

Method
Data analysis was conducted using Colaizzi's 27 seven-stage phenomenological analysis framework. A descriptive phenomenology 28

Data collection and analysis
Due to the national reach of sample participants, data were collected via phone or Skype interviews. The PI employed an interview guide ( Table 1) to structure the interview. The interview guide method 32 lists questions to be explored and is designed to ensure that each interview follows the same basic format. The probing questions were based on findings from a policy brief examining current IPV research on the MSFW population 33 and on the principles of biopsychosocial-spiritual model. [34][35][36] A model used to advocate that health is a biomedical, psychological, social and spiritual dimension. Data analysis was carried out using Colaizzi's 27 seven-stage phenomenological analysis framework. To become familiar with the data, the PI listened to each audio recording and read each transcript several times. Significant statements were then extracted from the transcripts directly, and each statement was assigned a formulated meaning. Common formulated meanings became evident and were organized into thematic clusters. Investigators were able to achieve 100% agreement on the findings at the conclusion of the analysis process. When there was a disagreement (13 times), each investigator would share his or her perspective, both would reexamine the raw data, and one or the other investigator would adjust his/her interpretation until both parties were able to reach a satisfactory agreement.

Verification processes
When conducting qualitative research, it is imperative that the investigator employs strate- gies for verifying the data's trustworthiness. 37 Therefore, all investigators prepared bias statements and referenced them regularly throughout the analysis process. For example, the PI identified biases related to being a White, heterosexual, upper-middle class male who has never personally experienced IPV. In addition, a triangulated researcher 37 ; (a second researcher who coded independently from the PI); reflexive journal 37 (used to bracket each investigator's experiences throughout the study) and audit trail 37 (used to note emerging themes and analysis processes) were also utilized to reduce the possibility that biases or deviations from Colaizzi's 27 framework could unintentionally influence or alter the data analysis process.

Results
The results revealed 391 significant statements, 108 formulated meaning statements, 13 thematic clusters and four emergent themes, which reflect the essence of the experiences of screening for IPV among MSFW women patients for healthcare providers. The emergent themes revealed by this study include the following: (i) providercentered factors, (ii) patient-centered factors, (iii) clinic-centered factors and (iv) communitycentered factors. Under each emergent theme below, a brief overall summary statement and detailed summary of each thematic cluster is provided. A summary of the thematic clusters and emerging themes is provided in Table 2. Table 3 illustrates examples of Colaizzi's stages 27 in action, with four significant statements and their associated formulated meanings, thematic clusters and emergent themes. Lastly, an exhaustive description was developed from the findings to highlight the essence of the participants' lived experiences and reflect the essential structure of the phenomena under investigation and is displayed in Table 4. 27

Emergent theme 1: Provider-centered factors
Participants shared their personal experiences with implementing and utilizing IPV screening protocols, responding to patient disclosures of IPV and encountering barriers to screening for and addressing IPV with their patients. The following thematic clusters illustrate these experiences.
Thematic cluster 1a: Screening protocols Participants discussed various components of the IPV screening process, such as determining when, whom, how (e.g., verbal or written, how frequently) and where to screen. Eight participants indicated that they typically administer verbal IPV screenings. Brenda described one of the screening questions she usually administers,    Health-care providers who serve the MSFW community display considerable passion, dedication and commitment towards caring for MSFW women who have been victimized by IPV. Despite their desire and willingness to lend aid, many health-care providers feel unequipped (e.g., lack of IPV training, lack of awareness of available IPV resources) to respond in such a manner that equips their patients with the knowledge and resources necessary to escape dangerous relations, and face several barriers to screening for and addressing IPV with MSFW patients, some of which are provider-related (e.g., inability to speak Spanish), some patient-related (e.g., lack of patient accessibility) and some clinic-related (e.g., lack of required IPV screening protocol) Although many health-care providers feel confident in their abilities to discuss IPV with MSFW patients, most indicated a sense of uncertainty in their ability to truly help their patients without placing them at risk for further abuse. Because MSFW patients often present for their medical visits with their partners, health-care providers struggle to effectively and discreetly screen for and address IPV with their patients. Providers believe that being as educated and informed as possible about the multifaceted problem of IPV among the MSFW community is essential. Provider trainings are one method in which to better educate health-care providers about IPV among the MSFW population Health-care providers recognize the complexities and pervasiveness of IPV among the MSFW community. Not only does IPV take multiple forms among MSFW patients (e.g., physical violence, rape, abuse during pregnancy, abuse by non-partner), but variability is evident in the ways that MSFW women respond to IPV as well. Additionally, just as health-care providers experience barriers to screening for and addressing IPV with MSFW patients, providers observe numerous barriers to disclosing and responding to IPV faced by MSFW patients Health-care providers also encounter clinic and communitycentered factors that influence their abilities to effectively screen for and address IPV among their MSFW patients. Despite the common perception among participants that IPV among the MSFW community is much more prevalent than the general population, and the many unique cultural factors among MSFW families that exacerbate IPV (e.g., traditional gender roles), variability is evident in the amount of support providers receive from the communities and health-care clinics in which they serve. These healthcare providers consider a multidisciplinary team approach to be an important element in the management of MSFW patients who have experienced IPV Thematic cluster 3b: Clinics can create barriers While most participants indicated that the clinics at which they work have some resources available to assist with screening for and addressing IPV with their MSFW patients, some participants indicated that the clinics could unintentionally create barriers for providers as well. Carol shared that she was once turned away by her employer when she suggested a change in the way that her clinic currently addressed IPV, 'I think when I first came here I did bring it up. . . and then I kind of backed off because I thought they'd think I'm crazy. Like, "Look at all the things we could be doing"'.

Emergent theme 4: Community-centered factors
Participants discussed the unique communitycentered factors associated with IPV within the Bonnie described that patients within the MSFW community normalize IPV as part of life and that she often worries that violence will extend beyond the partner relationship to other members of the family. Brenda emphasized that the MSFW community maintains a cultural independence from mainstream society. Additionally, Donna explained that stressors associated with immigration status and occupa-tional stressors among IPV perpetrators may exacerbate IPV.
Thematic cluster 4c: Communities provide resources to aid IPV victims Participants discussed various resources available within their communities for MSFW patients who have experienced IPV. Three participants indicated having access to local resources within the community to aid MSFW women experiencing IPV. One participant, Donna, later described one case example where she actually drove one of her patients from a dangerous home environment to a local shelter, 'We had the capacity to just load up that family and bring them back to [my town] about 150 miles from the small city, which we did'.
Thematic cluster 4d: Outcomes for IPV perpetrators vary Participants described a few different outcomes that they had observed for IPV perpetrators in their experiences. Four participants indicated that IPV perpetrators were required to serve jail time as a result of their violence. One participant, Lucy, reported that the partner of one of her patients was actually deported as a result of his violent behaviours, 'She reported her husband, and he was deported for the domestic violence'.

Discussion
This study aimed to generate a greater understanding of health-care providers' experiences screening for and addressing IPV with MSFW patients. Given that MSFW patients experience greater levels of IPV than the general population, 8  unequipped to begin to broach a problem so culturally engrained.

Provider-centered factors
While some participants utilized brief written or verbal screening tools for IPV (some with only one question), other participants engaged in open discussions with their patients about IPV. Consistent with previous research, participants reported several barriers to screening for IPV including training, 22,27 lack of time and referral resources, 21 self-assessed competence in identifying IPV, 9 lack of confidence in the ability to make referrals, discomfort in asking the IPV screening questions. 9 Further research is needed to better understand the effective methods for screening IPV with MSFW patients. Observational and survey design studies helping to identify the factors influencing health-care providers' decision to screen, as well as experimental studies testing which training mechanisms are most effective in increasing provider comfort and skill with IPV screening are needed. Additionally, communitybased focus group studies would help to expand on the unique strengths, challenges and cultural factors impacting health-care practices caring for the MSFW population, as well as identify needed changes in policy, procedure and available training/resources to improve screening frequency, intervention and referral rates.

Patient-centered factors
Consistent with previous studies of Latina women experiencing IPV, 7 participants indicated several culturally relevant factors that exacerbate IPV among the MSFW community including undocumented status, 7 limited education, 38 lack of English proficiency 7 and changes from acculturation and economic demands. 24,39 Furthermore, participants also described barriers MSFW patients face to disclosing IPV, including having partners or other family members present, lack of transportation, language barriers, confidentiality/privacy concerns and gender of healthcare provider. While provider perception of patient-centered factors is critical to understanding the issues they encounter in their workplace, mixed method studies comparing providers' and patients' perceptions from the same community will help to develop patient-centered and informed programmes and protocols versus IPV screening practices strictly developed from the providers' positions of privilege. No matter how well intended, it is difficult to think from another person's social location so involving patients as research and protocol advisors is recommended for advancements in IPV screening in the MSFW community. Although previous researchers 40 have documented the preferences of women in general regarding IPV screening (e.g., being screened in-person, verbally and by female providers), no one has specifically considered the unique cultural and legal influences of screening and identification on the MSFW population.

Clinic-centered factors
Providers reported mixed responses pertaining to the support they receive from the clinics in which they serve. For instance, some participants reported limited access to behavioural health providers and/or interpreters. Without these resources, they hesitated screening. Therefore, program evaluation studies are needed to garner more empirical evidence on the merits of behavioural health provider and interpreter inclusion as members of the health-care team serving the MSFW population. Future researchers should also seek to develop a screening tool for IPV that is empirically valid and reliable for use among MSFW patients and study its clinical, operational and financial impacts. Peek 41 argued that without consideration of all three of these worlds of healthcare, attempts at transforming the health-care system will fail.

Community-centered factors
Perhaps one of the most difficult challenges to overcome for MSFW women victimized by IPV is the lack of community resources available to them to lend aid. Some participants reported having community resources (e.g., women's shel- ters), but others reported having limited access or no access at all to such resources. Furthermore, participants acknowledged that because IPV is considered by many to be an accepted tradition within the MSFW community, few are willing to speak out against it. In order for these cultural norms to change, health-care providers, policy writers and researchers each must do their part in their respective arenas to influence the change that the MSFW community needs. Initial steps towards doing this may include appointing representatives from the MSFW community to serve on committees, boards and task forces to ensure that their unique needs and ideas are addressed in any of these forums. Researchers are also encouraged to get involved in their communities and study the impact of federal, state, and local legislation, community service programming, and public health trends on groups not often represented but who are largely impacted.

Limitations
There are two limitations to note based on the study design and sample. Because interviews were conducted via telephone, the depth of observation was limited to the participants' tone of voice, which may have influenced the manner in which data were interpreted. Furthermore, the use of the telephone may have created a barrier that impacted the flow of the interviews. For example, at various points, static noise would cause the conversation to cut out, creating an interruption in the conversation. However, the use of telephone also enhanced anonymity and provided flexibility of time, which may have led to more transparent disclosure of the participants' experiences and more participants being willing to participate. Ultimately, this method of interviewing was also utilized out of convenience to provide maximum accessibility to participants located across the United States. Furthermore, all participants in this study were female health-care providers and it is not known whether women versus men have differing perspectives on the MSFW female population with respect to IPV screening and treatment.
Thus, future research studies should seek to attain the lived experiences of male health-care providers, especially considering the unique gender-related aspects of IPV.

Conclusion
Based on the study's findings, health-care providers would benefit from education and training on how to detect, interview and care for MSFW women experiencing IPV. Resources such as the MCN (www.migrantclinician.org) offer support and information about IPV among the MSFW population.
In summary, the phenomenon of screening for and addressing IPV with MSFW patients presented the participants with many opportunities for personal and professional reflection, growth and the opportunity to consider the ways in which the current health-care practices in this area can improve. At the same time, it presented challenges that the participants continue to struggle through. Some of these challenges were self-imposed, while others were imposed by the imperfect health-care system in which the participants serve. Overall, it appeared that participants agreed that IPV among the MSFW community is a significant problem that needs to be better addressed by the health-care system, but many participants were unsure how they could really make a difference. These participants were attempting to find the line between where their own responsibility as providers ends and the responsibility of the health-care system at large to support its' providers begins.
A quick start strategy to promoting change would be with medical clinic administrators seeking or offering education and training to providers about existing state and local resources where they could send MSFW patients reporting IPV. In addition, culturally relevant education and training is needed in the community (e.g., performed in Latino churches, festivals, stores) where the patient-to-patient distribution of information can occur. Health-care begins in the community where patients talk to one another so it makes sense for education to be a priority there too.

Compliance with ethical standards
The authors declare that they have no conflicts of interest. This study was approved by a University and Medical Center Institutional Review Board (UMCIRB) and the Migrant Clinicians Network Institutional Review Board (MCN IRB). Confidentiality of participants was ensured using pseudonyms and identification numbers on raw data. All participants in this study completed an informed consent process approved by the aforementioned institutional review boards.