When user-centered design meets implementation science: integrating provider perspectives in the development of an intimate partner violence intervention for women treated in the United States’ largest integrated healthcare system

Intimate partner violence (IPV) against women is a global health problem because of its high prevalence, robust associations with poor health, and risk for premature death from homicide and suicide [1‐3]. Within the United States (US), IPV is a particularly relevant issue for women who have served in the military [4, 5], with 19% of women veteran’s experiencing IPV in the past-year alone [6]. Women who experience IPV use more healthcare services [1, 7‐9], a finding that is true across a number of service types within the Veterans Health Administration (VHA), the US’s largest integrated healthcare system [6, 10]. Consistent with some US-based recommendations for addressing IPV in health care settings [11, 12], VHA is in the process of implementing routing screening programs to identify women who experience IPV so that they can receive brief counseling and/or referrals to appropriate health and social services to address IPV.

Although differences in opinion exist about the impact of screening for IPV [13‐19], there is a global concensus that healthcare providers should provide a first-line response and intervention [20]. However, less is known about how to effectively intervene to improve health outcomes following IPV disclosure in healthcare settings. While several countries have begun to address violence that women experience (e.g., in Canada: the Intervention for Health Enhancement After Leaving [iHEAL], which is a primary health care intervention for women recently separated from violent partners [21]; in Australia: Women’s Evaluation and Violence care in general practice (WEAVE [22];); and in South Africa, Brazil, Spain, India, and Lebanon [20]) there have been varying success rates. By and large the majority of countries can improve on their healthcare responses and policy [20] and methods for psychological intervention [23], despite that many private and public service settings, including the VHA in the US, have implemented or are in the process of implementing routine screening protocols to identify women who experience IPV. The current sub-study is part of a larger multi-phase study that seeks to help address this issue by determining the preliminary effectiveness of an intervention for women veterans experiencing IPV [24], which – should it prove to be effective – could help to bridge the gap in healthcare response following IPV disclosure.

Even integrated healthcare settings, such as VHA where there is a focus on enhancing the uptake of IPV screening into routine care, are challenged to provide well-defined guidance on implementation of interventions for women who disclose experiences of IPV. More specifically, there is a need to develop feasible, acceptable, patient-centered and effective interventions for women who experience IPV, especially for the unique needs of women veterans, and to ensure that these interventions move swiftly along the research-to-practice pipeline via implementation science and user-centered design.

User-centered design (UCD) is an approach to developing and refining products or programs and is rooted in soliciting early and regular feedback from the individuals in settings where the product will ultimately be implemented [25]. The field of UCD has developed over the past few decades (e.g., in settings of industrial design, cognitive psychology) and has recently been theorized to have utility for the development and implementation of psychosocial interventions [25]. UCD serves to improve the usability of products; this is especially pertinent to the development and refinement of interventions, and for the implementation of evidence-based treatments (EBTs) as it may serve to lessen the gap between research and practice in which there is a lack of uptake in delivering EBTs [26]. As such, utilizing a UCD framework in which feedback from providers is integrated throughout the development and refinement of the intervention holds promise for enhancing the usability and effectiveness of the intervention. Optimizing of the role of implementation science early on to accelerate the research-to-practice pipeline is essential to filling critical gaps in care, such as those which currently exist for women who experience IPV.

Recovering from IPV through Strength and Empowerment (RISE) is a flexible, patient-centered, trauma-informed, variable-length, modular-based intervention developed by clinicians and researchers in VHA that is currently being evaluated as part of a larger multi-phase study to determine its preliminary effectiveness for women veterans [24]. This brief counseling intervention was developed using rigorous user-centered treatment-development methods, including individual and focus group interviews with women veteran VHA patients and providers, followed by surveys with women veterans to further clarify women’s IPV-related counseling preferences and priorities [27‐30]. RISE is an intervention based on empowerment, which is highly relevant for women who experience IPV [31, 32]. Based on this foundational research, RISE was developed to be flexible, with women veterans determining the intervention duration (between one and up to six 30–45 minute sessions) and choosing the topic to cover during each session. At the beginning of each RISE session, women are given a menu of options and encouraged to identify the area that would be most helpful to focus on that session to address their unique needs. RISE includes six topics addressing: A) safety planning, B) education on health effects of IPV, C) improving coping and self-care, D) enhancing social support, E) making difficult decisions, and F) connecting with resources; which align with recommended components of IPV interventions [33]. At the conclusion of each RISE session, in consultation with the provider, the woman is asked to set a goal related to the topic, and she is asked whether she would like to schedule an additional RISE session. RISE incorporates principles of Motivational Interviewing (MI) [34], an evidence-based approach designed to facilitate behavior change that is widely used to address numerous complex health issues, with some promise in addressing IPV [35, 36]. RISE was developed for delivery in integrated healthcare systems including in mental health outpatient clinics and primary care behavioral health. The intervention is designed to be user-friendly and accessible such that a range of providers, including psychologists and social workers, can implement it. The RISE manual is roughly 80 pages long, and separated into sections by modules, such that providers and patients can choose the section that is most relevant to them, without needing to go through each section sequentially [24].

RISE aims to improve women’s psychosocial functioning in domains that can reasonably expect to be enhanced in the context of a brief intervention for women experiencing recent and ongoing IPV. The proximal treatment targets include self-efficacy, valued action, patient activation, empowerment, and general psychological distress (e.g., depressive symptoms). Additionally, as part of a sub-study of this larger multiphase project, women veteran’s preferences for patient-centered outcomes were elucidated [37] to further enhance the likelihood that the RISE intervention will address women’s needs. Results demonstrated that women desired the following outcomes from RISE (and IPV intervention more broadly): increased empowerment, self-esteem, social support, IPV-related knowledge, valued action and goal setting [37]. While women veterans represent an important group of end-users of the RISE intervention, it is also critical that those whom are likely to provide the intervention give feedback that can enhance the likelihood that the intervention will be scalable in VHA.

The current sub-study is a part of a larger multi-phase project in the US designed to refine and formally evaluate RISE in preparation for an effectiveness trial within VHA. This sub-study focused on feedback from a wide array of providers regarding the acceptability and feasibility of RISE, and associated recommendations for refinements of content and context [38] in order to increase the likelihood of the usefulness, acceptability, and feasibility of the RISE intervention to VHA providers, the end-users, should RISE prove to be effective.

A total of 23 key informants participated in this study (62% participation rate, with nearly equivalent representation across the two study sites). The mean age of participants was 42.6 years (SD = 11.6; range: 25–63) and the sample predominately identified as female (91.3%; n = 21). Participants had worked in VHA for a range of 2–25 years (mean = 8.6, SD = 6.9). Table 1 provides a breakdown of the sample by provider profession.

Like other health care systems in the US and across the globe, VHA is integrating mechanisms for identifying women who experience IPV and is in need of evidence-informed, acceptable, and feasible interventions to offer women veterans who desire IPV-related treatment. The current study solicited provider feedback to refine the RISE intervention and plan for implementation in VHA. Results revealed that providers perceived the intervention as highly acceptable, noting strengths and relative advantages including RISE’s nonjudgmental and empowering stance, patient-centered agenda, user-friendly structure, and its facilitation of both provider and patient comfort. Barriers to implementation were also identified, including provider discomfort with IPV and trauma, as well as limited time and resources to provide this intervention in a busy clinical setting, especially when IPV is not viewed as a priority health issue by a healthcare system. These findings have guided refinements to the RISE intervention both in terms of content and implementation characteristics. Study findings have implications for the utilization of UCD for other emerging interventions for IPV and for adapting or modifying existing IPV interventions.

A robust theme that researchers identified was the discomfort providers experience in inquiring about IPV. While inquiry about suicide and homicide risk is routinely done in both primary care and mental health settings, informants described reluctance to ask about IPV, in part due to the paucity of interventions for addressing IPV. This finding is supported by the literature that points to many barriers to routine IPV screening in primary care and mental health settings [49, 50]. As such, RISE has the potential to fill a critical gap in the field and to provide a framework for responding to IPV disclosure that goes beyond routine IPV screening. According to our findings, RISE may help to facilitate provider comfort with not only asking about, but also addressing IPV in a more comprehensive manner through delivering RISE or referring a female patient to RISE. This is important because provider self-efficacy is an important provider-level facilitator in addressing complex health issues, including IPV [30, 51]. Furthermore, key informants provided insights into the type of training that would be needed to help them develop a sense of self-efficacy in using RISE to address IPV.

In addition, as knowledge regarding IPV becomes more sophisticated and there continues to be calls to address IPV within healthcare systems [1], there is a need for a nuanced provider response to the disclosure of IPV. While well-meaning providers have likely urged those in unhealthy relationships to ‘just leave,’ such a simplified approach risks missing the important nuances of the complexities involved, including shared children, and the ambivalence often experienced by women who both care about a partner and are simultaneously being hurt by their partner. As such, interventions for women who have already left the violent relationship (e.g., the Intervention for Health Enhancement After Leaving [iHEAL; 21]), while highly important, are insufficient on their own. Interventions for IPV need to reflect these nuances, and provide a patient-centered framework that can meet women where they are – independent of whether or not women are ready, willing, or able to leave the unhealthy relationship at any given moment in time. As Hegarty and colleagues highlight, it is not sufficient to only assess for the safety of women and children when addressing IPV, but rather [interventions] “must also respect and promote the dignity of women, validate and understand the diversity of women’s experiences, withhold judgment about what a woman should do and when, and place ongoing support at the centre of the interaction between the woman practitioner,” [52]. Similar to the WEAVE intervention [36, 52], RISE provides a framework in order to do such, utilizing MI principles to work through ambivalence and empowering and encouraging women to make the decisions that are best for themselves and (when applicable) their families. Findings support that providers are appreciative of these qualities of the RISE intervention, providing language and a theoretical framework that meets these needs and thereby is perceived to build confidence and comfort in ways to holistically treat women dealing with IPV. In addition, findings of this study bolster support for utilizing MI principles to address IPV by suggesting their acceptability and appropriateness from the provider perspective [35, 36].

In line with a UCD framework, end-users and stakeholders identified themes of content and context modifications that serve to inform refinement to the RISE intervention. Themes that researchers identified (e.g., about safety, trainings, goal setting, patient materials) align well with other evidence-based psychotherapies, both with the VHA setting and beyond [e.g., 47, 48, 53, 54]. For example, the request for a handout only manual for patients in addition to the provider manual, as well as ongoing consultation following an in-person workshop or training, is similar to formats used to increase the feasibility of delivering Cognitive Processing Therapy (CPT) [53, 54] a widely used intervention for posttraumatic stress disorder that has been rolled out within VHA. Further, the request by participants for safety check-ins during each RISE session, independent of whether the patient identifies safety as the topic that she wants to focus on during the session, aligns with the DBT approach [47, 48] in which safety is inquired about and prioritized. Additionally, the suggestion to utilize SMART goal terminology in the manual will likely help to set women up for success in setting goals each session, such that women are identifying specific, attainable, and realistic goals that she can plan for and address between sessions, as opposed to lofty, unrealistic goals, which may lead to feelings of inadequacy. These modifications identified during provider interviews have informed refinements and improved the RISE intervention and its implementation characteristics.

While this study focused on providers working with veterans in the US’s largest integrated healthcare system, findings may be broadly applicable to other countries that provide healthcare to former service members and veterans, such as the Veterans Affairs Canada, the Department of Veterans Affairs in Australia, and the Service Personnel and Veterans Agency in the United Kingdom [55]. For example, issues raised by providers in this study regarding vicarious traumatization, the importance of providers treating trauma and IPV seeking consultation and self-care, are not specific to providers in the US, and are broadly applicable to providers working with veterans and/or trauma globally. Consultation offers a possible venue for providers to seek support from peers that may help to offset some of the impact of vicarious traumatization.

Further, findings may be applicable for women’s health providers who are addressing IPV and trauma broadly. For example, the finding that having a structured approach to responding to IPV, which includes example scripts that could facilitate provider comfort in addressing IPV, may likely be transferrable for providers working with IPV across other settings and contexts. Additionally, the barrier identified that providers may have a difficult time utilizing a nonjudgmental stance and MI principles when responding to women who plan to remain in violent relationships is likely applicable broadly. Utilizing MI principles, and drawing from the Transtheoretical Model of Behavior Change [56] to understand the stages of change that a patient is currently in, as Hegarty and colleagues do in their WEAVE intervention in Australia [52], is a helpful tool in ensuring that therapy does not become a ‘tug of war’ between provider and patient, and that providers can meet patients where they are at in terms of readiness for change. This study supports utilization of Wiltsey Stirman and colleagues’ framework when conducting UCD research throughout the treatment development and evaluation for identifying content, context, and training modifications to interventions [38]. The framework was useful for organizing and characterizing the variety of suggestions for refinement, and may be useful in guiding or supporting intervention development or pre-implementation efforts to adapt other interventions to increase their relevance and feasibility in routine care delivery. Thus, this research may prove useful to other efforts that could benefit from established frameworks and methodologies for enhancing interventions and incorporating research on implementation characteristics that will likely increase the adoption, acceptability, and feasibility of the interventions by the intended end-users.

Several limitations exist in the present study. Providers interviewed in this study work at VA Healthcare Systems in the New England region of the US, and therefore findings may be specific to these regions and healthcare systems. As noted above, however, several findings are particularly applicable to other settings and to women’s health providers more generally. Nearly 40% of the sample were psychologists, and as such other professions may be under represented in the current study, possibly due to that physicians busy schedules may reduce engagement in voluntary research studies. Further, the current study did not formerly assess for provider’s level of training in or experience with IPV, which may have influenced results. Additionally, it is possible that other undue influences (e.g., social desirability) may have impacted provider response to study team members about the RISE intervention. Further, RISE was developed specifically to target the needs of women veterans who have experienced IPV, and while its principles likely could apply to some other settings in the US and across the globe, our findings may not be broadly applicable to implementing RISE in countries where healthcare resources are limited.

Future research should examine the RISE intervention in practice using hybrid study designs [57], in order to both examine the effectiveness of the intervention on psychosocial outcomes (i.e., clinical outcomes) as well as to provide evidence for the acceptability and feasibility (i.e., implementation outcomes) anticipated by providers in the current study. Trainings and workshops for the RISE intervention should be further developed and examined based on the feedback provided in this study. Calls for role-plays, web-based training, and ongoing consultation are aspects of implementation that may be particularly applicable to other IPV interventions and other health care systems across the globe.

An additional area for research involves determining the preferred settings for RISE implementation and dissemination. While providers in the current study expressed hesitancy about implementing RISE in primary care settings due to time and resource constraints, more research is needed to determine whether RISE can be effectively implemented in integrated primary care settings that include co-located mental, behavioral, or social health providers, such as social workers and psychologists, as part of the primary care medical home (referred to as Patient Aligned Care Teams in VHA) and primary care mental health integration. Primary care may be a setting that women are more willing to access given that it is not associated with the same stigma as mental health clinics, and many women veterans are already followed in primary care routinely. Further, RISE’s brief sessions (30–45 minutes) and short-term nature (one and up to six sessions) may make it an ideal intervention to implement in the fast-paced primary care setting. Further, providers noted IPV Coordinators as particularly well-suited for delivering RISE with women veterans, given that all VHA medical centers are required to have an identified IPV Assistance Program Coordinator to assist with policies and procedures for addressing IPV, as well as to accommodate ‘warm handoffs’ and referrals for women who disclose IPV and are interested in receiving interventions. In addition, if effective in an individual format, more research is needed to examine RISE in different formats, such as in a group setting, which would allow for social support and normalization among other women who have experienced IPV, but may not allow for as much individual autonomy in selecting the module most relevant to a patient’s specific needs.

IPV against women is a critical population health issue. There remains a need to develop and evaluate interventions to address IPV, especially among vulnerable population such as women who have served in the military. This study described an example of applying UCD and implementation science principles to inform refinement to the first IPV intervention of its kind for women veterans in the US, for which there is a great need. We are hopeful that by eliciting provider feedback early on in intervention development and by incorporating current findings into intervention refinement prior to formal effectiveness evaluation, we will accelerate the timeline for implementing RISE into routine care, should it prove effective. We are hopeful that these methods and findings can be applied broadly to other settings globally in which providers are working with women to address IPV and trauma.