What Is the Prevalence of Intimate Partner Violence and Traumatic Brain Injury in Fracture Clinic Patients?

Abstract

Background

Individuals in violent intimate relationships are at a high risk of sustaining both orthopaedic fractures and traumatic brain injury (TBI), and the fracture clinic may be the first place that concurrent intimate partner violence (IPV) and TBI are recognized. Both IPV and TBI can affect all aspects of fracture management, but prevalence of TBI and comorbid TBI and IPV is unknown.

Questions/purposes

(1) What are the previous-year and lifetime prevalence of IPV and TBI in women presenting to an outpatient orthopaedic fracture clinic? (2) What are the conditional probabilities of TBI in the presence of IPV and the reverse, to explore whether screening for one condition could effectively identify patients with the other? (3) Do patients with TBI, IPV, or both have worse neurobehavioral symptoms than patients without TBI and IPV?

Methods

The study was completed in the fracture clinic at a community Level 1 trauma center in Southern Ontario from July 2018 to March 2019 and included patients seen by three orthopaedic surgeons. Inclusion criteria were self-identification as a woman, age 18 years or older, and the ability to complete forms in English without assistance from the person who brought them to the clinic (for participant safety and privacy). We invited 263 women to participate: 22 were ineligible (for example, they were patients of a surgeon who was not on the study protocol), 87 declined before hearing the topic of the study, and data from eight were excluded because the data were incomplete or lost. Complete data were obtained from 146 participants. Participants’ mean age was 52 ± 16 years, and the most common diagnosis was upper or lower limb fracture. Prevalence of IPV was calculated as the number of women who answered “sometimes” or “often” to direct questions from the Woman Abuse Screening Tool, which asks about physical, emotional, and sexual abuse in the past year or person’s lifetime. The prevalence of TBI was calculated as the number of women who reported at least one head or neck injury that resulted in feeling dazed or confused or in loss of consciousness lasting 30 minutes or less on the Ohio State University Traumatic Brain Injury Identification Method, a standardized procedure for eliciting lifetime history of TBI through a 3- to 5-minute structured interview. Conditional probabilities were calculated using a Bayesian analysis. Neurobehavioral symptoms were characterized using the Neurobehavioral Symptom Inventory, a standard self-report measure of everyday emotional, somatic, and cognitive complaints after TBI, with total scores compared across groups using a one-way ANOVA.

Results

Previous-year prevalence of physical IPV was 7% (10 of 146), and lifetime prevalence was 28% (41 of 146). Previous-year prevalence of TBI was 8% (12 of 146), and lifetime prevalence was 49% (72 of 146). The probability of TBI in the presence of IPV was 0.77, and probability of IPV in the presence of TBI was 0.36. Thus, screening for IPV identified proportionately more patients with TBI than screening for TBI, but the reverse was not true. Neurobehavioral Symptom Inventory scores were higher (more symptoms) in patients with TBI only (23 ± 16) than those with fractures only (12 ± 11, mean difference 11 [95% CI 8 to 18]; p < 0.001), in those with IPV only (17 ± 11) versus fractures only (mean difference 5 [95% CI -1 to -11]; p < 0.05), and in those with both TBI and IPV (25 ± 14) than with fractures only (mean difference 13 [95% CI 8 to 18]; p < 0.001) or those with IPV alone (17 ± 11, mean difference 8 [95% CI -1 to 16]; p < 0.05).

Conclusion

Using a brief screening interview, we identified a high self-reported prevalence of TBI and IPV alone, consistent with previous studies, and a novel finding of high comorbidity of IPV and TBI. Given that the fracture clinic may be the first healthcare contact for women with IPV and TBI, especially mild TBI associated with IPV, we recommend educating frontline staff on how to identify IPV and TBI as well as implementing brief screening and referral and universal design modifications that support effective, efficient, and accurate communication patients with TBI-related cognitive and communication challenges.

Level of Evidence

Level II, prognostic study.

Introduction

Previous studies have shown a high prevalence of intimate partner violence (IPV) among women presenting with orthopaedic injuries [13, 34, 38], including a multinational study of 2945 women in which 1 in 6 reported IPV in the past year and 1 in 3 reported IPV in their lifetime [13, 34, 38]. Traumatic brain injury (TBI) also can be prevalent in orthopaedic clinics, as it can co-occur with orthopaedic injuries [21]. Most concerning is that orthopaedic patients can be at risk for comorbid IPV and TBI, as blows to the head and body can translate force to the brain, and strangulation-related hypoxia can cause additional damage [5, 9, 14]. IPV and TBI can be overlooked in healthcare settings where they are not the focus, however, including orthopaedic fracture clinics [24, 34]. Potential reasons for under- or misidentifying IPV and TBI include lack of provider knowledge about what to do if a patient reports IPV and lack of time and privacy for interviews [40]; IPV-related TBI being classified as mild, with brief or no loss of consciousness [29]; overlap between somatic and cognitive signs and symptoms of TBI with those of mental health and other disorders [22]; and general lack of provider awareness of the TBI risk among people who have experienced IPV [20].

Identification of patients with IPV is critical for patient safety and management, especially given evidence that fractures predict future domestic homicide. Orthopaedic surgeons are often the initial contact for patients and have an ongoing relationship through follow-up visits, and so are uniquely positioned to identify IPV [13]. Patients with IPV and comorbid TBI are at even greater risk of future violence, as TBI-related cognitive impairments can limit survivors’ capacity to avoid and manage potentially explosive situations in the home or plan and execute escape from these situations [25]. A person with cognitive impairments also may not be able to work, and loss of income and associated stressors are further risk factors for violence [3, 12, 35]. These same TBI-related cognitive impairments can affect multiple aspects of orthopaedic care, from the ability to give an accurate history to the likelihood of following treatment recommendations [31, 42]. Only one study has assessed the prevalence of TBI in fracture clinic patients [24], however, and the prevalence of comorbid TBI and IPV is unknown, as is the prevalence of cognitive signs and symptoms. This knowledge would help develop future screening, education, and training methods to improve the treatment of patients seen in fracture clinics.

Therefore, we asked: (1) What are the previous-year and lifetime prevalence of IPV and TBI in women presenting to an outpatient orthopaedic fracture clinic? (2) What are the conditional probabilities of TBI in the presence of IPV and the reverse, to explore whether screening for one condition could effectively identify patients with the other? (3) Do patients with TBI, IPV, or both have worse neurobehavioral symptoms than patients without TBI and IPV?

Patients and Methods

Study Design and Setting

We conducted a cross-sectional observational study of women receiving medical care at an outpatient orthopaedic fracture clinic associated with a Level I trauma center in a community hospital, during a 9-month period from July 2018 to March 2019. Research assistants attended the fracture clinic on 33 days during that time and invited any female patient to participate. Overall, the methods followed those used by investigators in the Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation (PRAISE) study [29, 35], which involved asking patients direct questions about IPV and TBI history over the previous year and their lifetime.

Participants

Patients were eligible if they presented to the clinic for an appointment with one of three orthopaedic surgeons who gave consent to approach their patients (none were study authors); self-identified as a woman aged 18 years or older, because IPV primarily affects women; could read, understand, and write in English, by self-report; and could complete the study without the presence of anyone who accompanied them to their clinic appointment, to ensure participants’ privacy while completing study tasks. Potential participants were excluded if an accompanying person stated that the patient was too ill or lacked the cognitive ability to participate. To protect patient privacy and safety, the purpose of the study was not disclosed at the time of recruitment.

Once a patient was determined eligible, a trained research assistant led her to an area outside the clinic to complete the study tasks. The research assistant obtained informed consent and completed a short, structured interview with the participant, and the participant completed electronic questionnaires on an iPad. Participants also answered demographic questions to permit comparison of this study to previous work. Demographic questions did not include any identifying information, and no identifiable information was collected for any task. Participants were compensated with a CAD $10 gift card (approximately USD 7) to a nearby coffee shop and their choice of either a parking pass or a bus pass.

Patients’ Descriptive Data

Research assistants invited 263 patients to participate in the study during a 9-month period from July 2018 to March 2019. Recruitment was halted after that point because of time and funding. Of the 263 women we invited to participate in the study, 22 were ineligible for various reasons (such as, they were patients of a surgeon who was not on the study protocol), and 87 declined before hearing the topic of the study (Fig. 1). Research assistants noted the characteristics of women who declined to participate, and these were typically older women with hip fractures who appeared to be in acute pain. Participant data were excluded from the analysis if the participant did not complete all sections of the study (eight patients), for example, if they were called for their clinic appointment and had to abandon the study midway through.

Fig. 1.

The study flow diagram is shown here.

The final sample for analysis was 146 women. Of these, 92% (135 of 146) self-identified as White and 40% as married (58 of 146), with a mean age of 52 ± 16 years and a median (IQR) of 14 years of education (12 to 16) (Table 1). Fifty-nine percent (84 of 146) of patients reported that a fracture was the reason for their clinic visit, 16% (24 of 146) said it was because of surgery, 57% (83 of 146) indicated it was lower limb, 34% (50 of 146) noted it was upper limb, and one patient reported a head and face injury (Supplementary Table 1; http://links.lww.com/CORR/A886).

Table 1.

Participant demographic data (n = 146)

Parameter	Value
Mean age in years	52 ± 16
Median years of education	14 (12-16)
Racial group
Asian	2 (3)
Black	1 (2)
First Nations indigenous	1 (2)
Latin	1 (1)
Mixed	1 (1)
White	92 (135)
Other	1 (2)
Self-reported relationship status group
Common law	5 (8)
Dating	11 (16)
Divorced	9 (13)
Engaged	2 (3)
Married	40 (58)
Separated	3 (5)
Single	18 (27)
Widowed	11 (16)

Data presented as mean ± SD, median (IQR), or % (n). All data were self-reported.

Primary Outcomes

The lifetime prevalence of TBI was determined using the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID), a standardized procedure for eliciting lifetime history of TBI through a 3- to 5-minute structured interview [11]. The OSU TBI-ID asks about any injuries to the head and neck, if the person was “knocked out or unconscious” or felt “dazed or confused” after any of those injuries, and if the person experienced any repeated injuries as in sports, military duty, or IPV. Probable head or neck injury, without changes in consciousness, was defined as any report of an injury to the head or neck that did not result in loss of consciousness, feeling dazed, or a memory gap after the injury [17]. Probable mild TBI was defined as at least one report of a head or neck injury that resulted in feeling dazed or confused after the injury or loss of consciousness lasting 30 minutes or less, and probable moderate-severe TBI was defined as loss of consciousness lasting 30 minutes or more [17].

The lifetime prevalence of IPV was identified by asking participants the three direct questions from the Woman Abuse Screening Tool [4], as used by PRAISE investigators [28, 34]: “In your lifetime, have you been physically abused by an intimate partner?,” “In your lifetime, have you been sexually abused by an intimate partner?,” and “In your lifetime, have you been emotionally abused by an intimate partner?” The three questions were repeated for the past year. Response options were “often,” “sometimes,” and “never.”

The lifetime prevalence of comorbid TBI and IPV was defined as the number of women who screened positive for lifetime mild TBI or moderate-severe TBI on the OSU TBI-ID and answered “sometimes” or “often” to the direct question about physical abuse.

Secondary Outcomes

The 12-month TBI prevalence was calculated from OSU TBI-ID responses. The OSU TBI-ID records the current age of the interviewee and the age at which brain injuries were experienced. Women were screened as having TBI within the past 12 months if they reported symptoms related to a mild TBI or moderate-severe TBI that occurred within 1 year of their self-reported current age. The 12-month IPV prevalence was calculated from answers of “sometimes” or “often” to any of the three Women Abuse Screening Tool questions, modified to say, “In the past year …”.

Symptoms were assessed using the Neurobehavioral Symptom Inventory (NSI), a 22-item self-report symptom inventory developed for use in patients with mild TBI [8]. The NSI generates a total score comprised of subscores for cognitive, somatic, and affective symptoms. These symptom subscores were compared across four groups of women identified by the Women Abuse Screening Tool and OSU TBI-ID: no TBI or IPV, IPV only, TBI only, and TBI and IPV. For this analysis, mild TBI and moderate-severe TBI were combined.

To better understand processes and outcomes when IPV and TBI co-occur, we also obtained descriptive information about IPV history. Although there is currently no standardized tool to characterize TBI in the context of IPV, previous research has identified the widely used HELPS Brain Injury Screening [33] as a useful tool in this setting [20]. The HELPS is a five-item screening questionnaire that asks if the person has ever Hit their head or been hit on the head and related to that was ever seen in the Emergency room, hospital, or by a doctor as a result; Lost consciousness or were dazed or confused; experienced Problems in daily life; or had other Sicknesses that could cause brain injury. We used a modified version of the HELPS that adapted three questions to be framed in relation to blows to the head or strangulation inflicted by a current or past intimate partner: Have you ever hit your head/been hit on the head? Were you ever seen in the emergency room, in the hospital, or by a doctor because of an injury to your head? Did you ever lose consciousness or experience a period of being dazed and confused because of an injury to your head? For example, the first question was rephrased as, “Has a former or current spouse, domestic partner, or intimate partner ever hit you in the face or head?” The modified HELPS was administered to any woman who self-reported IPV using the direct method, described above.

Sample Size Determination

Based on previous outpatient research on IPV-related TBI [5], we expected that 50% of women with an IPV history would self-report lifetime TBI. Using a formula for calculating sample size for prevalence studies, we calculated that a sample size of 212 participants would provide an estimate of IPV-TBI prevalence with 95% confidence. Using the same methods for our secondary outcomes, we aimed to recruit a sample of 217 women to assess the 12-month prevalence of IPV and 277 to assess the 12-month prevalence of TBI. Thus, we aimed for a total sample size of 277. The three surgeons who consented to allow recruitment of their patients reported scheduling an average of 60 patients per clinic, with one clinic each week for each surgeon, and estimated that 50% of patients were women. Thus, the potential number of participants was 90 per week. A proportion of these were follow-up visits, and consequently, patients would have already been approached for the study; clinics could be cancelled for staff absences, holidays, or other unexpected events; and there could be patient cancellations or missed appointments. Research assistants also were students who could have competing academic schedules. Thus, we estimated it would take 6 months to reach target recruitment. This was extended by 3 months when enrollment targets were not met, and as noted, recruitment was halted at that time.

Ethical Approval

Approval for this study was obtained from the relevant ethics review board before the initiation of any study activities.

Statistical Analyses

Prevalence data were analyzed descriptively. We used a Bayesian analysis to calculate conditional probabilities for lifetime TBI in the presence of reported IPV and the reverse to determine whether screening for one condition would identify patients with the other. NSI total scores were compared across the four participant groups using one-way ANOVA. Because the number of NSI items differed among subscores (somatic = 11, affective = 7, cognitive = 4), raw scores were converted to z-scores for the subscore comparison. z-scores were compared across groups using two-way repeated-measures ANOVA, with group as a between-participants variable and subscore as a within-participants variable. Post hoc Bonferroni tests were used to follow any main effects. All analyses were completed in Stata (StataCorp) [43].

Results

Prevalence of IPV and TBI

For previous-year prevalence, 19% (27 of 146) of the women in the study reported experiencing IPV: 7% (10 of 146) reported physical IPV, 17% (25 of 146) reported emotional IPV, and 1% (2 of 146) reported sexual IPV. For lifetime prevalence (Fig. 2), 48% (70 of 146) reported experiencing IPV: 28% (41 of 146) reported physical IPV, 44% (64 of 146) reported emotional IPV, and 10% (15 of 146) reported sexual IPV. Of the women who reported lifetime physical IPV, 66% (27 of 41) said they had been hit in the face or head, 46% (19 of 41) said a partner had pushed their head into a wall or other object, 44% (18 of 41) said their partner had physically shaken them, 37% (15 of 41) said a partner had tried to choke them or otherwise made it hard for them to breathe, 24% (10 of 41) had been pushed so they fell and hit their head, and 32% (13 of 41) reported losing consciousness or feeling dazed and confused because of something the partner did (Table 2). We compiled all participant responses to the HELPS questionnaire (Supplementary Table 2; http://links.lww.com/CORR/A887). Prevalence numbers sum to more than the total number reporting IPV, as some participants reported multiple types or instances of IPV.

Fig. 2.

The figure shows the prevalence of IPV, TBI, and both among study participants.

Table 2.

HELPS Brain Injury Screening Tool questionnaire responses for participants who reported physical IPV, with or without TBI

HELPS question	IPV only	IPV and TBI
Past year (n = 10)	(n = 5)	(n = 5)
Within the past year, has a former or current spouse, domestic partner, or intimate partner ever hit you in the face or head?	20 (1)	40 (2)
Within the past year, has a partner ever pushed your head into a wall or another object?	40 (2)	20 (1)
Within the past year, have you been physically shaken by a partner?	0 (0)	40 (2)
Within the past year, has a partner pushed you so that you fell and hit your head?	0 (0)	20 (1)
Within the past year, has a partner tried to choke you or do anything else that made it hard for you to breathe?	0 (0)	20 (1)
Within the past year, have you lost consciousness, blacked out, or felt dazed and confused as a result of what your partner did to you?	0 (0)	60 (3)
If, within the past year, a partner caused you to feel dazed and confused as a result of something they did to you, how long did this last?
1- < 5 minutes		0 (0)
2- 6 to 15 minutes		20 (1)
3- 16 to 30 minutes		20 (1)
4- > 30 minutes		20 (1)
If you answered yes to any of the above questions, did you go to the emergency department after being injured?		20 (1)
Lifetime (n = 41)	(n = 15)	(n = 26)
In your lifetime, has a former or current spouse, domestic partner, or intimate partner ever hit you in the face or head?	47 (7)	77 (20)
In your lifetime, has a partner ever pushed your head into a wall or another object?	33 (5)	54 (14)
In your lifetime, has a partner ever physically shaken you?	47 (7)	42 (11)
In your lifetime, has a partner ever pushed you so that you fell and hit your head?	7 (1)	35 (9)
In your lifetime, has a partner ever tried to choke you or do anything else that made it hard for you to breathe?	33 (5)	38 (10)
In your lifetime, have you ever lost consciousness, blacked out, or felt dazed and confused as a result of something a partner did to you?	0 (0)	50 (13)
If you answered yes to any of the above questions, did you go to the emergency room after being injured?	0 (0)	8 (2)
In the emergency room did anyone ask you if you were hit in the head, neck, or face or mention the words head injury or concussion?	0 (0)	8 (2)

Data presented as % (n); IPV = intimate partner violence; TBI = traumatic brain injury

According to OSU TBI-ID interview responses, 8% (12 of 146) of participants screened positive for TBI in the past year; 3% (4 of 146) reported at least one injury resulting in feeling dazed or a memory gap after the injury, 4% (6 of 146) reported at least one injury that led to loss of consciousness for less than 30 minutes, and 1% (2 of 146) reported an injury that resulted in loss of consciousness for 30 minutes or more. For lifetime TBI, 49% (72 of 146) screened positive; 32% (46 of 146) reported at least one head or neck injury that led to either feeling dazed or a memory gap after the injury, 25% (37 of 146) reported at least one injury that led to loss of consciousness for less than 30 minutes, and 8% (12 of 146) reported at least one injury that led to loss of consciousness for 30 minutes or more. Prevalence numbers sum to more than the total number reporting TBI because some participants reported multiple subtypes of TBI (such as, one or more injuries that resulted in feeling dazed and one or more that resulted in loss of consciousness).

Conditional Probabilities

Screening for TBI in those with IPV yielded proportionately more positive cases than in the full study sample. The probability of lifetime TBI in the full sample was 0.49 ([46 + 26]/146), and the probability of TBI given the identification of IPV was 0.77 (P(TBI|IPV) = (P(IPV|TBI)*P(TBI))/P(IPV)). Screening for IPV among those with TBI identified a similar number of cases as in the full sample. The probability of lifetime IPV in the full sample was 0.28 ([15 + 26]/146), and the probability of IPV given a TBI diagnosis was 0.36. This differed from a random distribution of both IPV and TBI (chi-square (1) = 16.07; p < 0.001). Thus, screening for IPV identified proportionately more patients with TBI than in the general clinic, but screening for TBI did not identify proportionately more patients with IPV than in the general clinic.

Neurobehavioral Symptoms

NSI scores were higher (meaning, more symptoms) overall in participants with TBI, with or without IPV (Fig. 3 and Supplementary Table 3; http://links.lww.com/CORR/A888). Scores were higher in patients with TBI only (23 ± 16) than those with fractures only (12 ± 11, mean difference 11 [95% CI 8 to 18]; p < 0.001) and in those with both TBI and IPV (25 ±14) than in those with fractures only (mean difference 13 [95% CI 8 to 18]; p < 0.001) or IPV alone (17 ± 11, mean difference 8 [95% CI -1 to 16]; p < 0.05). Scores also were higher in participants with IPV only (17 ± 11) than fractures only (mean difference 5 [95% CI -1 to -11]; p < 0.05). Scores did not differ between those with TBI only versus both TBI and IPV (mean difference 2 [95% CI -9 to 2]; p = 0.45) or with IPV alone versus TBI alone (mean difference 6 [95% CI -3 to 15]; p = 0.10).

Fig. 3.

Average NSI symptom checklist total scores by group. ^ap < 0.05.

NSI subscore z-scores differed by group (Fig. 4). There were higher subscores in the TBI-only group than in the three other groups, and higher scores in the TBI and IPV group than in the IPV-only group (all p < 0.05). This was true for all subscores across all groups, that is, there was no difference by subscore (p = 0.84) or interaction of subscore by group (p = 0.84).

Fig. 4.

Average NSI symptom checklist raw subscores by group.

Discussion

A fracture clinic may be the first point of healthcare contact for women with a history of IPV and TBI, both of which commonly co-occur with orthopaedic injuries. Thus, fracture clinic staff have a unique opportunity to identify these patients, refer them for appropriate services, and consider effects of IPV and TBI in patient management. Data on prevalence of both IPV and TBI are scarce, however, making it difficult to determine appropriate management methods. Our study adds data on the prevalence of IPV and TBI in a fracture clinic at an urban Level 1 trauma hospital. We found a high prevalence of both in women presenting to the clinic, and a higher prevalence of TBI among women with IPV than in the sample. Women with TBI also reported more somatic, cognitive, and emotional symptoms regardless of IPV history. These findings support the need to identify IPV and TBI and consider screening for symptoms that can affect fracture management and outcomes.

Limitations

This study has several limitations. First, our sample might not represent all patients seen in this clinic or patients in other fracture clinics. Sample size and composition were limited by barriers to participant recruitment, mostly related to the physical layout of the clinic, which was small, cramped, and with insufficient seating for patients. We used several strategies to make it possible for patients to “keep their spot” in the clinic while they participated but had limited success. Our observations suggested that physical barriers particularly excluded older women, which is concerning given risks for IPV related to elder abuse [1]. Despite the barriers, the prevalence of IPV was almost identical to that reported in both a study several years earlier in the same clinic [39] and studies in other clinics internationally [15, 34]; nevertheless, further replication is needed.

Because of the reduced sample size, the study was underpowered for the NSI comparison, which is a second limitation. We found differences among patient groups—notably higher NSI scores in those with TBI—suggesting that the NSI is capturing TBI-related symptoms, but further study is needed to determine whether this tool can identify patients with either TBI or symptoms that merit clinical attention.

A third limitation is that TBI data were self-reported based on recall of events, and these events could have been many years in the past. Self-report could lead to under-reporting mild injuries that the survivor might not have viewed as a causing “brain damage” or over-reporting if the person had psychologic or somatic symptoms unrelated to the TBI [6]. To our knowledge, there has been only one other fracture clinic study of TBI [24], and that study included medical records review, but patients were asked only about TBI related to the fracture for which they were seeking treatment; that is, it excluded patients with TBI from other injuries, including previous fractures, so the results likely underestimated the total in the sample. Potential bias was minimized by using the OSU TBI-ID, a formal questionnaire with good interrater reliability and predictive validity for everyday cognitive symptoms [11]. The OSU TBI-ID is the gold standard for research on mild TBI, including a study of IPV-related TBI [18], so we judged it to be the best tool available for our study. Even if patients had been screened closer in time to events, they might not disclose IPV [45], and many people with mild TBI do not ever seek medical care [6], so self-report might be the best approach for a first-pass screening and referral.

The fourth limitation, also related to generalization, is that this study focused on women because they are the largest group with IPV, but the same considerations apply to other groups at risk of both IPV and TBI, including transgender and gender-diverse people [30, 44], older adults [47], individuals with mental health disorders [37], and in general individuals who experience health disparities [41]. Future studies should ensure that all genders and those in other at-risk groups are represented.

Prevalence of IPV and TBI

In this sample, almost one of two women had experienced IPV in her lifetime, and one of five reported IPV in the previous year. Violence type varied across women, but the prevalence of lifetime physical violence—which could be a risk factor for TBI—was 28%. This prevalence was like that reported in the same clinic 7 years before the current study [34] (Table 3). Previously reported IPV prevalence data have varied widely by country, setting, interview method, and population [38], making it challenging to generate expectations for service needs in a given clinic. The finding of similar prevalence across cohorts in this clinic, and the high prevalence in both cohorts, support the continued need for screening, staff training, and management strategies that ensure the safety of women with an IPV history.

Table 3.

Prevalence of IPV by type in the PRAISE study [34] (n = 284) and the current study (n = 146)

Study	Physical IPV	Emotional IPV	Sexual IPV	Overall IPV
PRAISE study
Past year	4 (11)	22 (62)	2 (5)	22 (63)
Lifetime	23 (65)	42 (119)	12 (34)	42 (120)
Current study
Past year	7 (10)	17 (25)	1 (2)	18 (27)
Lifetime	28 (41)	44 (64)	10 (15)	48 (70)

Data presented as % (n). Proportions were not different between studies (chi-square p = 0.19); PRAISE = Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation.

The prevalence of reported TBI was also very high, with one of two women reporting a lifetime history of TBI. As in the general population [17], most women reported mild injuries, with either a disruption in memory without loss of consciousness or a loss of consciousness less than 30 minutes, although 12 women reported injuries that would be classified as moderate or severe. In the general region where the study was conducted, the TBI prevalence is approximately 12 per 1000 women [32]. Because the regional prevalence data are based on hospitalization and emergency room admissions, they likely reflect more severe injuries and excluded people with mild TBI, who often do not present to the emergency room [7]. However, even severe injuries were much higher in our current sample. A high proportion of TBI is expected in a fracture clinic, given that falls, sports, and motor vehicle collisions are common causes of TBI and fractures, but one in two women is a remarkable number, nonetheless. We do not know whether these women had received rehabilitation for their injuries or might need a referral, or whether clinic staff were aware of the patients’ TBI history and the potential need to modify clinic procedures to accommodate injury-related sensory and cognitive impairments.

Screening for TBI Using IPV, and Vice Versa

Comorbid IPV and TBI was more prevalent than IPV alone, consistent with the idea that fracture clinic patients are at increased risk for both (that is, that the violent event could cause a fracture and a mild TBI). Although the conditional probabilities suggested that screening for IPV would identify proportionately more women with TBI than screening all women in the clinic, this would miss the 32% of patients who reported TBI but not IPV.

Symptom Profiles Associated With IPV and TBI

Patients who reported TBI reported more neurobehavioral symptoms regardless of their IPV history. This differed from results of a study of women with IPV in the military [23] that used the same instrument, in which women with both IPV and TBI reported more symptoms than those with IPV alone.

Identifying patients with TBI may help get them referred to appropriate services and identify factors that could affect fracture outcomes (for example, if patients report memory problems that affect their ability to follow recommendations). We expected that patients with TBI would report more symptoms on the cognitive subscale of the NSI than patients in the other two groups, given the known effects of TBI on cognition, but there was no interaction of group by subscore. Results (Fig. 4) suggest that cognitive symptom scores were higher than scores for other types of symptoms in the TBI-only group, whereas somatic symptom scores were highest in the IPV with TBI group, perhaps because the latter group had more somatic symptoms potentially related to anxiety and depression, such as loss of appetite or nausea. That difference could help clinicians determine whether to refer patients to mental health or cognitive rehabilitation services and could be explored in a larger sample.

The most important reason to screen patients for IPV and TBI is patient safety. IPV-related TBI is associated with chronic impairments in cognitive functions such as memory, thinking speed, and executive functions (such as self-control and flexibility) [18, 22, 46]. These cognitive impairments put the survivor at additional risk of future violence by decreasing their capacity to avoid and manage potentially explosive situations in the home or plan and escape from these situations [25]. Additionally, a person with cognitive impairments may not be able to work, and loss of income and associated stressors are further risk factors for violence [3, 12, 35].

Conclusion

In this interview-based study of women presenting to an outpatient fracture clinic, 1 in 5 women reported IPV in the previous year, and 1 in 2 reported a lifetime history of IPV, with 1 in 4 reporting physical violence. Two-thirds of these women also reported a history of TBI, and in the entire sample, TBI was as common as IPV. These figures are not specific to our clinic: Similar and even higher numbers have been reported in other studies [20, 23, 27, 42]. Patients reporting TBI, with or without IPV, had more somatic, emotional, and cognitive complaints than those without TBI, which is also consistent with other research [2, 26, 37].

Based on our study and others with similar findings, we have three recommendations for fracture clinic staff. The first recommendation is to educate frontline staff about TBI and IPV to raise awareness. Online resources such as the Educate program (https://www.ipveducate.com/the-educate-training-program), which includes one-page training updates on IPV and TBI, and the Abused and Brain Injured toolkit (https://abitoolkit.ca/) provide accessible information about both IPV and TBI.

The second recommendation is to consider incorporating universal design principles [10] into clinic processes. Universal design in healthcare has mostly been discussed in the context of physical modifications to make clinics accessible, flexible, and safe for all patients [16]. It is equally applicable to accessible communication. Simple universal design modifications can help any patient with cognitive or language challenges access care, and it can support efficient, effective, and accurate communication with clinic staff. Examples of modifications include pausing to check that a patient has understood or asking them to “teach-back” information after hearing it; facing the patient rather than a computer monitor to maximize cues to comprehension, such as when taking a history; when patients arrive at the clinic, providing them with questions they will be asked so they have time to formulate an accurate response; minimizing demands for patients to recall spoken details (for example, providing notes or encouraging patients to note relevant information in their electronic devices); and giving patients enough time to respond to questions. The IPV-Educate website includes an infographic that can support clinicians in effectively caring for patients with TBI who are seen in fracture clinics.

The third recommendation is to consider screening, particularly for IPV because of the risks to patient safety. To quote the title of a study of IPV knowledge among orthopaedic residents, “I never asked one question” about IPV [19]. There are many resources for how to screen and what to do if a patient acknowledges IPV, including government sources such as the Agency for Healthcare Quality Research (https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/partner-violence.html#practices). The Women Abuse Screening Test used in our study can be done within a few minutes, and the potential benefits to patient safety far outweigh the cost in time.