Changes in Incidents and Payment Methods for Intimate Partner Violence Related Injuries in Women Residing in the United States, 2002 to 2015

Open AccessPublished:June 28, 2020DOI:https://doi.org/10.1016/j.whi.2020.05.002

      Abstract

      Background

      Violence in interpersonal relationships is a substantial health and social problem in the United States and is associated with a myriad of immediate and long-term physical, behavioral, and neurocognitive impairments. The present study sought to determine the incidence of U.S. emergency department (ED)-attended intimate partner violence (IPV) from 2002 to 2015 and examine the differences in payment sources before and after implementation of the Affordable Care Act.

      Methods

      We analyzed ED visits among female patients aged 15 years or older between 2002 and 2015 from the National Hospital Ambulatory Medical Care Survey. Using International Classification of Disease, Ninth Revision, Clinical Modification, codes from patient visit records, we classified each ED visit to determine the frequency and estimate the relative proportion and national frequency of IPV visits. We explored bivariate and multivariate associations between IPV-related injuries with age, race, ethnicity, method of payment, and region, noting changes over time.

      Results

      Between 2002 and 2015, female patients visited EDs an estimated 2,576,417 times for IPV-related events, and the proportion of ED visits for IPV increased during that time period. The percentage of ED visits for IPV-related events did not differ significantly by region, race, or ethnicity. Compared with women 25–44 years of age, women aged 65 to 74 (odds ratio, 0.15; 95% confidence interval, 0.05–0.43; p < .001) and 75 years and older (odds ratio, 0.20; 95% confidence interval, 0.08–0.53; p = .001) were less likely to visit an ED for IPV. Women were more likely to pay for IPV-related services out-of-pocket (i.e., self-pay) (odds ratio, 1.85; 95% confidence interval, 1.24–277; p = .003) before the enactment of the Affordable Care Act.

      Conclusions

      The increase in the percentage of IPV-related ED claims paid by private insurance suggests that the Affordable Care Act may have increased women's willingness and ability to seek medical attention for IPV-related injuries and disclose IPV as the source of injuries.
      Intimate partner violence (IPV) is one of the most common forms of violence against women, with 4.0% of women residing in the United States reporting being physically assaulted by a current or former sexual partner in the past 12 months (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ). Women who experience physical injuries owing to IPV seek medical care in a variety of places (e.g., emergency departments [EDs], offices of general practitioners, and dentists [
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ,
      • Bonomi A.E.
      • Thompson R.S.
      • Anderson M.
      • Reid R.J.
      • Carrell D.
      • Dimer J.A.
      • Rivara F.P.
      Intimate partner violence and women’s physical, mental, and social functioning.
      ]), and are more likely to use health care services than women without IPV experience, regardless of whether those injuries were sustained from a recent physical assault (
      • Tjaden P.
      • Thoennes N.
      Full report of the prevalence, incidence, and consequences of violence against women (NCJ 183781).
      ) or were for injuries unrelated to IPV (
      • Bonomi A.E.
      • Anderson M.L.
      • Rivara F.P.
      • Thompson R.S.
      Health care utilization and costs associated with physical and nonphysical-only intimate partner violence.
      ,
      • Fishman P.A.
      • Bonomi A.E.
      • Anderson M.L.
      • Reid R.J.
      • Rivara F.P.
      Changes in health care costs over time following the cessation of intimate partner violence.
      ).
      There is emerging evidence that the medical costs associated with IPV-related injuries are borne by the victim (
      • Max W.
      • Rice D.P.
      • Finkelstein E.
      • Bardwell R.A.
      • Leadbetter S.
      The economic toll of intimate partner violence against women in the United States.
      ,
      National Center for Injury Prevention and Control
      Costs of Intimate partner violence against women in the United States.
      ). For example, the
      National Center for Injury Prevention and Control
      Costs of Intimate partner violence against women in the United States.
      collated data from multiple sources (i.e., the 1995–1996 National Violence Against Women Survey, the 1996 Medical Expenditure Panel Survey, and the Medicare 5% Sample Beneficiary Standard Analytic Files) and reported that 28.6% of physical and 32.0% of mental health costs were paid out of pocket by IPV survivors. Similarly, using national survey data (i.e., the 1995 National Violence Against Women Survey and the 1995 Medical Expenditure Panel Survey)
      • Max W.
      • Rice D.P.
      • Finkelstein E.
      • Bardwell R.A.
      • Leadbetter S.
      The economic toll of intimate partner violence against women in the United States.
      estimated that 48.3% of physical assault costs were borne by the individual's private insurance and/or group plan, 20.1% by public insurance plans (i.e., Medicare and Medicaid), 30.4% by the IPV victim, and 1.2% by other sources.
      Although there are a number of reasons why female survivors of IPV pay for services using their own funds rather than using private insurance, recent research has indicated that women often pay out of pocket out of fear that their abuser will find out they have sought medical attention and/or that their insurance provider would use their IPV history to deny, revoke, or increase their health insurance premiums (
      • Duplessis V.
      • Levenson R.
      Integrating health services into domestic violence programs: Tools for advocates.
      ,
      • Fromson T.
      • Durborow N.
      Insurance Discrimination Against Victims of Domestic Violence.
      ,
      • Reeve M.
      Institute of Medicine (U.S.)
      The impacts of the Affordable Care Act on preparedness resources and programs: Workshop summary.
      ). Indeed, before 2010, U.S. insurance companies could classify IPV as a preexisting condition. In practical terms, the insurance company would calculate potential treatment costs for a current/former IPV victim (e.g., mental health treatment, surgery, postinjury treatment, and medications), and require the individual to pay a higher premium (or deny them coverage) if the costs associated with treatment were found to be substantial (
      • Fromson T.
      • Durborow N.
      Insurance Discrimination Against Victims of Domestic Violence.
      ).
      Recent changes in U.S. health policy have improved health care access and coverage for survivors of IPV. Specifically, the Affordable Care Act (ACA) sought to expand coverage to individuals and improve the quality and efficiency of preventive services (
      • Oehme K.
      • Stern N.
      The case for mandatory training on screening for domestic violence in the wake of the affordable care act.
      ). One provision particularly important for women experiencing IPV is the prohibition on insurance companies denying or revoking coverage or charging higher premiums based on preexisting conditions (
      • Jones A.S.
      • Dienemann J.
      • Schollenberger J.
      • Kub J.
      • O’Campo P.
      • Gielen A.C.
      • Campbell J.C.
      Long-term costs of intimate partner violence in a sample of female HMO enrollees.
      ,
      • Reeve M.
      Institute of Medicine (U.S.)
      The impacts of the Affordable Care Act on preparedness resources and programs: Workshop summary.
      ).
      To examine how the ACA might have influenced the use of emergency care for IPV-related injuries, the aim of the current study was to examine ED visits by female patients aged 15 years or older using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data, a nationally representative sample of all ED visits in the United States between 2002 and 2015. We estimate national frequencies and document the secular trends in IPV-related ED visits. We explore time trends and potential differences in the proportion of ED visits for IPV-related injuries by race, ethnicity, payment method, and U.S. region. Finally, we examine the payment sources for IPV-related injury before and after implementation of the ACA.

      Methods

       Data Source

      We conducted a secondary analysis of the NHAMCS ED database for 2002 to 2015. The NHAMCS is a four-stage probability sample collected by the National Center for Health Statistics and the Centers for Disease Control and Prevention of visits to the emergency and outpatient departments during a randomly assigned 4-week data period (
      Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
      Intimate partner violence: Consequences.
      ). In the NHAMCS, EDs and outpatients are randomly selected from primary sampling units (i.e., county or other geographical units) from the 50 states and the District of Columbia. The NHAMCS stratifies each primary sampling unit by socioeconomic and demographic variables, and then selects primary sampling units with a probability proportional to their size. NHAMCS collects approximately 234 variables each year, including patient demographics (e.g., race, ethnicity, and age), hospital demographics (e.g., geographical region, metropolitan area, and ownership), administrative visit information (e.g., length of visits, length of stay, waiting time, time of arrival, and payment type), and medical variables (e.g., physician diagnoses, cause of injury, vital signs, and procedures). This study used and merged hospital ED data from 2002 to 2015. We excluded data from males, girls younger than 15 years of age, and incidents with poison-related causes from all analyses. Furthermore, data from 2004 were excluded because cases of IPV were substantially different, suggesting potential coding error or coding changes relative to other years. More information on procedure, coding, and data reporting is available at www.cdc.gov/nchs.

       Case Definition IPV

      Although this study focuses on violence against women inflicted by an intimate partner, we included causes directly related to IPV and incidents in which women were abused or assaulted by another adult. IPV cases were identified using the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes found in the cause of injury (rape [E960.1], spouse abuse [E967.3]) and diagnosis (adult abuse [995.80–995.83, 995.85], history of violence [V15.41, V15.42], and counseling [V61.10, V61.11]) fields. These IPV ICD-9-CM codes were selected based on prior research (
      • Btoush R.
      • Campbell J.C.
      • Gebbie K.M.
      Care provided in visits coded for intimate partner violence in a national survey of emergency departments.
      ,
      • Rovi S.
      • Johnson M.S.
      Physician use of diagnostic codes for child and adult abuse.
      ,
      • Rudman W.
      Coding and documentation of domestic violence.
      ,
      • Weiss H.B.
      • Ismailov R.M.
      • Lawrence B.A.
      • Miller T.R.
      Incomplete and biased perpetrator coding among hospitalized assaults for women in the United States.
      ) and the belief that they would capture the various forms of IPV that might present at an ED (
      • Btoush R.
      • Campbell J.C.
      • Gebbie K.M.
      Visits coded as intimate partner violence in emergency departments: Characteristics of the individuals and the system as reported in a national survey of emergency departments..
      ). Furthermore, codes such as rape and adult abuse were included in this study because women are more likely to be raped and abused by an intimate partner (
      • Smith S.G.
      • Basile K.C.
      • Gilbert L.K.
      • Merrick M.T.
      • Patel N.
      • Walling M.
      • Jain A.
      National Intimate Partner and Sexual Violence Survey (NISVS): 2010–2012 state report.
      ).

       Statistical Analysis

      We classified each ED visit to identify one outcome: an IPV event. For the outcome of interest (i.e., IPV), we calculated the frequency (number) of diagnoses and/or causes by year, as well as the proportion of all ED visits during which the outcome of interest was diagnosed by year. Furthermore, we used weights included in the data to calculate national estimates of IPV-ED visit frequencies by year. Secular trends were assessed with the weighted χ2 test for trend. We then examined bivariate relationships between patient demographic and visit characteristics (i.e., age, race, ethnicity, geographic region, and method of payment) and visit rates. Pearson's χ2 was used to evaluate the significance of comparison.
      Subsequently, multivariable logistic regression was used to assess differences in IPV-related ED visits by patient demographics and payment method before and after the ACA went into effect. Bivariate group difference analysis included the following payment methods: private, Medicare, Medicaid, workers’ compensation, self-pay, charity/no charge, other, unknown, and blank. Self-pay and charity/no charge were combined to form a single group for the interacted model presented. A p value of less than .05 was considered to be statistically significant.
      Data management and analysis were performed using the survey [svy] commands in Stata software (version 13.1, Stata Corporation, College Station, TX). Institutional review board exemption was granted by the institutional review board at San Francisco State University because data were de-identified and publicly available.

      Results

      In a total sample of 188,448 ED visits, there were 652 cases of ED visits for IPV (0.35%) in female ED visits from 2002 to 2015. After appropriate weighting, this represents 2,576,417 national ED visits for IPV-related injuries from a total of 749,418,720 national ED visits. Figure 1 presents the annual rates of IPV-related ED visits. Between 2002 and 2015, the annual rate of IPV-related ED visits ranged from 24 to 55 visits per 10,000 ED visits, with an average of 34 IPV-related ED visits per 10,000 ED visits (0.34% [Supplemental Table 1]). Using linear regression, we estimate that the annual rate of increase for IPV-related ED visits was 4.27%.
      Figure thumbnail gr1
      Figure 1Intimate partner violence (IPV)-related emergency department estimated visits. This figure uses 2002–2015 National Hospital Ambulatory Medical Care Survey data (N = 188,448) to show the secular trend of IPV-related ED visits.
      As seen in Table 1 column 1, there were significant differences by age, χ2 (4, N = 188,443) = 253.37, p < .0001; payment method, χ2 (8, N = 188,443) = 282.59, p < .0001; and timing, χ2 (12, N = 188,443) = 96.10, p = .0365; in IPV-related ED visits in univariate analyses. In Table 1 column 2, we present multivariate logistic regression models including indicator variables for year, race, ethnicity, age, geographical region, and payment method. Based on a sample of 150,396 ED visits, women were more likely to visit an ED for an IPV-related injury in 2010 (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.19–3.47; p = .009), 2013 (OR, 2.37; 95% CI, 1.14–4.02; p = .021), and 2014 (OR, 2.63; 95% CI, 1.33–5.23; p = .006), compared with 2002. In addition, we found that women were more likely to self-pay for IPV-related care (OR, 1.46; 95% CI, 1.02–2.08; p = .039) than to use insurance. In comparison with women aged 25–44 years, women aged 65 to 74 (OR, 0.15; 95% CI, 0.05–0.43; p < .001) and 75 years and older (OR, 0.20; 95% CI, 0.08–0.53; p = .001) were less likely to visit an ED owing to IPV. We did not find significant differences by race, ethnicity, or census region in the proportion of ED visits for IPV-related injuries.
      Table 1Demographic Characteristics, Percent of ED Visits for IPV (N = 2,576,417), and OR (95% CI) for IPV-related ED Visits (N = 150,396), United States, 2002–2015
      CharacteristicsPercent of IPV-related ED Visits, n (%)IPV-related ED Visits OR (95% CI)
      Year
       2002118,055 (4.58)Reference
       2003110,529 (4.29)1.03 (0.56–1.91)
       2005155,022 (6.02)1.43 (0.80–2.56)
       2006136,059 (5.28)1.19 (0.68–2.08)
       2007147,544 (5.72)1.24 (0.67–2.29)
       2008249,976 (9.70)1.79 (0.98–3.26)
       2009221,343 (8.59)1.60 (0.90–2.82)
       2010238,280 (9.24)2.04 (1.19–3.47)
      p < .01.
       2011172,494 (6.69)1.42 (0.77–2.61)
       2012219,952 (8.53)1.82 (0.98–3.38)
       2013239,821 (9.31)2.37 (1.14–4.02)
      p < .05.
       2014353,530 (13.72)2.63 (1.33–5.23)
      p < .01.
       2015213,806 (8.29)1.78 (0.86–3.70)
       χ296.10
      p < .05.
      Race
       White1737,861 (67.45)Reference
       Black729,046 (26.84)1.05 (0.72–1.55)
       Other109,508 (4.25)1.11 (0.56–2.17)
       χ221.72
      Ethnicity
      Ethnicity percentage denote the proportion of women who reported their ethnicity; observations of those who did not report their ethnicity were excluded (N = 2,094,798). Column 1 presents estimated number and percentage of National IPV ED visits and Column 2 presents results from logistic regression based on the sample of IPV ED visits after controlling for year, race, ethnicity, age, region, and payment method.
       Non-Hispanic/White181,9483 (86.85)Reference
       Hispanic275,314 (13.14)0.95 (0.67–1.36)
       χ20.74
      Age (y)
       15–242,815,962 (31.67)1.20 (0.89–1.63)
       25–441,118,983 (43.43)Reference
       45–64560,514 (21.75)0.81 (0.51–1.28)
       65–7424,288 (0.94)0.15 (0.05–0.43)
      § p < .001.
       ≥7556,669 (2.19)0.20 (0.08–0.53)
      § p < .001.
       χ2253.37
      § p < .001.
      Census region
       Northeast473,831 (18.39)Reference
       Midwest716,407 (27.80)1.09 (0.75–1.59)
       South936,834 (36.36)0.87 (0.59–1.28)
       West449,343 (17.44)0.93 (0.64–1.33)
       χ220.28
      Payment method
       Private717,337 (27.84)Reference
       Medicare152,152 (5.90)0.74 (0.35–1.55)
       Medicaid821,356 (31.87)1.30 (0.88–1.92)
       Workers' compensation5,520 (0.21)0.31 (0.04–2.27)
       Self-pay504,710 (19.58)1.46 (1.02–2.08)
      p < .05.
       Charity/no charge42,527 (1.65)1.18 (0.50–2.79)
       Other93,436 (3.62)1.23 (0.68–2.20)
       Blank49,167 (1.90)Not enough observations
       Unknown190,205 (7.38)Not enough observations
       χ2282.59
      § p < .001.
      Abbreviations: CI, confidence interval; ED, emergency department; IPV, intimate partner violence; OR, odds ratio.
      This table uses 2002–2015 National Hospital Ambulatory Medical Care Survey data. Observations from 2004 were excluded owing to coding changes and/or potential survey administrator coding error.
      p < .01.
      p < .05.
      Ethnicity percentage denote the proportion of women who reported their ethnicity; observations of those who did not report their ethnicity were excluded (N = 2,094,798). Column 1 presents estimated number and percentage of National IPV ED visits and Column 2 presents results from logistic regression based on the sample of IPV ED visits after controlling for year, race, ethnicity, age, region, and payment method.
      § p < .001.
      We then examined differences in payment methods for IPV-related ED visits before (i.e., 2002–2009, N = 93,336) and after the ACA (i.e., 2010–2015, N = 55,527). In Table 2, we present stratified multivariate analyses comparing payment methods before and after the enactment of the ACA. Women were more likely to use self-pay/charity for IPV-related ED visits relative to other ED visits before ACA enactment. Self-pay/charity for IPV-related ED visits was almost two times higher compared with private insurance before ACA enactment (OR, 1.85; 95% CI, 1.24–277; p = .003). In contrast, there were no statistically significant difference in payment method type post-ACA implementation.
      Table 2OR (95% CI) for IPV-related U.S. ED Visits before and after ACA Enactment
      IPV ED Visits OR (95% CI)
      Pre-ACA (N = 93,336)Post-ACA (N = 55,527)
      PrivateReferenceReference
      Self-pay/charity1.85 (1.24–2.77)
      p < .01.
      1.08 (0.60–1.96)
      Medicare0.70 (0.23–2.16)0.74 (0.28–1.91)
      Medicaid1.37 (0.91–2.08)1.23 (0.66–2.26)
      Other1.04 (0.50–2.16)1.34 (0.60–3.02)
      Abbreviations: ACA, Affordable Care Act; CI, confidence interval; ED, emergency department; OR, odds ratio.
      This table uses 2002–2015 National Hospital Ambulatory Medical Care Survey. Observations from 2004 were excluded owing to coding changes and/or potential survey administrator coding error. Workers' compensation, unknown, and blank observations were excluded from payment method category (N = 244,892). Colum 1 presents results from 2002 to 2009 and column 2 presents results from 2010 to 2015 logistic regression based on the sample of intimate partner violence ED visits after controlling for year, race, ethnicity, age, region, and payment method.
      p < .01.

      Discussion

      In this study, we examined ED visits by female patients aged 15 years or older using NHAMCS data between 2002 and 2015, exploring time trends and potential differences in the proportion of ED visits for IPV-related injuries by race, ethnicity, payment method, and U.S. census region. We observed the following main findings. First, the analysis of secular trends indicated that the number of IPV-related ED visits increased between 2002 and 2015. Second, there were significant differences in ED visits for IPV by age, but not race or ethnicity. Third, before the ACA, IPV-related ED visits were more likely to be paid for by the survivors relative to non–IPV-related ED visits. In contrast, after the ACA took effect, there was no systematic difference in the method that women used to pay for IPV-related ED visits compared with non–IPV-related ED visits. This discussion focuses primarily on these new findings.
      The data from the present study indicate that from 2002 to 2015, 34 of every 10,000 ED visits were by women seeking care for IPV-related injuries. Although differences in methodology make comparisons of prevalence estimates difficult, the number of ED visits obtained in the present study is slightly higher than
      • Btoush R.
      • Campbell J.C.
      • Gebbie K.M.
      Care provided in visits coded for intimate partner violence in a national survey of emergency departments.
      , who derived a national estimate of 21 per 10,000 visits between 1997 and 2001 using the NHAMCS dataset, but lower than that reported by prior studies that used population-based random telephone surveys (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ,
      • Bonomi A.E.
      • Thompson R.S.
      • Anderson M.
      • Reid R.J.
      • Carrell D.
      • Dimer J.A.
      • Rivara F.P.
      Intimate partner violence and women’s physical, mental, and social functioning.
      ,
      • Breiding M.J.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization - National Intimate Partner and Sexual Violence Survey, United States, 2011.
      ), family practice clinics (
      • Coker A.L.
      • Smith P.H.
      • Bethea L.
      • King M.R.
      • McKeown R.E.
      Physical health consequences of physical and psychological intimate partner violence.
      ,
      • Hux K.
      • Schneider T.
      • Bennett K.
      Screening for traumatic brain injury.
      ), and ED-based convenience samples (
      • Brokaw J.
      • Fullerton-Gleason L.
      • Olson L.
      • Crandall C.
      • McLaughlin S.
      • Sklar D.
      Health status and intimate partner violence: A cross-sectional study.
      ,
      • Ernst A.A.
      • Nick T.G.
      • Weiss S.J.
      • Houry D.
      • Mills T.
      Domestic violence in an inner-city.
      ).
      An analysis of secular trends indicated that there was a 4.3% increase in the proportion of IPV-related injuries across the 13-year period (Figure 1). Although it is possible that the rates of severe IPV (e.g., broken bones, internal injuries, loss of consciousness) have been increasing since the early 2000s, it is more plausible that these findings are due to the changing social and cultural norms regarding gender-based violence (
      • Rivara F.P.
      • Anderson M.L.
      • Fishman P.
      • Reid R.J.
      • Bonomi A.E.
      • Carrell D.
      • Thompson R.S.
      Age, period, and cohort effects on intimate partner violence.
      ), and insurance policy changes and medical care access that have affected how injuries attributed to IPV are coded by hospital administrators (
      • Rudman W.
      Coding and documentation of domestic violence.
      ). This finding is incongruent with prior studies using survey-based methodologies (i.e., National Crime Victimization Survey) that have reported a decrease in the prevalence of IPV between 1993 and 2010 (
      • Catalano S.M.
      Intimate partner violence, 1993–2010.
      ,
      • Catalano S.M.
      Intimate Partner Violence–Attributes of Victimization, 1993--2011.
      ,
      • Truman J.
      • Morgan R.
      Criminal victimization, 2015.
      ). This decrease is said to be due, in large part, to national and statewide gender-based violence policies (e.g., the 1994 Violence Against Women Act [
      • Clark K.A.
      • Biddle A.K.
      • Martin S.L.
      A cost–benefit analysis of the Violence Against Women Act of 1994.
      ]), Violence Crime Control and Law Enforcement Act (
      • Amaranto E.
      • Steinberg J.
      • Castellano C.
      • Mitchell R.
      Police stress interventions.
      ), female empowerment and the feminist movement (
      • Rivara F.P.
      • Anderson M.L.
      • Fishman P.
      • Reid R.J.
      • Bonomi A.E.
      • Carrell D.
      • Thompson R.S.
      Age, period, and cohort effects on intimate partner violence.
      ), and the availability of resources for survivors (
      • Dugan L.
      • Nagin D.S.
      • Rosenfeld R.
      Explaining the decline in intimate partner homicide: The effects of changing domesticity, women's status, and domestic violence resources.
      ,
      • Dugan L.
      • Nagin D.S.
      • Rosenfeld R.
      Exposure reduction or retaliation? The effects of domestic violence resources on intimate-partner homicide.
      ,
      • Sev’er A.
      • Dawson M.
      • Johnson H.
      Lethal and nonlethal violence against women by intimate partners: Trends and prospects in the United States, the United Kingdom, and Canada.
      ).
      Alternatively, given the large body of literature indicating that job instability directly affects marital conflict and IPV rates (
      • Benson M.L.
      • Fox G.L.
      • DeMaris A.
      • Van Wyk J.
      Neighborhood disadvantage, individual economic distress and violence against women in intimate relationships.
      ,
      • Fox G.L.
      • Benson M.L.
      • DeMaris A.A.
      • Van Wyk J.
      Economic distress and intimate violence: Testing family stress and resources theories.
      ,
      • Schneider D.
      • Harknett K.
      • McLanahan S.
      Intimate partner violence in the Great Recession.
      ), it is possible that the current findings are a result of financial instability during the Great Recession (starting in December 2007) and the subsequent slow recovery that continued to affect household resources well into 2014. For example,
      • Schneider D.
      • Harknett K.
      • McLanahan S.
      Intimate partner violence in the Great Recession.
      reported that women who experienced economic hardship in the Great Recession were twice as likely to experience violent or controlling behavior by their male intimate partners, with an increase in violent and controlling behavior toward women in situations where both adults were unemployed.
      An analysis of NHAMCS data revealed significant differences for age, but not race or ethnicity. Consistent with prior studies (
      • Beach S.R.
      • Carpenter C.R.
      • Rosen T.
      • Sharps P.
      • Gelles R.
      Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse.
      ,
      • Coker A.L.
      • Smith P.H.
      • Bethea L.
      • King M.R.
      • McKeown R.E.
      Physical health consequences of physical and psychological intimate partner violence.
      ,
      • Crockett C.
      • Brandl B.
      • Dabby F.C.
      Survivors in the margins: The invisibility of violence against older women.
      ,
      • Thompson R.S.
      • Bonomi A.E.
      • Anderson M.
      • Reid R.J.
      • Dimer J.A.
      • Carrell D.
      • Rivara F.P.
      Intimate partner violence: Prevalence, types, and chronicity in adult women.
      ,
      • Truman J.
      • Morgan R.
      Criminal victimization, 2015.
      ,
      • Yan E.
      • Chan K.L.
      Prevalence and correlates of intimate partner violence among older Chinese couples in Hong Kong.
      ), we found that women 65 years of age and over were less likely to visit an ED for IPV, compared with women ages 25–44 years of age. This finding may be due to several factors related to aging, such as age-related decreases in violent behavior and/or the death of the abuser (
      • Gerino E.
      • Caldarera A.M.
      • Curti L.
      • Brustia P.
      • Rollè L.
      Intimate partner violence in the golden age: Systematic review of risk and protective factors.
      ,
      • Rivara F.P.
      • Anderson M.L.
      • Fishman P.
      • Reid R.J.
      • Bonomi A.E.
      • Carrell D.
      • Thompson R.S.
      Age, period, and cohort effects on intimate partner violence.
      ), injury miscategorization in older people who are less likely to be asked about IPV (
      • Beach S.R.
      • Carpenter C.R.
      • Rosen T.
      • Sharps P.
      • Gelles R.
      Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse.
      ,
      • Zink T.
      • Fisher B.S.
      • Regan S.
      • Pabst S.
      The prevalence and incidence of intimate partner violence in older women in primary care practices.
      ), and shifts from physical to nonphysical abuse over the course of the relationship (
      • Harris S.B.
      For better or for worse: Spouse abuse grown old.
      ,
      • Kim H.K.
      • Laurent H.K.
      • Capaldi D.M.
      • Feingold A.
      Men’s aggression toward women: A 10-year panel study.
      ,
      • Quigley B.M.
      • Leonard K.E.
      Desistance of husband aggression in the early years of marriage.
      ).
      The nonsignificant relationship between race or ethnicity and the proportion of ED visits for IPV-related injuries is intriguing given the large corpus of research indicating that Black (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ,
      • Cho H.
      Racial differences in the prevalence of intimate partner violence against women and associated factors.
      ,
      • Lacey K.K.
      • West C.M.
      • Matusko N.
      • Jackson J.S.
      Prevalence and factors associated with severe physical intimate partner violence among US Black women: A comparison of African American and Caribbean Blacks.
      ,
      • Truman J.
      • Morgan R.
      Criminal victimization, 2015.
      ) and Hispanic women (
      • Caetano R.
      • Schafer J.
      • Cunradi C.B.
      Alcohol-related intimate partner violence among white, black, and Hispanic couples in the United States. Domestic Violence: The Five Big Questions.
      ,
      • Cunradi C.B.
      • Caetano R.
      • Schafer J.
      Socioeconomic predictors of intimate partner violence among White, Black, and Hispanic couples in the United States.
      ,
      • Stockman J.K.
      • Hayashi H.
      • Campbell J.C.
      Intimate partner violence and its health impact on ethnic minority women.
      ,
      • West C.M.
      Domestic violence in ethnically and racially diverse families.
      ) are more likely to report IPV victimization and are at a higher risk for severe and recurrent violence inflicted by an intimate partner compared with non-Hispanic White women (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ,
      • Caetano R.
      • Schafer J.
      • Cunradi C.B.
      Alcohol-related intimate partner violence among white, black, and Hispanic couples in the United States. Domestic Violence: The Five Big Questions.
      ,
      • Lipsky S.
      • Caetano R.
      • Field C.A.
      • Bazargan S.
      The role of alcohol use and depression in intimate partner violence among black and Hispanic patients in an urban emergency department.
      ). Given that our methods were comparing rates of IPV-related ED visits with non–IPV-related visits, it could be that Black and Hispanic women have higher rates of ED visits overall compared with non-Hispanic White women, which would mask differences in IPV incidents. Although the risk of IPV victimization may be similar across racial and ethnic groups, it is more likely that the nonsignificant results obtained in the present study are due to historical medical mistrust, perceived discrimination, and structural inequities experienced by minoritized groups (
      • Bell C.C.
      • Mattis J.
      The importance of cultural competence in ministering to African American victims of domestic violence.
      ) that lead them to rely on informal (e.g., friends and family) rather than formal support systems (
      • Hampton R.
      • Oliver W.
      • Magarian L.
      Domestic violence in the African American community: An analysis of social and structural factors.
      ,
      • Karlsen S.
      • Nazroo J.Y.
      Relation between racial discrimination, social class, and health among ethnic minority groups.
      ).
      We also found that IPV-related ED visits were higher in 2010, 2013, and 2014. It is possible that some of the increases in the number of visits in 2013 and 2014 were related to changes in reimbursement and coverage policies owing to the enactment of key provisions of the ACA that affected IPV survivors in particular (
      • Lee L.K.
      • Chien A.
      • Stewart A.
      • Truschel L.
      • Hoffmann J.
      • Portillo E.
      • Galbraith A.A.
      Women’s coverage, utilization, affordability, and health after the ACA: A review of the literature: A literature review of evidence relating to the Affordable Care Act’s impact on women’s health care and health.
      ). For example, the preventive health coverage funds increased in 2013, which by extension increased federal funding and resources for IPV services (i.e., mandatory IPV screenings, supplemental physician training on IPV screenings, and administrator training on IPV reporting [
      • Oehme K.
      • Stern N.
      The case for mandatory training on screening for domestic violence in the wake of the affordable care act.
      ]). In addition, in 2014 insurance companies and health care providers that received federal funds were prohibited from denying health care coverage to survivors of IPV and sexual violence (
      • Duplessis V.
      • Levenson R.
      Integrating health services into domestic violence programs: Tools for advocates.
      ) and Medicaid coverage was expanded in several states for previously ineligible adults. Factors outside the scope of this study are likely related to the higher IPV-related ED visits in 2010.
      Interestingly, multivariate analysis using stratified models, separating the pre-ACA and post-ACA period (as shown in Table 2), and models that interact the post-ACA period with payment type (Supplemental Table 2) show similar results and indicate that women were more likely to self-pay for IPV-related services before the enactment of the ACA. One hypothesis for this finding is that insurance companies could deny, cancel, exclude, and increase health insurance premiums for preexisting conditions such as IPV before the ACA (
      • Shaw F.E.
      • Asomugha C.N.
      • Conway P.H.
      • Rein A.S.
      The Patient Protection and Affordable Care Act: Opportunities for prevention and public health.
      ). This situation changed with the enactment of the 2014 ACA provision that prohibits insurance from engaging in any form of discrimination based on IPV victimization (
      • Shaw F.E.
      • Asomugha C.N.
      • Conway P.H.
      • Rein A.S.
      The Patient Protection and Affordable Care Act: Opportunities for prevention and public health.
      ). Furthermore, many women gained insurance coverage under the expansion of Medicaid in certain states in 2014. Obtaining insurance could have made women more likely to seek care for physical injuries.

       Implications for Practice and/or Policy

      The results of the present study have implications for future research and policy. First, the increasing incidence of ED visits for IPV between 2002 and 2015 observed in the present study highlight that IPV is a significant health problem in the United States. However, it is not clear what changes have caused the increase. Future research should explore whether these changes are driven by increases in the severity of IPV incidence that require immediate attention from health care systems and professionals, such as changes in attitudes that lead to an increase in patient disclosures, and/or changes in reimbursement and coding practices. Second, our finding that there was a differential financial burden on IPV survivors for payment of ED-related visits relative to non-ED related visits before, but not after, ACA enactment highlights the importance of the ACA for women generally and IPV survivors in particular. Current presidential proposals and legal challenges to the ACA may lead to an environment where women and IPV survivors will have to disproportionately shoulder the cost of their victimization once again. Any future changes to health insurance policy must consider its effects on IPV survivors.

       Study Strengths and Limitations

      The present study's main strength is its use of hospital-level data that allowed for the examination of IPV-related injury secular trends between 2002 and 2015. The NHAMCS stratifies each primary sampling unit by socioeconomic and demographic variables, and via the use of a four-stage probability sample, enabled for the extrapolation of IPV-related injury national estimates by applying appropriate weights.
      As with all research, this study has some limitations. First, the NHAMCS codes patient visits, rather than individual patients. Women who visited the ED on more than one occasion were counted independently. Furthermore, the NHAMCS is an administrative dataset, and the determination of race and ethnicity is sometimes self-reported by the patient, inferred by staff observation, transferred from another hospital record, or inferred from the patient's surname. We cannot rule out the possibility that some patients' race and ethnicity were misclassified.
      Second, we acknowledge that the use of a limited set of ICD-9-CM codes to define IPV may have underestimated the magnitude of IPV-related ED visits, given that IPV is associated with a multitude of health conditions (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ). Furthermore, the present study examined cases of IPV that were severe enough to require immediate medical attention. Our data set likely does not include injuries treated in doctors' offices, walk-in clinics, and urgent care (e.g., sprains, strains, and headaches). Because women seek medical attention from a variety of providers (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • Stevens M.R.
      The national intimate partner and sexual violence survey: 2010 summary report.
      ,
      • Bonomi A.E.
      • Thompson R.S.
      • Anderson M.
      • Reid R.J.
      • Carrell D.
      • Dimer J.A.
      • Rivara F.P.
      Intimate partner violence and women’s physical, mental, and social functioning.
      ), future research should examine care utilization across medical settings with varying levels of charity care provision and Medicaid acceptance.
      Third, IPV injuries are rare events among all ED visits. Our analysis yielded 652 weighted cases out of 188,448 weighted ED visits. Logistics regression can underestimate the probability of such rare events, which may cause biases in estimated associations. However, our results were similar when we examined linear probability models that are not affected by the rarity of the events. Thus, we believe the results are valid.

      Conclusions

      This study examined IPV-related injuries that were severe enough to require immediate medical attention and found a 4.27% increase in the proportion of ED visits for IPV-related injuries between 2002 and 2015. Before the implementation of the ACA, women were more likely to pay out of pocket for IPV-related services. Our findings suggest that the implementation of the ACA may have reduced barriers to receiving medical care for IPV-related injuries.

      Supplementary Data

      References

        • Amaranto E.
        • Steinberg J.
        • Castellano C.
        • Mitchell R.
        Police stress interventions.
        Brief Treatment and Crisis Intervention. 2003; 3: 47
        • Beach S.R.
        • Carpenter C.R.
        • Rosen T.
        • Sharps P.
        • Gelles R.
        Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse.
        Journal of Elder Abuse & Neglect. 2016; 28: 185-216
        • Bell C.C.
        • Mattis J.
        The importance of cultural competence in ministering to African American victims of domestic violence.
        Violence Against Women. 2000; 6: 515-532
        • Benson M.L.
        • Fox G.L.
        • DeMaris A.
        • Van Wyk J.
        Neighborhood disadvantage, individual economic distress and violence against women in intimate relationships.
        Journal of Quantitative Criminology. 2003; 19: 207-235
        • Black M.C.
        • Basile K.C.
        • Breiding M.J.
        • Smith S.G.
        • Walters M.L.
        • Merrick M.T.
        • Stevens M.R.
        The national intimate partner and sexual violence survey: 2010 summary report.
        National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 19, Atlanta, GA2011: 39-40
        • Bonomi A.E.
        • Anderson M.L.
        • Rivara F.P.
        • Thompson R.S.
        Health care utilization and costs associated with physical and nonphysical-only intimate partner violence.
        Health Services Research. 2009; 44: 1052-1067
        • Bonomi A.E.
        • Thompson R.S.
        • Anderson M.
        • Reid R.J.
        • Carrell D.
        • Dimer J.A.
        • Rivara F.P.
        Intimate partner violence and women’s physical, mental, and social functioning.
        American Journal of Preventive Medicine. 2006; 30: 458-466
        • Breiding M.J.
        Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization - National Intimate Partner and Sexual Violence Survey, United States, 2011.
        Morbidity and Mortality Weekly Report. Surveillance Summaries. 2014; 63: 1-18
        • Brokaw J.
        • Fullerton-Gleason L.
        • Olson L.
        • Crandall C.
        • McLaughlin S.
        • Sklar D.
        Health status and intimate partner violence: A cross-sectional study.
        Annals of Emergency Medicine. 2002; 39: 31-38
        • Btoush R.
        • Campbell J.C.
        • Gebbie K.M.
        Care provided in visits coded for intimate partner violence in a national survey of emergency departments.
        Women's Health Issues. 2009; 19: 253-262
        • Btoush R.
        • Campbell J.C.
        • Gebbie K.M.
        Visits coded as intimate partner violence in emergency departments: Characteristics of the individuals and the system as reported in a national survey of emergency departments..
        Journal of Emergency Nursing. 2008; 34: 419-427
        • Caetano R.
        • Schafer J.
        • Cunradi C.B.
        Alcohol-related intimate partner violence among white, black, and Hispanic couples in the United States. Domestic Violence: The Five Big Questions.
        Routledge, New York, NY2017: 145-153
        • Catalano S.M.
        Intimate partner violence, 1993–2010.
        U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Washington, DC2012
        • Catalano S.M.
        Intimate Partner Violence–Attributes of Victimization, 1993--2011.
        U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Washington, DC2013
        • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
        Intimate partner violence: Consequences.
        (Available:)
        • Cho H.
        Racial differences in the prevalence of intimate partner violence against women and associated factors.
        Journal of Interpersonal Violence. 2012; 27: 344-363
        • Clark K.A.
        • Biddle A.K.
        • Martin S.L.
        A cost–benefit analysis of the Violence Against Women Act of 1994.
        Violence Against Women. 2002; 8: 417-428
        • Coker A.L.
        • Smith P.H.
        • Bethea L.
        • King M.R.
        • McKeown R.E.
        Physical health consequences of physical and psychological intimate partner violence.
        Archives of Family Medicine. 2000; 9: 451
        • Crockett C.
        • Brandl B.
        • Dabby F.C.
        Survivors in the margins: The invisibility of violence against older women.
        Journal of Elder Abuse & Neglect. 2015; 27: 291-302
        • Cunradi C.B.
        • Caetano R.
        • Schafer J.
        Socioeconomic predictors of intimate partner violence among White, Black, and Hispanic couples in the United States.
        Journal of Family Violence. 2002; 17: 377-389
        • Duplessis V.
        • Levenson R.
        Integrating health services into domestic violence programs: Tools for advocates.
        Futures Without Violence, San Francisco, CA2014
        • Dugan L.
        • Nagin D.S.
        • Rosenfeld R.
        Explaining the decline in intimate partner homicide: The effects of changing domesticity, women's status, and domestic violence resources.
        Homicide Studies. 1999; 3: 187-214
        • Dugan L.
        • Nagin D.S.
        • Rosenfeld R.
        Exposure reduction or retaliation? The effects of domestic violence resources on intimate-partner homicide.
        Law & Society Review. 2003; 37: 169-198
        • Ernst A.A.
        • Nick T.G.
        • Weiss S.J.
        • Houry D.
        • Mills T.
        Domestic violence in an inner-city.
        Annals of Emergency Medicine. 1997; 30: 190-197
        • Fishman P.A.
        • Bonomi A.E.
        • Anderson M.L.
        • Reid R.J.
        • Rivara F.P.
        Changes in health care costs over time following the cessation of intimate partner violence.
        Journal of General Internal Medicine. 2010; 25: 920-925
        • Fox G.L.
        • Benson M.L.
        • DeMaris A.A.
        • Van Wyk J.
        Economic distress and intimate violence: Testing family stress and resources theories.
        Journal of Marriage and Family. 2002; 64: 793-807
        • Fromson T.
        • Durborow N.
        Insurance Discrimination Against Victims of Domestic Violence.
        Pennsylvania Coalition Against Domestic Violence, Harrisburg2016
        • Gerino E.
        • Caldarera A.M.
        • Curti L.
        • Brustia P.
        • Rollè L.
        Intimate partner violence in the golden age: Systematic review of risk and protective factors.
        Frontiers in Psychology. 2018; 9: 1595
        • Hampton R.
        • Oliver W.
        • Magarian L.
        Domestic violence in the African American community: An analysis of social and structural factors.
        Violence Against Women. 2003; 9: 533-557
        • Harris S.B.
        For better or for worse: Spouse abuse grown old.
        Journal of Elder Abuse & Neglect. 1996; 8: 1-33
        • Hux K.
        • Schneider T.
        • Bennett K.
        Screening for traumatic brain injury.
        Brain Injury. 2009; 23: 8-14
        • Jones A.S.
        • Dienemann J.
        • Schollenberger J.
        • Kub J.
        • O’Campo P.
        • Gielen A.C.
        • Campbell J.C.
        Long-term costs of intimate partner violence in a sample of female HMO enrollees.
        Women's Health Issues. 2006; 16: 252-261
        • Karlsen S.
        • Nazroo J.Y.
        Relation between racial discrimination, social class, and health among ethnic minority groups.
        American Journal of Public Health. 2002; 92: 624-631
        • Kim H.K.
        • Laurent H.K.
        • Capaldi D.M.
        • Feingold A.
        Men’s aggression toward women: A 10-year panel study.
        Journal of Marriage and Family. 2008; 70: 1169-1187
        • Lacey K.K.
        • West C.M.
        • Matusko N.
        • Jackson J.S.
        Prevalence and factors associated with severe physical intimate partner violence among US Black women: A comparison of African American and Caribbean Blacks.
        Violence Against Women. 2016; 22: 651-670
        • Lee L.K.
        • Chien A.
        • Stewart A.
        • Truschel L.
        • Hoffmann J.
        • Portillo E.
        • Galbraith A.A.
        Women’s coverage, utilization, affordability, and health after the ACA: A review of the literature: A literature review of evidence relating to the Affordable Care Act’s impact on women’s health care and health.
        Health Affairs. 2020; 39: 387-394
        • Lipsky S.
        • Caetano R.
        • Field C.A.
        • Bazargan S.
        The role of alcohol use and depression in intimate partner violence among black and Hispanic patients in an urban emergency department.
        The American Journal of Drug and Alcohol Abuse. 2005; 31: 225-242
        • Max W.
        • Rice D.P.
        • Finkelstein E.
        • Bardwell R.A.
        • Leadbetter S.
        The economic toll of intimate partner violence against women in the United States.
        Violence and Victims. 2004; 19: 259
        • National Center for Injury Prevention and Control
        Costs of Intimate partner violence against women in the United States.
        Centers for Disease Control and Prevention, Atlanta2003
        • Oehme K.
        • Stern N.
        The case for mandatory training on screening for domestic violence in the wake of the affordable care act.
        (University of Pennsylvania Journal of Law and Social Change, 17, 1)2014
        • Quigley B.M.
        • Leonard K.E.
        Desistance of husband aggression in the early years of marriage.
        Violence and Victims. 1996; 11: 355
        • Reeve M.
        • Institute of Medicine (U.S.)
        The impacts of the Affordable Care Act on preparedness resources and programs: Workshop summary.
        National Academies Press, Washington, DC2014
        • Rivara F.P.
        • Anderson M.L.
        • Fishman P.
        • Reid R.J.
        • Bonomi A.E.
        • Carrell D.
        • Thompson R.S.
        Age, period, and cohort effects on intimate partner violence.
        Violence and Victims. 2009; 24: 627
        • Rovi S.
        • Johnson M.S.
        Physician use of diagnostic codes for child and adult abuse.
        Journal of the American Medical Women's Association (1972). 1999; 54: 211-214
        • Rudman W.
        Coding and documentation of domestic violence.
        Family Violence Prevention Fund. 2000; : 1-20
        • Schneider D.
        • Harknett K.
        • McLanahan S.
        Intimate partner violence in the Great Recession.
        Demography. 2016; 53: 471-505
        • Sev’er A.
        • Dawson M.
        • Johnson H.
        Lethal and nonlethal violence against women by intimate partners: Trends and prospects in the United States, the United Kingdom, and Canada.
        Violence Against Women. 2004; 10: 563-576
        • Shaw F.E.
        • Asomugha C.N.
        • Conway P.H.
        • Rein A.S.
        The Patient Protection and Affordable Care Act: Opportunities for prevention and public health.
        Lancet. 2014; 384: 75-82
        • Smith S.G.
        • Basile K.C.
        • Gilbert L.K.
        • Merrick M.T.
        • Patel N.
        • Walling M.
        • Jain A.
        National Intimate Partner and Sexual Violence Survey (NISVS): 2010–2012 state report.
        National Center for Injury Prevention and Control, Centers for Disease Control and Prevention., Atlanta, GA2017
        • Stockman J.K.
        • Hayashi H.
        • Campbell J.C.
        Intimate partner violence and its health impact on ethnic minority women.
        Journal of Women's Health. 2015; 24: 62-79
        • Thompson R.S.
        • Bonomi A.E.
        • Anderson M.
        • Reid R.J.
        • Dimer J.A.
        • Carrell D.
        • Rivara F.P.
        Intimate partner violence: Prevalence, types, and chronicity in adult women.
        American Journal of Preventive Medicine. 2006; 30: 447-457
        • Tjaden P.
        • Thoennes N.
        Full report of the prevalence, incidence, and consequences of violence against women (NCJ 183781).
        National Institute of Justice, Office of Justice Programs, Washington, DC2000
        • Truman J.
        • Morgan R.
        Criminal victimization, 2015.
        U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Washington, DC2016
        • Weiss H.B.
        • Ismailov R.M.
        • Lawrence B.A.
        • Miller T.R.
        Incomplete and biased perpetrator coding among hospitalized assaults for women in the United States.
        Injury Prevention. 2004; 10: 119-121
        • West C.M.
        Domestic violence in ethnically and racially diverse families.
        Domestic Violence at the Margins: Readings on Race, Class, Gender, and Culture. 2005; : 157-173
        • Yan E.
        • Chan K.L.
        Prevalence and correlates of intimate partner violence among older Chinese couples in Hong Kong.
        International Psychogeriatrics. 2012; 24: 1437-1446
        • Zink T.
        • Fisher B.S.
        • Regan S.
        • Pabst S.
        The prevalence and incidence of intimate partner violence in older women in primary care practices.
        Journal of General Internal Medicine. 2005; 20: 884

      Biography

      Tatiana L. Mariscal, MS, is a Lecturer who uses her academic background in movement science and public health to explore the health determinants associated with intimate partner violence among the underserved female population in the U.S and developing countries.

      Biography

      Charmayne M.L. Hughes, PhD, uses her background in motor control neuroscience and engineering to elucidate the impact of violence and trauma on underlying neurocognitive and neuromotor functioning, and to develop technological solutions that benefit resource-constrained and vulnerable populations.

      Biography

      Sepideh Modrek, PhD, is an assistant professor of Health Economics at the Health Equity Institute at San Francisco State University. Her research examines social determinants and structural inequities that impact health outcomes.