Secondary prevention of domestic violence in HMO primary care: Evaluation of alternative implementation strategies

Objectives: To compare the effectiveness of 2 system-level multifaceted quality improvement approaches to enhancing the secondary prevention of domestic violence (DV) in health maintenance organization (HMO) primary care settings. Study Design: A "2 new interventions" pre/post design that compared a basic implementation strategy using current staff levels with an augmented basic strategy that added a paid part-time role for medical office social workers as DV social change agents. Methods: Comparison of pre-/postimplementation changes in clinicians' DV-related knowledge, attitudes, and self-reported practices (KAP) and rates of inquiry about DV with female patients. Study outcomes were measured in surveys of primary care clinicians and women aged 18 to 45 years who had recent appointments with them. Results: Both strategies resulted in significant improvements in rates of clinician inquiry about DV and in most clinician KAP measures, but only 2 clinician KAP measures showed significantly greater improvement in the augmented strategy arm. Conclusions: Our finding that substantial sustainable improvement in secondary prevention of DV in primary care is feasible in an HMO primary care setting using existing organizational mechanisms and current staff levels should be encouraging to other such organizations considering undertaking similar initiatives. Our findings support viewing clinician behavior change as a process of organizational cultural change to be undertaken over the long term using multifaceted implementation strategies that employ techniques consistent with accepted theories of behavior change. They also emphasize the need to investigate and address the special barriers to screening that apparently exist in the pediatric setting.