Background: Approximately 25% women experience intimate partner violence (IPV) during the perinatal (pregnancy through 24 months postpartum) period. Most physical IPV involves blows to the head, face, and neck and/or episodes of strangulation, which could result a brain injury (BI). These BIs tend to be mild, occur repetitively over the course of months or years, are remote in time, and result in chronic symptoms and psychopathological comorbidities. Pregnancy and childbirth could be a time of vulnerability to violence because of changes in physical, emotional, social, and economic demands and needs. Perinatal IPV (P-IPV) may impact the health of the child bearer, developing fetus, and post-birth child. The prevalence of physical P-IPV has not been recently explored. Therefore, the primary objective of this review was to describe the prevalence of physical P-IPV during the perinatal period. Secondarily, we wished to determine the probable linkage between the physical P-IPV and BI based on the available literature.

Methods: Medline (PubMed), Embase, CINAHL and PsycINFO were searched (2000 - 2023) using the PIO (Population, Issue, Outcome) model, MeSH terms, and Boolean operators (AND, OR). Studies that described the prevalence of IPV during the perinatal period were included. Reviews, meta-analysis, case study/reports, and qualitative studies were excluded. Forest plots were generated to summarize the effect size-weighted averages for prevalence and visualize the prevalence of physical P-IPV findings.

Results: In total, 55 articles were included in the review. The effect size-weighted average prevalence of physical IPV during pregnancy was 13.5% (n= 48) and during the postpartum period was 18.3% (n= 16). Insufficient data was available to calculate the prevalence of physical P-IPV across the entire perinatal period (pregnancy and 24 months postpartum) as only one study included in the review measured physical P-IPV across the entire period (prevalence= 3.8%). The effect size-weighted average prevalence of physical IPV was highest in Africa during pregnancy (average 17.9%, n= 25), and was highest in Asia during the post-partum period (average 30.3%, n= 6). Similarly, the effect size-weighted average prevalence of physical IPV was highest in low-income countries during pregnancy (average 18.0%, n= 18) whereas it was highest in lower middle-income countries during the post-partum period (average 31.0%, n= 6).

Discussion and Conclusions: The prevalence of physical P-IPV remains a looming threat to child bearer, fetal, and early childhood health. Given the > 80% prevalence of IPV-BI among survivors of physical IPV, further research that directly examines the possibility that BI is also occurring in the perinatal population should be undertaken to uncover the true prevalence and impact of perinatal IPV-BI, prevent P-IPV, and improve the response to P-IPV and perinatal IPV-BI.

Introduction: Complex biopsycho-ecological concerns are increasingly being attended to by paramedics. Intimate partner violence (IPV) is an ongoing and persistent public health pandemic with damaging health sequela. This complex clinical circumstance frequently co-occurs with IPV-caused traumatic brain injury (IPV-TBI) in the majority of survivors of physical IPV, harmfully extending health detriments. It is unknown if the current services provided by paramedics and paramedic service organizations meet the ranging and versatile needs of survivors of IPV and if they account for IPV-TBI.

Objectives: Explore the experiences of survivors of IPV who have been attended to by paramedics.

Methods: Semi-structured qualitative video interviews with self-identified women who experienced IPV and were attended to by paramedics in western Canada were designed, conducted, and analyzed using an interpretive description approach for applied disciplines. Interviews discussed the survivors’ experiences with IPV, services received from paramedics, barriers and facilitators to receiving services, and desired services and practices. Verbatim transcripts were de-identified, categorized, reviewed, and mobilized into relevant challenges and corresponding survivor-derived solutions to service delivery deficits (NVivo).

Results: Nine survivors of IPV (Race - White 6/9 (67%), Asian 1/9 (11%), Black 1/9 (11%), Not Listed 1/9 (11%); Age 37±10 years) participated in interviews. Survivors reported that they encountered paramedics after experiencing IPV (overall IPV history (multiselect): physical 9/9 (100%), emotional 8/9 (89%), sexual 7/9 (78%), stalking 5/9 (56%), not listed 3/9 (33%)). All survivors reported signs and symptoms consistent with enduring an IPV-TBI following bouts of physical IPV, commonly at repeated timepoints and including bouts of non-fatal strangulation. Common challenges survivors faced when being attended to by paramedics included 1) a lack of trauma-informed and IPV-aware care by paramedics, 2) insufficient service pathways available to survivors, 3) disadvantageous social determinants of health impacting care, 4) insufficient infrastructure to address complex cases and multidisciplinary challenges, including consideration for co-presentation with trauma responses, IPV-TBI, mental health conditions, and/or substance use. Corresponding solutions for paramedics and paramedic service organizations included 1) having paramedics recognize IPV and provide an appropriate trauma-informed response supported by mandatory education and training, 2) having paramedic service organizations develop, sustain, and continuously improve divergent service pathways for survivors during conveyance and non-conveyance, 3) prioritize health equity efforts specifically targeting related social determinants of health, and 4) develop collaborative interagency infrastructure to support continued multimodal and holistic service access for survivors.

Conclusions: These survivor-identified challenges and corresponding solutions begin to provide guidance to overcome key service delivery deficits for those accessing services through paramedics. Adequate paramedic service delivery requires advancements to develop functional pathways across a spectrum of patient needs. Formal implementation science is warranted to develop parallel education, training, and infrastructure to positively effect paramedic service access for survivors of IPV.

Background: Intimate partner violence (IPV) is a pattern of physical violence, sexual violence, stalking, and/or psychological harm with coercive control. These violent events often include injuries to the head, face, and neck and therefore can also result in brain injury (BI). Despite the high incidence of IPV-BI, there has been relatively little quantitative analysis on the associations between IPV-BI and its resulting pathophysiological and psychopathological sequelae including changes to balance and postural control. From a biomechanical perspective, maintenance of upright posture during quiet-stance relies on the whole-body centre-of-mass (COM) falling within the limits of the base of support. To accomplish this, adjustments in the underfoot centre-of-pressure (COP) are used to guide the COM towards equilibrium. Larger and/or faster movements of the COP represent a worsening of postural control. The purpose of this study was to characterize different aspects of postural stability to determine the effect of IPV-BI on quiet stance postural control. It was hypothesized that quiet stance postural control would be impaired with worsening severity of IPV-BI.

Methods: The participants in this study were recruited from local community partner sites if they had at least one reported incidence of IPV (n = 40). IPV-BI was assessed using the Brain Injury Severity Assessment (BISA) tool, a semi-structured interview used to characterize BI exposure resulting from impacts targeting the head, face, and neck, and non-fatal strangulation that resulted in alterations of consciousness during episodes of IPV. During testing, participants completed one 60-second quiet stance trial for each of two conditions (eyes-open and eyes-closed). Force plate data was sampled at 1000 Hz and filtered with a dual-pass, 4th-order, low pass digital Butterworth filter using a 10 Hz cut-off frequency. Ground reaction forces and moments were recorded by the force plate in the X (mediolateral; ML) and Y (anteroposterior; AP) directions relative to the center of the plate. COP profiles were used to calculate measures of postural steadiness (amplitude, variability, and velocity) as well as total COP area.

Results: Results of a two-way repeated measures ANOVA showed significant main effect of BISA Score on COP area (p = 0.031), ML-Amp (p = 0.012), and ML-Var (p = 0.015).

Discussion: This study provides one of the first examinations of balance control in women who have experienced IPV-BI. Total COP area, ML-Amplitude, and ML-Variability worsened with more exposure to IPV-BI. These results align with results of other studies reporting that individuals with acute concussion and collegiate athletes with a history of concussion present with persistent, chronic balance impairments. These results underscore the complexity of the relationship between IPV-BI and postural control, highlighting the need for further research to elucidate the underlying mechanisms and potential factors influencing postural stability in this population.

Introduction: Intimate partner violence (IPV) most often affects women and has significant consequences on their physical and mental health. Many women survivors of IPV experience traumatic brain injuries (TBIs) and potential hypoxic-ischemic brain injuries due to nonfatal strangulation. Limited prior research has examined cognitive functioning following IPV-related TBI, finding worse performances on tests of executive functions and memory associated with the injury. This study employed a case-control design to compare women survivors of IPV with and without IPV-related TBI on subjective and objective cognitive outcomes, hypothesizing that women with IPV-related TBI would report more cognitive concerns and perform worse on cognitive tests.

Method: Women survivors of IPV were recruited from domestic violence shelters, IPV service organizations, and the local community in Kentucky. Women with 2 or more IPV-related TBIs (n=33; M=36.5±9.4 years-old; 63.6% White) were compared to women survivors without IPV-related TBI history (n=22; M=34.4±10.3 years-old; 77.3% White) on the Neurological Quality-of-Life (Neuro-QoL) Cognitive Function questionnaire, Rey Auditory Verbal Learning Test (RAVLT), and the NIH Toolbox Cognition Battery (NIHTB-CB). Women also completed the Posttraumatic Stress Disorder (PTSD) Checklist-5 (PCL-5) and questions on pain frequency and duration, screening for PTSD and chronic pain, respectively.

Results: Women with repetitive IPV-related TBIs screened positive for elevated cognitive concerns (81.8%) more often that women without IPV-related TBI (50.0%), with a large group difference in severity of cognitive concerns (one-tailed p=.006, d=0.71). Women with IPV-related TBIs performed worse on cognitive tests, with lower scores on RAVLT total learning (Trials 1-5) (p=.045, d=0.47) and delayed memory (p=.034, d=0.51) and reduced fluid cognition on the NIHTB-CB per the Crystallized-Fluid Composite T-score difference (p=.035, d=-0.51). The largest group differences on individual NIHTB-CB tests were observed for executive functions, specifically the Dimensional Change Card Sort (p<.001, d=-1.01). Adjusted analyses controlled for positive PTSD and chronic pain screens as covariates, finding the RAVLT total learning no longer significantly differed between groups (p=.070, partial η²=0.05), whereas the RAVLT delayed memory (p=.025, partial η²=0.08), NIHTB-CB Crystallized-Fluid Composite T-Score Difference (p=.012, partial η²=0.10), and the Dimensional Change Card Sort test score (p<.001, partial η²=0.24) remained significantly worse among women with repetitive IPV-related TBI.

Discussion: In alignment with our hypothesis, repetitive IPV-related TBIs were associated with greater cognitive concerns and worse objective cognitive test performances. The group differences associated with IPV-related TBI were not fully attributable to comorbid PTSD or chronic pain. These results indicate that women with IPV-related TBIs experience unaddressed cognitive health needs that may benefit from assessment and intervention. These results require replication in larger samples recruited from broader geographical regions with more demographic diversity.

Introduction: Globally, one in three women experience intimate partner violence (IPV). The injuries to the head, neck, or face common in physical IPV confer high risk for IPV-related head trauma (IPV-HT), or probable brain injury (IPV-BI). Researchers have hypothesized that both past and current stressors can impact brain functioning and promote persistent functional difficulties after HT and BI. Understanding how past stressors, such as adverse childhood experiences (ACEs; e.g., abuse, neglect, and challenges within the household), may affect cognition, neurobehavioral symptoms, and posttraumatic stress disorder (PTSD) symptom burden among individuals who have experienced IPV-HT is essential for screening and improving the prognostic accuracy.

Methods: For a broader study, 98 women (aged 19-59 years) with a history of exposure to IPV-HT completed self-reported measures: 1) ACEs 10-item questionnaire, 2) Brain Injury Screening Questionnaire IPV Module (BISQ-IPV), 3) Rivermead Post-Concussion Symptoms Questionnaire (RPQ), 4) Neuro-QoLTM (Quality of Life in Neurological Disorders) Cognition v2, 5) PTSD Checklist for DSM-5 (PCL-5), and 6) Conflict Tactics Scale Revised (CTS2). Questions from the BISQ-IPV probing loss of consciousness or feeling dazed/confused after HT were used to determine severity, per American Congress of Rehabilitation Medicine guidelines, and time since most recent IPV-HT injury. Total RPQ score determined neurobehavioral symptom severity. Neuro-QoL Cognition T-score determined perceived difficulty in cognitive abilities. Total PCL-5 score determined PTSD symptom severity. CTS2 determined severity of IPV in the past year. We constructed separate linear regressions to determine the effect of total ACEs and IPV-HT severity on 1) RPQ total score, 2) Neuro-QoL T-score, 3) PCL-5 total score, while adjusting for past year IPV exposure (CTS2), time since most recent IPV-HT injury, and age.

Results: Greater total ACEs score predicted higher RPQ total score (p<0.001), lower Neuro-QoL Cognition T-score (p=0.002), and higher PCL-5 total score (p=0.004). Greater IPV-HT severity only predicted higher RPQ total score (p<0.001).

Discussion: Both greater exposure to ACEs and IPV-HT severity were significant predictors of neurobehavioral symptoms. However, only greater ACEs were significantly associated with more perceived difficulty with cognition and greater PTSD symptom burden among women with a history of IPV-HT. Previous work has shown that heightened baseline mental health concerns (e.g., increased PTSD symptom severity) increase the risk for greater, and persistent, functional difficulties after BI. Thus, it is possible that ACEs place individuals at higher risk for greater neurobehavioral symptoms and cognitive difficulties due to their potential influence on brain development, stress responses and PTSD symptoms. Future work should explore the relationship between ACEs, neurobehavioral, and PTSD symptoms among individuals with IPV exposure longitudinally to demonstrate any causal relationships.

Background: Global estimates suggest one in three women will experience intimate partner violence (IPV). Recent Canadian statistics suggest IPV impacts 44% of Canadian women. Physical violence from IPV is often concentrated on the head, face, and neck, including strangulation, which puts survivors at high risk of both traumatic and hypoxic brain injury (BI). Independently, both BI and IPV have significant and long-lasting impacts, including an elevated risk of mental health challenges (MH). A recent scoping review exploring the intersection of these concerns identified higher rates of MH among IPV survivors with BI than those without yet noted a dearth of research exploring these experiences and their impacts on care. This research addressed this noted gap.

Methods: Interpretive description methodology, involving semi-structured individual and group interviews, explored two research questions:
1) What are the BI- and MH-related needs and experiences of IPV survivors?
2) What are barriers and facilitators to providing/receiving appropriate care for IPV survivors with BI and MH concerns?
24 participants (aged 18+) were recruited across Canada using purposeful sampling. Participants included women survivors of IPV (n=6), executive directors/program managers (n=5), frontline workers (n=7), and employers (n=6). Interviews were conducted in English via Zoom, lasted approximately 60-90 minutes, and were audio recorded. Recordings were transcribed by a professional transcription service, quality checked by the research team, and analyzed using reflexive thematic analysis as described by Braun and Clarke. Andersen’s Behavioural Model of Health Service Use helped guide the analysis.

Findings: Several themes were developed through thematic analysis, reported in two published manuscripts. Survivors spoke of IPV, BI, and MH as a “whole big ball of all-togetherness” that had impacts far beyond their relationship. They shared that finding appropriate care was like a full-time job and emphasized the importance of connecting to other survivors. Providers noted the importance of recognizing all three facets of a survivor’s experience (IPV, BI, MH) to provide better support. They emphasized the need for flexibility and a “toolbox full of strategies” to support survivors, as well as the benefits of connecting and collaborating across sectors to address challenges outside of their own expertise. Findings were used to develop a mental health module on the Abused and Brain Injured Toolkit (www.abitoolkit.ca/supporting-survivors/mental-health-and-brain-injury/) and actionable recommendations for providers.

Conclusions: This project addresses a critical gap in understanding the impact of IPV, BI, and MH on healthcare-related needs and experiences. It is the first investigation of its kind in Canada, and among the first globally, providing insights, resources, and practical solutions to better support IPV survivors with BI and MH.

Background: Globally, one in three women will experience intimate partner violence (IPV) over their lifetime. Physical violence during IPV can cause neurological deficits, loss of consciousness, and brain injury (BI). IPV and BI are associated with elevated rates of unemployment, poverty, and homelessness, as well as increased mental health challenges. These social determinants of health impact women’s wellbeing through access to safe accommodations, food security, and disability supports, leaving them vulnerable to ongoing violence and permanent disability.
This qualitative study (1) explored the intersection of intimate partner violence-related brain injury (IPV-BI) and employment; (2) identified support needs, priorities, facilitators, and barriers to service delivery; and (3) generated recommendations for improved outcomes.

Methods: Qualitative, semi-structured interviews lasting 60-90 minutes were conducted exploring: (a) survivors’ experiences of work; (b) perceived employment-related support needs; (c) existing support programs, policies, and practices; (d) valued characteristics of healthcare and social support services; and (e) systemic challenges to employment. Participants were purposively recruited from a national informal IPV-BI network, or through snowball sampling. Twenty-four individuals participated: six women survivors, six executive director/program managers, seven direct service providers, and five employer/union representatives. Interviews were audio-recorded and transcribed verbatim. Ethical approval was granted by University of Toronto and Wilfrid Laurier University Research Ethics Boards.

Findings: Using a qualitative, thematic analysis approach, descriptive codes were attached and then grouped into broad, topic-oriented categories. Memoing, reflexivity, and triangulation were used to enhance rigour. Trustworthiness was maintained through debriefing, analyst triangulation, regular meetings to discuss and ensure code consistency, and development of an audit trail. Findings include the extraordinary level of complexity within the intersection of IPV-BI itself, the impact of a socially derived culture of shame and stigma that shapes the experience of IPV-BI, and the recognition/consideration of the complex layers of power that survivors are exposed to, both structural and individual. Micro level findings present the lived experiences of women survivors, the importance of work, and practical challenges to obtaining and/or maintaining employment. They also explore what is working and what support professionals can do to improve outcomes. Findings were used to develop a module detailing employment needs and solutions on the Abused and Brain Injured Toolkit (www.abitoolkit.ca) and recommendations for practice and policy.

Conclusion: This project addresses a critical gap in understanding the impact of IPV-BI on employment experiences. It is the first investigation of its kind globally, providing insights, resources, and practical solutions to better support women exposed to IPV-BI.

Introduction: According to the World Health Organization, one in three women worldwide will experience physical or sexual violence in their lifetime. In Canada, among women victims of intimate partner violence (IPV), 42% suffer physical injuries, most commonly to the head and neck. These women are at high risk of traumatic brain injury (TBI) which remains undiagnosed and untreated, limiting access to essential care. The main objectives of this project were to describe an initial experience of integrating occupational therapy (OT) student placements in shelters for women victims of IPV and traumatic brain injury to explore the obstacles encountered as well as potential solutions to overcome them.

Methods: This study adopted a research-intervention approach. Four occupational therapy students participated in a 12-week research internship across four shelters in Quebec, Canada. Workshops and training sessions were provided to both shelter staff and women victims of IPV on the topic of the intersection between IPV and TBI. Students screened women victims of IPV for possible TBI using the HELPS tool. For those with a positive screening, OT services were provided. Each student kept a journal that was later analyzed using qualitative content analysis to identify the obstacles and potential solutions to integrating OT services in women's shelters.

Results: Thirty-four shelter staff members and 47 women survivors of IPV participated in TBI awareness activities. Of the 31 women screened using the HELPS tool,19 (66%) tested positive for possible TBI. Sixteen women received follow-up OT services tailored to each woman's specific needs, focusing on enhancing independence in activities of daily living. Analysis of the students' journals identified five obstacles to integrating OT services: 1) mental health challenges; 2) limited accessibility and availability of women; 3) limited collaboration of survivors during the OT process; 4) risks related to case documentation and women's safety; 5) lack of staff knowledge about TBI and its functional impacts. Proposed solutions included 1) training OT professionals and students on the mental health effects of IPV and TBI; 2) adapting assessment tools to fit the IPV context; 3) offering more flexible service hours and integrating OT professionals into the shelter teams to encourage engagement; and 4) building trust with survivors and establishing clear guidelines for OT care, with additional time allotted to understand each woman's background.

Conclusions: This project provided valuable insights into the challenges of integrating OT TBI services in shelters for women affected by IPV. It underscored the importance of collaboration between shelter staff and OT professionals and highlighted the need for specialized care for TBI. The findings lay the groundwork for future efforts to improve the quality of care for women survivors of IPV and TBI, with further collaborations anticipated to address ongoing needs.