Abstract
Background: Periodic universal screening for anxiety and for intimate partner violence (IPV) for women and adolescent girls are national clinical practice recommendations. However, screening rates in primary care settings are low. This study aimed to increase awareness and adoption of screening for anxiety and for IPV in women and adolescent girls by identifying screening barriers and facilitators to inform clinical resource development.
Methods: Two-phase, qualitative study using semistructured interviews to identify screening barriers and facilitators; thematic analysis of interview data using a rapid evaluation approach.
Results: Twenty-seven clinicians and staff members were interviewed in 12 clinics in 2 primary care networks in Oregon. All participants recognized the importance of screening in primary care settings but were generally unaware of screening recommendations and insurance coverage and were unsure of their clinic’s policies and practices, citing a lack of protocols for referrals for positive screens. Barriers to both anxiety and IPV screening included screening fatigue, lack of metrics, uncertain documentation and reporting, and unclear referral and follow-up procedures. For IPV screening specifically, barriers included discomfort with screening, privacy concerns, and perceived low occurrence. Facilitators for both services included leveraging existing screening practices and electronic health record tools, and clear recommendations for universal screening best practices.
Conclusion: Implementation of routine screening for anxiety and IPV in women and adolescents in primary care is low but may improve with targeted clinician resources and education. Workflow diagrams and resource guides responsive to identified screening barriers and facilitators, including clarification of insurance coverage for preventive services, and resources to support implementation of protocols of screening methods, clinical documentation, and referrals for anxiety and IPV in primary care settings, could improve screening practices.
- Anxiety
- Health Policy
- Intimate Partner Violence
- Insurance Coverage
- Interpersonal Violence
- Mental Health
- Oregon
- Preventive Health Services
- Primary Health Care
- Quality Improvement
- Referral and Consultation
- Women's Health
Introduction
Periodic universal screening for anxiety and for intimate partner violence (IPV) for women and adolescent girls aged 13 years and older are national clinical practice recommendations.1–4 They are based on evidence of effectiveness5–8 and supported by the Health Resources and Services Administration (HRSA) for coverage by most insurance plans under the preventive services mandate of the Affordable Care Act (ACA).9 Although anxiety and IPV are recognized as significant public health problems that disproportionately affect women,10–12 routine screening in primary care practice is not widely delivered.
Benefits of universal screening are supported by indirect evidence of effectiveness in reducing adverse health outcomes.7,13–15 While several barriers to anxiety and IPV screening have been identified in previous studies,16–19 including time constraints, concerns about patient privacy and safety, inadequate training, and lack of support resources for patients who screen positive,20 it remains unclear how to support screening in clinical practice.
The goal of this project was to increase awareness and adoption of universal screening for anxiety and for IPV for women and adolescent girls–two, separate, HRSA-supported recommendations developed by the Women’s Preventive Services Initiative (WPSI). These preventive services were selected because they are unique to the WPSI and either predated other recommendations (anxiety screening)1,3 or are more expansive than existing recommendations (IPV screening)4,21 and provided an opportunity to focus on the specific impact of HRSA-recommended preventive services for women. This report describes the methods and results of a two-phase, qualitative research project to identify current practices for screening for anxiety and IPV in primary care settings and describe barriers to and facilitators of screening. Findings from this qualitative research informed the development of clinical support materials to improve adoption of anxiety and IPV screening in primary care practice (Figures 1 and 2).
Screening for anxiety and depression workflow diagram.
Screening for Intimate Partner Violence (IPV) workflow diagram.
Methods
This qualitative study was based on semistructured interviews of clinicians and staff in primary care clinics to 1) understand current screening practices, and 2) identify barriers and facilitators to implementing recommended preventive services to inform the development of clinical support materials. The protocol was approved by the Oregon Health & Science University (OHSU) Institutional Review Board (STUDY00025057).22
Setting
This project included 27 clinicians and staff from 12 clinics in 2 primary care clinical networks in Oregon, the Oregon Rural Practice-based Research Network (ORPRN) and the OHSU and Hillsboro Medical Center (HMC) health system.23,24 Networks included different primary care settings that varied by affiliation, size, funding mechanism, location, and patient population (Table 1) and serve patients who represent a wide range of populations including those in urban and rural communities, Medicaid recipients, and adolescents receiving care at school-based health centers, among others.
Clinic and Participant Characteristics
Sampling and Recruitment
Participants were recruited between January and April 2023 from eligible clinics using a purposive recruitment strategy,25 based on variation in clinic size, type, location, and patient population. Clinicians and administrators or managers were contacted via e-mail and invited to participate and/or recommend clinic staff eligible for an interview about their clinic’s anxiety and IPV screening practices. Snowball sampling was used to identify additional clinic staff who could also respond to questions about screening practices.26
Data Collection
Twenty-seven semistructured key informant interviews were conducted to identify existing clinic practices, barriers, and facilitators for implementing anxiety and IPV screening. Interview questions were open-ended to collect participants’ input on clinic policies and workflows related to screening practices at the clinic and individual clinician level. Questions concerned multi-level barriers and facilitators to screening, how screening policies are created and approved at each clinic, desired resources to increase adoption of screening, and overall perception and impacts of screening for anxiety and IPV in the clinics (Table 2). The interview guide (see Supplement) was pilot tested with 1 clinician and revised based on feedback from participants to optimize wording and question sequence. Two master’s level research analysts (CB, TWL) with qualitative training and experience conducted interviews via teleconference with video, teleconference without video, or telephone, based on participant preference. Interviews were recorded with participants’ consent and lasted approximately 45 minutes. Interview data were transcribed using professional transcription software (Webex or Rev.com). The interviewers met regularly throughout data collection to assess gaps in responses and determine data saturation, specifically that no new findings or themes were emerging from continued data collection.27
Selection of Structured Interview Questions for Primary Care Clinicians and Staff (n = 27 Participant Interviews)
Data Analysis
Baseline clinical practices were examined through a thematic analysis using a rapid evaluation approach to inform the development of the interview guide.28 A qualitative analysis matrix (Table 3) was developed based on the interview guide for preliminary review of interview transcripts to categorize data and identify relevant patterns and themes. Matrix domains served as column headers and each individual interview was represented in its own row. Two qualitative analysts (CB, TWL) independently populated the matrix with transcript data from 2 interviews and reviewed each other’s responses for consistency. Transcript data were populated into matrix cells, organizing data for each interview into the respective domains of interest. Data were primarily copied directly from transcripts, but in some instances, summaries were used to optimize data management. The 2 analysts then completed the matrix for subsequent interview transcripts on a rolling basis as interviews were completed. Following completion of data entry from all interviews, analysts (CB, SLA, TWL) reviewed the matrix and created analytic memos to compare data across participants and identify patterns and emergent themes. Using a systematic and iterative process, patterns and themes were refined through a consensus forming approach, including identifying exemplary quotations. Final themes were reviewed and validated by all investigators through group discussion and consensus.
Rapid Qualitative Analysis Matrix Domains
Results
A total of 27 interviews were conducted at 12 clinics (4 clinics in the OHSU/HMC network and 8 clinics in the ORPRN network).
Current Screening Policies and Practices
As a preliminary step to understand existing practices, a review of current screening practices in a representative sample of eligible clinics was conducted to inform question development for the interview guide (see Supplement). In some cases, there was discordance between participants from the same clinic about which screening methods were used. There were no differences in screening protocols (ie, recommended frequency, tool, and procedure) within clinics for specific population groups (eg, male/female, adolescent/adult). For both preventive services, clinics used the same tool and screening protocol within the clinic for all adult patients. Clinics used the adolescent version of the screening tools for relevant populations but otherwise did not have different screening protocols for specific types of patients. All participants reported awareness of the importance of screening for anxiety and for IPV and identified the primary care setting as appropriate for screening, although they were often unaware of screening recommendations and ACA coverage.
Anxiety
Five of 12 clinics described having a universal anxiety specific screening practice because of patient populations with high rates of anxiety and/or the perception that this was an essential practice to provide quality care. When implemented, anxiety screening was conducted using the General Anxiety Disorder (GAD) screening tools, GAD-2 or GAD-7. Screening frequency, tool, and procedure did not differ for adult populations (eg, based on age, gender, or pregnancy status). The remaining 7 clinics used the GAD-729 for diagnostic purposes for patients who reported anxiety symptoms or used the GAD-2 for initial assessment of patients reporting symptoms. For clinics with a universal anxiety screening protocol, screening workflows were identified for in-person visits while few clinics had integrated universal screening for telehealth visits. For most respondents, screening for depression, which was routinely done in most clinics, was perceived as a proxy for anxiety screening, which was not routinely done. One participant described the overlap between depression and anxiety screening in the following quote:
“I feel like we kind of already do [screen for anxiety] by talking about the depression screen, because everybody well, not everybody, but almost everybody has a score other than 0” -Medical Director, T1C
Intimate Partner Violence
Nine of 12 clinics described some type of universal screening for IPV, but respondents were generally unsure of current clinic-wide policies and practices. Like anxiety screening, IPV screening frequency, tool, and procedure were the same within a clinic for all adult populations. A variety of screening approaches were used for IPV screening. Most clinics describing a universal screening approach with a brief screening tool for IPV as a part of another screening tool (eg, social needs assessment, behavioral assessment, annual wellness questions, or health history questions). Screening approaches ranged from forms available in the electronic health record (EHR), article forms, or verbal questions directly from clinicians. Although there was low compliance with universal screening, all clinicians reported screening patients who were perceived as presenting with signs or symptoms of IPV during a visit.
Barriers and Facilitators to Screening
Barriers to Screening
For both anxiety and IPV, barriers to screening included screening fatigue, or the burden of completing too many questionnaires and forms, for both clinicians and patients (Table 4). In addition, participants described a broader concern around lack of time for addressing required health maintenance, especially for patients presenting with multiple medical concerns. Participants reported that “lack of integration in the EHR” and the “inability to report or document screening” were perceived barriers to routine screening. One participant described how they hoped integrating screening into the EHR would help address these barriers in the following quote:
Summary of Screening Barriers and Facilitators
“I'm hoping with EPIC, there's less paperwork… so it's quicker… If there's a way to make that side easier, I think it would help also because… what other ways we can ask the questions without having to have the paperwork, but obviously we want the documentation, right? So, you got to figure out the happy medium.” -Clinic Administrative Manager, C3D
Clinic participants described the lack of payment incentives or clinical performance measures as significant barriers to implementation for both anxiety and IPV screening, indicating awareness of the competing priorities in primary care where guideline recommendations that are monitored with quality metrics are prioritized because of limited time and resources.30 Respondents had a lack of awareness that screening can be billed as a preventive service and expressed concerns about limited resources, unclear performance measures, and lack of follow-up protocols.
For IPV screening, additional barriers included concerns about documentation and reporting, with some reluctance to document positive screening results based on concerns about patient safety or privacy. Some participants noted the high resource demand, including appointment time and staff/clinician emotional toll, that made addressing positive IPV screening difficult. Further, the perception of the low prevalence of IPV in daily practice was a concern for additional investment in limited clinic resources. Participants also expressed concern that a positive screen would not be addressed and wanted a formal process in place for follow-up and resources if a patient screened positive. This concern is demonstrated in the following quote:
"I think it's tricky. I think it's really important, but I also think that if you can't support somebody, I do believe that you shouldn't screen because you are presenting a situation where maybe you're gonna give someone hope that you can help them when you can’t.” -Medical Director, T2A
Participants underscored their concern about the sensitive nature of documenting IPV and the potentially negative consequences for the patient. Participants felt it was extremely important to be cautious of which IPV-related information was recorded in the patient's chart, particularly if a perpetrator had access to the patient record or a visit summary a patient may take home. Given the level of caution around documentation of IPV, participants said that screening follow-up was rarely noted in the EHR.
Facilitators for Screening
For both services, participants suggested having screening tools for anxiety or IPV built into the EHR with automatic notifications or reminders. Additional feedback from participants included creating opportunities to leverage existing screening practices and workflows would also facilitate increased screening by reducing the burden on clinical staff and patients (Table 4). Implementing practices for universal screening that would not vary by patient population, other than established age-appropriate tools for adolescents, was also identified by participants as a strategy to help normalize routine screening and reduce stigma. Participants felt that universal screening would also reduce clinic staff bias and help to identify positive screens that might have otherwise gone undetected. For IPV, participants also identified populations that could benefit from additional attention or specialized approaches, including Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) populations, adolescents, Spanish speakers, migrant or refugee populations, and prenatal or postpartum patients, who they considered at increased risk for IPV. Participants felt individuals in these groups may respond better to tailored screening, education, and referral approaches. For anxiety, the increasing prevalence and awareness among participants increased understanding about the need to screen for anxiety. Some reported a shift in individual and clinic level screening practices attributable to increased awareness.
Interviewees identified other facilitators for screening including using existing screening practices. For example, participants suggested using existing screening workflows as a framework to facilitate protocols for implementing IPV screening. Specifically, participants described a preference for integrating IPV questions into existing forms such as social needs screening, annual wellness forms, or substance use screening. In addition, participants noted that bundling screening services could reduce the likelihood that individual screenings would be missed. Participants described the importance of a clear clinical workflow for addressing positive IPV screens, such as provision of community resources (eg, information for a local shelter), facilitating warm hand-offs (eg, calling resources with the patient during the appointment or bringing in an in-house community health worker or behavioral health provider),31 and referring the patient to an outside group, where follow up with the patient was shielded from the provider, in an effort to ensure patient privacy. A participant talks about the importance of follow-up in the following quote:
"Part of it is if we ask the question [about IPV], we need to be ready for the answer. And what does that look like on the other side… cause our clinicians here at [Clinic Name] want to do everything for everyone because they are wonderful humans.” -Practice Manager, T4A
Participants often noted that because experiencing IPV is a sensitive topic for patients, it requires staff to be trained and prepared to handle it appropriately. Many participants expressed concern that staff may not be comfortable or aware of the best approaches to address IPV with patients and discussed that, in addition to implementing an IPV screening workflow, clinics may also need to invest time and resources into training staff on IPV best practices for identification, management and referrals. Participants often felt this was an important first step to successful IPV screening implementation. Consideration for the sensitive nature of IPV screening was expressed by a participant, stating:
“…If someone were to be having something really bad happen, if they can… say yes instead of saying something out loud, because I know that can be hard if you're going through a violent situation. So I think it's good… it's just kind of reminding people… we give these screenings to everybody… just for your own wellbeing.” -Office Manager, C7C
Discussion
Interviews with 27 clinicians and staff in 12 primary care practices in a variety of community settings indicated that current practices and policies for anxiety and IPV screening vary widely. While some clinics reported screening for anxiety or IPV, variation in reported workflows, confusion around best practices, and limited documentation highlighted opportunities to improve implementation of recommended screening services. For anxiety screening, clinics commonly perceived it as part of depression screening, despite differences between the 2 conditions and separate screening tools and recommendations. For IPV, participants reported concerns about limited resources in place for referrals when screening was positive. For both preventive services, clinicians and staff were often unaware of screening recommendations and ACA coverage and acknowledged efforts to prioritize screening services that were more clearly attached to performance metrics. For IPV specifically, concerns about privacy and safety were an important barrier to screening.
Universal screening for anxiety can identify patients experiencing unrecognized symptoms and lead to effective treatments in adults and adolescents.7 Brief screening instruments demonstrate comparable accuracy to longer instruments and are applicable to primary care practices. However, screening may not be appropriately implemented in practice. While some clinics reported screening for anxiety in this study, several relied on the patient health questionnaire (PHQ) as a universal screening tool because of the perceived overlap between anxiety and depression. Improved understanding of these differences could lead to more effective screening. In addition to the WPSI recommendation, a recent U.S Preventive Services Task Force (USPSTF) guideline for universal anxiety screening (B recommendation)1 may help increase awareness of the differences between screening for anxiety and depression.
Clinical support materials responsive to barriers to and facilitators for screening for anxiety and IPV may facilitate implementation of screening in primary care practice. During this project, clinical support materials were developed in response to low screening rates and inconsistent screening practices identified by key informant interviews. Qualitative analysis of the interviews showed that participants believed screening could be facilitated by education; clarification of insurance coverage for screening; and resources and standardized protocols for screening methods, documentation, and referrals for patients with positive screening results. Participants suggested coupling screening for anxiety with screening for depression, which is more commonly implemented, to optimize the opportunity to screen for both conditions using screening tools appropriate for each condition. In addition, participants expressed uncertainty about how to assess the risk for self-harm when screening for anxiety and depression and for patient safety when screening for IPV.
Primary care is the most common first contact with the health care system and has been identified as an increasingly important setting for IPV screening and referrals.32 Utilization of health care services is 20% higher among women experiencing current or past IPV,33 providing many opportunities to deliver appropriate IPV-related care. Despite research supporting the importance of identifying best practices for IPV screening and referral,34 recent studies have focused on specific components or considerations for screening rather than factors influencing screening uptake.35 Access to services may occur through multiple clinical pathways,20 including services to treat an IPV-related condition, such as an injury resulting from acute trauma as a direct consequence of IPV; or when receiving care for different reasons, such as during a routine maternity visit.2,4 The WPSI recommends universal IPV screening, at least annually, and, when needed, providing or referring for initial intervention services.4
Limitations of this project include its reliance on a small number of participants from clinical networks in one region of the United States. However, the sample represented a variety of clinic settings, including urban and rural clinics, and participants with different clinical roles. Findings may not be applicable in other states since Oregon has a unique payment context with Coordinated Care Organizations (CCOs), or managed care organizations for Medicaid-insured patients, that affects incentives and how clinics prioritize efforts in their practice. Recently, Oregon added the “SDOH: Social Needs Screening and Referral” measure in 2023 to the set of incentive measures, which includes an IPV metric, potentially impacting rates of IPV screening in incentivized clinical settings. Importantly, interviews about screening practices are subject to recall bias or social desirability bias, resulting in participants who may overestimate the amount of screening conducted.36 Similarly, clinics’ screening policies may not be followed precisely by all clinic members.
How to effectively measure the frequency of screening given the high level of concern around documenting IPV in the patient record, remains a challenge. Despite the lack of new research, the findings from this project indicate that implementation of recommended services in primary care settings is low and that clinician resources and education could improve uptake. Additional studies support increased education and training as strategies to address clinicians’ perceived barriers to IPV screening. Future research directions for IPV screening include standardizing approaches for data audit and data capture to learn how to measure changes in screening practices. Further evaluation of effective metrics for routine anxiety and IPV screening and changes in screening practices over time is needed. Site observations to observe screening interactions and follow-ups could help identify missing information about clinical workflows. Protocols and universal workflows, including information about additional resources and referrals could also improve screening uptake and ensure patient safety, confidentiality, and follow-up to reassure patients and clinical staff. Clinicians and staff participating in this study, along with experts and clinicians reviewing the clinical workflow diagrams, endorsed the clinical applicability of the one-page workflow diagrams of the screening process and the resource guides providing detailed information and resources. However, these materials serve only as a starting point for implementing screening in individual clinics and health systems.
Clinical workflows require additional customization to meet specific needs of individual practices and settings, such as choosing screening tools; creating protocols and assigning roles for screening, referrals, and follow-up; identifying local resources within and outside health systems; documenting encounters; and coding and billing for services, among others. Integration with the health system EHR, providing adequate staffing and scheduling, and training clinicians and staff, including designated clinical advocates, require additional efforts beyond the scope of the support materials.37 Nonetheless, clinical support materials may bridge essential gaps in the implementation of screening and have potential to improve identification and management of anxiety and IPV.
Improvement in rates of screening for anxiety and IPV may occur through additional efforts, including development of national and health system quality metrics for screening. Next steps in this project include dissemination of training materials to support clinician education. Awareness around current screening recommendations and coverage, and the availability of brief, clinically validated, and effective screening tools could also improve application of recommended preventive services.
Conclusion
Implementation of routine screening for anxiety and IPV in women and adolescents in primary care is low but may improve with targeted clinician resources and education. Workflow diagrams and resource guides responsive to identified screening barriers and facilitators, including clarification of insurance coverage for preventive services, and resources to support implementation of protocols of screening methods, clinical documentation, and referrals for anxiety and IPV in primary care settings, could improve screening practices.
Acknowledgments
The authors acknowledge Tiffany Weekley and Caitlin Dickinson for their contributions to this work.
Appendix
Notes
This article was externally peer reviewed.
Conflict of interest: The authors have no conflicts of interest to report.
Funding: This study was funded by the U.S. Health Resources and Services Administration under a cooperative agreement with the American College of Obstetricians and Gynecologists (6 UHDMC29440-06-01; 6 UHDMC29440-08-01). The Oregon Health & Science University (OHSU) Institutional Review Board approved the study protocol (STUDY00025057).
- Received for publication March 17, 2025.
- Revision received July 16, 2025.
- Accepted for publication August 18, 2025.
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