Initial organizational practices and contextual factors related to brain injury screening and referral in intimate partner violence serving community- based organizations

Technical Summary: Initial Organizational Practices and Contextual Factors Related to Brain Injury Screening and Referral in IPV-Serving CBOs

Problem Statement
Intimate partner violence (IPV) is a pervasive public health issue with severe neurological consequences. IPV survivors face a high risk of brain injury (BI), particularly through head, neck, and face trauma or strangulation, with prevalence estimates ranging from 50% to 90% among women experiencing IPV. Despite this high risk, BI screening and referral are not standard practices within community-based organizations (CBOs) that serve IPV survivors. Existing literature indicates that BI is often under-detected due to overlapping symptoms with other trauma responses (e.g., PTSD), lack of provider awareness, and systemic barriers to care. While CBOs are critical access points for survivors, there is limited understanding of the current state of BI screening practices within these organizations or the contextual factors that influence the implementation of such services. This paper addresses the gap in knowledge regarding the baseline organizational readiness and contextual barriers to integrating BI screening and referral into IPV-serving CBO workflows.

Methodology
This study presents baseline findings from an ongoing, stepped-wedge, mixed-methods implementation study conducted in a Midwestern U.S. state. The research employs a participatory, community-engaged dissemination and implementation (CEDI) approach.

• Study Design: Twelve IPV-serving CBOs (ranging from rural to urban settings, including shelters and walk-in services) were randomly assigned to three Action Learning Collaborative (ALC) cohorts. Data were collected prior to the initiation of the ALC implementation strategy.
• Theoretical Frameworks: The study is guided by the Practical Robust Implementation and Sustainability Model (PRISM) to assess contextual factors and the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate implementation outcomes.
• Data Collection:
  • Organizational Records: Monthly reports and screening tool data were analyzed to quantify the number of BI screenings and referrals completed during the baseline period (November 2023–February 2024).
  • Staff Surveys: A baseline survey (n=72 staff members) assessed perceptions of implementation readiness, barriers, and facilitators. Items were mapped to PRISM domains, including organizational characteristics, patient perspective, external environment, and implementation infrastructure. Responses were scored on a 1–5 Likert scale.
• Analysis: Descriptive statistics were used to summarize screening/referral counts and survey demographics. Survey items were coded by research team members to identify strengths and gaps across PRISM constructs.

Key Contributions
The paper makes four primary contributions to the literature:

1. Baseline Characterization: It identifies initial practices and pathways for BI screening and referral in IPV-serving CBOs, a setting where these services are critically needed but not yet standardized.
2. Pre-Strategy Assessment: It demonstrates the application of community-engaged science to identify multilevel contextual factors before co-designing implementation strategies, ensuring future interventions are grounded in local realities.
3. Feasibility Evidence: It provides initial evidence regarding the feasibility of integrating BI screening into CBO workflows using a participatory approach.
4. Framework Application: It applies the PRISM and RE-AIM frameworks to organize initial practices and contextual factors, offering a structured approach to understanding implementation barriers in complex service settings.

Results

• Screening and Referral Activity: At baseline, implementation activity was inconsistent. Of the 12 participating CBOs, only 7 had conducted at least one BI screening, and only 1 had completed a referral to follow-up care. While some organizations had initiated screening independently, referral pathways were largely unestablished.
• Staff Demographics: The 72 survey respondents were predominantly female (92%), White (83%), and held roles as direct service providers (65%). Most held college degrees.
• Contextual Strengths (High Mean Scores): Staff demonstrated high awareness of BI (M=4.4) and recognized the importance of screening and referral for clients (M=4.3). There was strong recognition of client competing demands (e.g., housing, childcare; M=4.5) and general management support for the initiative.
• Contextual Barriers (Low Mean Scores): Significant gaps were identified in implementation readiness and process flow.
  • Readiness: Staff readiness to conduct screening and referral was low (M=3.4).
  • Process Flow: The seamlessness of the transition from screening to referral was rated lowest (M=3.3).
  • Communication: Staff reported low confidence in the ease of clients understanding screener results (M=3.4) and the ease of the referral process for clients.
  • Support: Challenges were noted regarding the availability of dedicated champions, adequate training, and the usability of the screening tool.

Significance and Claims
The authors claim that these findings shift the focus from merely recognizing the problem of IPV-related BI to understanding the implementation context required to address it. The paper argues that screening and referral should not be treated as a single, uniform task. The disparity between screening initiation and referral completion suggests that establishing referral pathways requires a higher level of organizational coordination, cross-system linkage, and staff confidence than screening alone.

The study posits that successful integration of BI screening depends on aligning the intervention with the specific organizational characteristics, staff capacity, and the realities of survivors' lives, rather than relying solely on technical training. By identifying specific contextual constraints—such as the need for dedicated teams, improved communication of results, and workflow integration—the paper provides a roadmap for developing site-tailored strategies. The authors conclude that future efforts must address these contextual determinants to ensure that screening leads to timely referral and sustainable follow-up support, rather than assuming a uniform implementation package will be effective across diverse CBO settings.