Transcript Interventions for Women & Girls Experiencing Violence

New Healthcare Policies on
Screening for Domestic
Violence: Opportunities for DV
Practitioners & HealthCare
Professions
Jacquelyn Campbell, PhD, RN, FAAN
Anna D. Wolf Chair & Professor
Johns Hopkins University School of Nursing
National Program Director, Robert Wood Johnson Foundation
Nurse Faculty Scholars Programs
• In memorium to two of the heroines of the battered
woman’s movement
• Ellen Pence 1948-2012
• Linda Saltzman 1949-2005
Institute of Medicine (2011) action
IOM examined all the evidence & recommended routine
screening & “brief counseling”
http://iom.edu/Reports/2011/
Clinical-Preventive-Services-for-Women
 Instead of prior US Preventive Task Force –
“insufficient evidence” finding
DHHS – 2011 Sec Sebelius put into Affordable
Health Care Act implementation (2012-2013)
 Office of Women’s health in DHHS responsible for
implementation – in HIV/AIDS prevention & Tx programs,
MH Tx, reproductive health programs, primary care
CDC NISVS Survey Results on IPV weighted
prevalence & Health Outcomes (2011)
Physical violence
Rape
Females
lifetime
Females
Past Year
Males
Lifetime
Males
Past Year
32.9
4
28.2
4.7
9.4
.6
*
*
Stalking
10.7
2.8
2.1
.5
Rape, physical violence, &/or stalking
35.6
5.9
28.5
5
With IPV-related impact (fear, PTSD
Sx, Injury, pregnancy, STI, missed
work, need for services)
28.8
-
9.9
-
Severe physical violence (vs.
pushing/shoving/slapping)
24.3
2.7
13.8
2
Any psychological aggression
(expressive or coercive control)
48.8
13.9
48.4
18.1
Injury/needed medical care from IPV
14.8/7.9
*Cell size too small or standard error too large
4/1.6
MMRW ‘08 – BRFSS ‘05 – 4 questions – physical
&/or sexual or threats; weighted; 16 states
 Lifetime IPV – 11.5% for men; 23.6% for women
 Significantly higher among multiracial, non-Hispanic & AI/ AN women;
(same as NISVS) & lower-income respondents.
 600,000 injuries to men 1.2 ml injuries to women
 Average of 1600-1700 IP homicides per year of women –
500-600 for men (BJS ‘09) - #1 risk factor – prior DV
against female partner (NVS –about 5:1F:M DV incidents)
 45-47% of women killed seen in health care system before homicide;
83% of cases somewhere in system (Campbell ‘03; Wadman ’01)
 Past year – higher rates documented – esp. low income
settings, IPV specific, w/safety protocols &/or anonymous
 Urban, 12 cities pop based - 9.8% past 2 yrs (Walton-Moss et al ‘05)
 Clinic based computerized – 18% - (Campbell ‘10)
Coker (’10) Framework
Overlap between physical, sexual and emotional
abuse (N = 889) (Campbell et. al. ’02 from Ellsberg ’00)
Sexual (N = 243)
32 (3.6)
31
(3.5)
14
(1.6)
166 (18.7)
177
(19.9)
166 (18.7)
Emotional (N = 677)
303 (34.0)
Physical (N = 649)
PHYSICAL HEALTH EFFECTS
• Physical Injury (Facial, fractures, dental,
neurological -
soft tissue, internal, “falls”- Grisso ‘91)
• (TBI & Strangulation: McClane ’05; Corrigan ’03; Valera &
Berenbaum ’03; Campbell et al 2011)
• Neurological Sx - Coker ’00
• IPV & stroke or Sx consistent with a stroke: 2 of 3
•
•
•
•
studies (Black ‘08; Lown,‘01; Loxton ‘06)
Chronic Pain (Back, abdominal, chest, head) (Campbell
‘00; Coker ’02;. Wuest et al ‘09)
• Fibromyalgia (Alexander ‘99; Walker ‘00)
Chronic Irritable Bowel Syndrome (Drossman ‘98)
Hypertension (Schollenberger et al ’02; Coker ’99)
Smoking (30-34% IPV 13-15% controls) (MMWR ’08)
Data from BRFSS (MMWR ’08; Breiding,
Black & Ryan ’08a & b)
Women -lifetime IPV
High Cholesterol: AOR 1.3 ([CI] = 1.1--1.4)
Disability AOR = 1.7; activity limitations 2.1
Arthritis AOR = 1.6
Heart Attack; Heart Disease; Stroke :1.4; 1.7; 1.8
Smoking AOR = 2.3
Risk factors for HIV/STD’s 3.1 (CI = 2.4--4.0).
Men: increased use of disability equipment, arthritis,
asthma, activity limitations, stroke, risk factors for HIV
infection or STDs, smoking, and heavy or binge drinking.
(AOR’s 1.4 (CI = 1.0--2.0) - stroke to 2.6 (CI = 2.0--3.6)
– HIV/STD risk
Well established negative health outcomes
of IPV – (C. Mitchell ‘09)
Mental Health: PTSD, Depression, Suicidality (AOR =
10.4 in African American women), Substance Abuse
MH – Largest proportion of excess cost – Snow-Jones et
al ‘06
GI symptoms – chronic irritable bowel, some indication
of BMI
Chronic pain
Wuest et al ‘09 – chronic pain after IPV ends
From immune system effects – pro-inflammatory
response with PTSD Gil et al ‘05; Woods et al ‘05
Cutting edge research – intersections with genetics –
telomeres lengthening – Humphreys, Blackburn et al ‘11
Well established negative health
outcomes of IPV – new findings
Forced sex – continuum of behaviors (physical force
or threats of force); other threats; pressure
HIV/AIDS intersections (Campbell et al ‘08; Jewkes et
al 2010)
USA - Sareen, Pagura, & Grant, GHP ’09 – 11.8% of
cases attributable to recent IPV – rep sample – women
Increased STI’s; cervical cancer (Coker ‘02; ‘03)
Forced first sex – Stockman et al ‘09 – up to 21% of
US women whose first sexual experience <14
Other GYN problems – UTI, vaginal itching/pain; etc
Campbell et al ‘2002; Coker et al ‘02; Campbell &
Soeken ‘99
Abuse During Pregnancy – Health
Correlates
 Patterns of abuse during pregnancy – from PRAMS (‘03)
 Unintended pregnancy(Saltzman ’03; Pallito et al, ‘04)
 Maternal health correlates: depression, substance abuse,
low social support, spontaneous abortion, smoking, risk
of homicide (Campbell ’92, ‘02; Alhusen in press)
 Infant outcomes: LBW & SGA (Murphy et. al. ’01 – meta
analysis – CMAJ; Alhusen in press) & through connections w/
smoking, low weight gain & substance abuse & stress
(Curry et al ’99; Altarac & Strobino ‘02)
 Child abuse (most severe - nonbiological father)
 Maternal Mortality (Chang & Horon, 2010; Saltzman et al)
 Post partum depression – PRAMS analysis – MMWR ‘09
Average Healthcare Costs by Timing of Abuse
$8,000
*
$7,000
$6,000
$5,000
Never Abused
Abused in Year Prior to Survey
$4,000
Abused, Not in Year Prior to Survey
$3,000
**
$2,000
$1,000
Snow-Jones et al ‘06
$0
1995
1996
1997
1995-1997
And if we do not routinely assess &
appropriately refer
Indicator based assessment – so many indicators – will
we remember?
We will often mis or incompletely Dx & inadequately
treat if we fail to identify current or past IPV (e.g. CNS
Sx w/o identifying TBI from IPV HI or choking)
RADAR (MASS Medical Assoc) - National Consensus
Guidelines at www.endabuse.org)
R = Routine Inquiry
A = Assessment – types of IPV, associated px, forced sex, HIV
risk, mental health
D = Document – for now & for later
A = Assess immediate safety – homicide & suicide risk
R = Review Options; appropriate referral
Health Care Setting Inquiry
We know routine assessment or inquiry or screening
does no harm – MacMillan et al (JAMA ‘09)
Creating an opportunity
We know women – abused & not – support routine
inquiry – in many samples & contexts – ED’s, military,
US national population based (Gielen et al ‘06)
We know what to “assess” with – Abuse Assessment
Screen (Helton & McFarlane – ’86; Rabin et al, ‘09 AJPM
We know
How to “assess” – computer based approaches well
supported - 3 studies – women prefer computerized
inquiry – build into HIT – computer tablets or apps?
Trautman et al –’07 - ED – increased disclosure
through computerized assessment
O’Connor et al – pediatric primary care setting – well
child and acute illness – handheld
McMillan et al . – ED’s & primary care in Canada
Current study in Baltimore, MD – X3- X4 prevalence
using ACASI system than question on history form or
over phone assessment in same population
Takes away issues of asking badly!! – (Rhodes ’09)
Single Question – Gender Neutral
Are you safe at home? (JHH) – does NOT work
well
Are you afraid (or concerned) that someone at
home or someone you love has (or may) hurt you or
tried to hurt you?
If yes, need to ask specifically about forced sex – or
have a separate forced sex question
Also need to develop well validated & tested
question about perpetration – with attention to
safety of victim - several are working on (e.g. Singh
et al ‘11)
PURPOSES OF ROUTINE
ASSESSMENT
 OPPORTUNITY CREATION –
 FOR DISCLOSURE, SEEKING HELP EARLY, A PLACE OF SANCTUARY
FOR THOSE NOT READY FOR SHELTER, COUNSELING, CRIMINAL
JUSTICE
 PRIMARY PREVENTION - EDUCATION ABOUT ISSUE
 RATHER THAN DETECTION
 Among pregnant women (Renker ’06)
97% not embarrassed, offended or angry – abused & not
Almost ½ of abused did not disclose but would have if
known would not be reported to CPS
 Part of new Women’s Health Initiative in VA
 Routine Screening & Brief Counseling recommended by 2011
IOM report & accepted by Sec Sebelius of DHHS – to be in
affordable health care act implementation in primary care
What matters – how you ask–“You’re not a
victim of Domestic Violence, Are You?”
 Kaiser West Health System – All providers incorporating into
assessment (McCaw et al 2010) with onsite DV advocates
 ED provider (46 attendings, 47 residents, 4 NP’s)
communication behaviors associated with women disclosing
IPV (Rhodes et al ’09)
Included probing (asking 1 additional topically related
question),
Providing open-ended opportunities to talk
Being generally responsive to patient clues (any
mention of a psychosocial issue)
What Matters – System Change –
Campbell et al ‘02
How you introduce the screen
Because domestic violence happens to so many
women, we are asking ALL women
Because domestic violence results in so many
health problems for women…..
The environment – posters – signals we care
Notices in rest rooms
Forms changing
Incentives for staff
What matters - culture
Hispanic women in LA – afraid of deportation –
self, - do not know can self petition for citizenship –
VAWA (citizenship classes, English language classes –
content on DV)
perpetrator, - want him to stop, not be deported
family members – he has threatened her with
deportation of family if she discloses
M. Rodriguez ‘07; ‘09
Moving Forward
 Identifying best “brief counseling”
 Depends on context – health care setting, availability
of “in house” DV advocate, trained SW, woman’s
preference –who she wants to talk to, where she is
in process of recognition of DV & how it is affecting
her & children’s physical & mental health
of commitment to relationship
of risk of homicide &/or serious injury (shortened DA
for health care settings – www.dangerassessment.org
Snider et al (‘09)
Cultural & immigration processes
• Several are being developed & tested
Decision Aid – “Iris” Study –
N. Glass, PI
• Computerized decision aid (from current personalized
medicine advances) for safety planning for abused women
• Tailored to level of danger (Danger Assessment) & type of
abuse
• Tailored to area of residence & resource availability –
rural vs. urban, available advocacy
• Tailored to culture & citizenship status
• Women report decreased stigma concerns
• Secondary & tertiary intervention – potential for primary
prevention for children
23
Ten Minute or Empowerment IPV
Intervention (McFarlane, Parker JOGNN ‘98)
• “Brochure Driven” or computerized (e.g. Kiely ’10)
• Brochure is for provider – not for woman to take home
• Can be modified for various audiences/settings
• Cover is Walker “cycle of violence” – or use Power &
Control Wheel – purpose is to start dialogue with her
• Inside – modification of Danger Assessment
• Menu of intervention and safety strategies to choose from
– including those for staying with partner – can add hers
• Offer to make calls WITH her (e.g. police Campbell,
Gielen ‘02)
• Resource #’s made local
• Intervention on March of Dimes website – also brochure
microsoft publisher – www.nnvawi.org
Others with Evidence
Koziol-McLain, Ritchie – promising intervention in NZ –
specific adaptation for Maori women
For Pregnant women/prenatal care – all with significant
advocacy collaboration
‘09 Tiwari (& Humphreys) adaptation of 10 minute
intervention (McFarlane & Parker) in Hong Kong – clinical
trial supporting health care system intervention
Sharps, Bullock – DOVE adaptation for home visitation
Feder et al – Prevention intervention in Nurse Family
Partnership Home Visitation
Brief computerized intervention – resulting in significantly
less repeat IPV & fewer very LBW babies & preterm
Opportunities
• Opportunities for DV Advocates and Health Care
Professionals to work together to develop, test and
train professionals to conduct effective “brief
counseling”
• PCADV & Kaiser models
NATIONAL DOMESTIC VIOLENCE
HOTLINE: 1 800 799-SAFE (7233)
DATING VIOLENCE HOTLINE
1-866-SAFEYOUTH
1-866-723-3968
Never forget who it’s for “please don’t let her death be for nothing – please get
her story told”
(one of the Moms of a woman killed)
“I want to be able to see my daughter grow. I want her
to be able to be a little girl. I don’t want to keep the
cycle going. I want her to see good things while she
grows up & not abuse.”
(abused woman)