Interventions for Women & Girls Experiencing Violence
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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)