Specifically, we propose building the site using WordPress: a free, open source content management system and blogging platform. WordPress allows an unlimited number of sequentially-ordered posts and global navigation items (each with one or more child pages), as well as a large number of additional pages for the purpose of organizing and sharing content. WordPress 3.0, which was released in June 2010, also allows the flexibility to create and manage custom menus, headers, content types, and taxonomies. In short, WordPress has taken another large step from blogging platform to a full featured content management system, and will meet all the needs of SILvR as we understand them.

Specifically, we propose building the site using WordPress: a free, open source content management system and blogging platform. WordPress allows an unlimited number of sequentially-ordered posts and global navigation items (each with one or more child pages), as well as a large number of additional pages for the purpose of organizing and sharing content. WordPress 3.0, which was released in June 2010, also allows the flexibility to create and manage custom menus, headers, content types, and taxonomies. In short, WordPress has taken another large step from blogging platform to a full featured content management system, and will meet all the needs of SILvR as we understand them.

As part of a special Office on Women’s Health funded initiative on maternal child health and violence called Project Connect: A Coordinated Public Health Initiative to Respond to Domestic and Sexual Violence (see more about Project Connect in this issue), Futures Without Violence is releasing a curriculum on domestic violence for home visitors. The curriculum is one of several resources that have been created through Project Connect, a special initiative on maternal and child health and violence (see more about Project Connect in this issue). Informed by several years of working with home visitation programs, authors Linda Chamberlain and Rebecca Levenson have developed and piloted a curriculum that includes PowerPoint presentations with speaker’s notes and a supporting bibliography of relevant research. This training resource is designed to be interactive and also includes discussion questions, exercises, role plays as well as accompanying training DVDs. The following topics are covered in the curriculum:

• Overview of Federal Benchmarks for Addressing Domestic Violence in Home Visitation Programs
• How Domestic Violence Affects Home Visitation Goals and Staffing
• Brief Overview of Domestic Violence: Definitions and Dynamics
• Screening and Safety Planning for Domestic Violence in Home Visitation
• Impact of Domestic Violence on Perinatal Health Outcomes
• Making the Connection: Domestic and Sexual Violence and Reproductive Coercion
• The Effects of Domestic Violence on Children
• Impact of Violence on Mothering and Promoting Resiliency for Children
• Childhood Exposure to Violence and Its Impact on Parenting
• Preparing Your Program And Supporting Staff Exposed to Violence and Trauma
• Fathering After Violence
• Mandated Reporting for Child Abuse: Challenges and Considerations

The curriculum includes safety cards for clients and a video demonstrating how a home visitor can use the Healthy Moms, Happy Babies safety card (see more information below) to talk with clients about domestic violence and safety planning. It also includes another safety card, Loving Parents, Loving Kids and an accompanying video to support home visitors educating parents about how childhood exposure to violence can affect parenting and steps to take that make a difference as a child abuse prevention strategy. Also included are the First Impressions DVD, a resource designed to educate parents about how exposure to domestic violence can impact brain development, and the DVD, Something My Father Would Do, which features men who describe their experiences of growing up in violent households and how it influenced their lives, relationships, and parenting skills. Pre-training and post-training surveys are also provided. The curriculum and training resources will become available shortly on a combination DVD/CD that can be requested at www.futureswithoutviolence.org/health.

2) Home Visitation Safety Card: Healthy Moms, Happy Babies

Healthy Moms, Happy Babies: Creating Futures without Violence is a folding card that asks questions in a self-quiz format to help mothers to assess if they are in a healthy relationship or a relationship that may be unsafe or dangerous. The safety card also asks about coping strategies and includes information about safety planning and how to get help (national hotlines). This tool folds up to the size of a business card (3.5″ x 2″) and is available in English and Spanish. Safety cards can be requested at www.futureswithoutviolence.org/health.

3) Home Visitation Safety Card: Loving Parents, Loving Kids

Loving Parents, Loving Kids: Creating Futures without Violence is a safety card for women that perinatal health care providers can distribute to patients. In addition to providing safety resources for women, this tool also functions as a prompt for perinatal health care providers by providing quick phrases to improve discussions with women about the impact of domestic violence on their parenting and children. This safety card outlines questions women may ask themselves about their relationships, birth control use and parenting, while offering supportive messages and referrals to national support services for help. This tool folds up to the size of a business card (3.5″ x 2″) and is available in English and Spanish. Safety cards can be requested at www.futureswithoutviolence.org/health.

4) Quality Improvement/Quality Assessment Tool

Futures Without Violence has developed a quality improvement/quality assessment tool to help home visitation programs to measure how their programs are addressing domestic violence. The tool includes sections on:

• Assessment methods including screening for lifetime exposure to violence and integrated assessment for violence, depression, and substance abuse
• Intervention strategies for clients who disclose victimization
• Networking and training
• Self-care and support for staff
• Data and evaluation
• Client education and prevention
• Resources and policies

This comprehensive assessment tool, which outlines optimal responses for each of the sections, can be used to track progress as home visitation programs implement new violence policies, and is also useful resource for program evaluation. The tool can be downloaded at www.futureswithoutviolence.org/health.

5) Guide for Policy Makers

Futures Without Violence recently released a guide for policy makers on home visitation and domestic violence. The publication, Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment, highlights the importance of addressing domestic violence within the context of home visits, makes the connection between domestic violence and home visitation program goals, and describes the overlap between domestic violence and child maltreatment. An overview of national home visitation models includes innovative home visitation programs that are designed to address domestic violence. Practice recommendations for integrating domestic violence into home visiting are outlined for policy makers. The guide can be downloaded atwww.futureswithoutviolence.org/health.

6) Home Visitation and Intimate Partner Violence: Recommendations for Policy and Program Development

The purpose of this document is to build on the strategies described in the Guide for Policy Makers (see item 5 above) by outlining ten core recommendations that funders, policymakers, and program managers should incorporate into home visiting programs. These recommendations, shown below, can be downloaded at www.futureswithoutviolence.org/health.

10 Core Recommendations:

1. Establish goals and objectives for home visiting programs to address the complexities and continuum of intimate partner violence (IPV) and its relationship to maternal and child health, safety, and wellbeing.
2. Collect data on IPV and incorporate IPV into all program evaluations.
3. Incorporate routine questions on IPV, reproductive coercion, and children’s exposure to violence into intake and other program forms and add content on IPV in resources and educational materials for families.
4. Train staff on IPV and children’s exposure to violence.
5. Make appropriate service referrals for IPV, sexual assault, reproductive coercion, and for children exposed to violence.
6. Collaborate and develop partnerships with domestic violence and sexual assault advocacy programs/shelters and child welfare agencies to coordinate policies and develop best practices.
7. Build capacity to address IPV by providing culturally appropriate services and hiring staff that reflect the diversity of the community being served
8. Implement standard practices and safety protocols related to IPV.
9. Support and supervise staff toaddress vicarious trauma and support those who have their own experiences of violence and abuse.
10. Engage and work with fathers and father-figures.

Elena Cohen

Safe Start Center
5515 Security Lane, Suite 800
North Bethesda, MD 20852
Email: ecohen@jbsinternational.com

Isa M. Woldeguiorguis

Safe Start Center
@ JBS International
5515 Security Lane, Suite 800
North Bethesda, MD 20852

Points of view and opinions in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice.

In the past two decades, we have gained an increased understanding of the scope and consequences of children’s exposure to domestic violence. Focus has shifted from thinking that children are tangential and disconnected from the violence and trauma of their parents to learn that children’s responses and recovery from exposure to violence are particularly dependent on the context of the experience—especially their relationship with their families.

Exposure to violence and other forms of traumatic stress frequently co-occur with child abuse, neglect, and substance abuse forming a complex web of issues that pose significant challenges for programs and service systems. Many of the services designed to prevent or address these problems are “siloed” and often inadequate in their capacity to address family issues comprehensively. In addition, poverty and institutional racism limit families’ and service providers’ options and can undermine possible solutions resulting in disparities in health and well-being outcomes for children and families. The same is true for home visiting programs.

The purpose of this article is to raise awareness and provide practical suggestions for home visiting programs with regards to working with families affected by domestic violence. This article will focus on addressing the safety and developmental needs of children exposed to violence by ensuring safety and expanding parenting capacity of non-abusive caregivers while rebuilding broken family relationships.

Home Visiting Programs

Home visiting has been used as an early intervention and prevention strategy that pairs families—particularly those that are distressed—with trained staff (professional or paraprofessional) to provide parenting information, resources, and support throughout the child’s first few years. Using strengths-based approaches, home visitors create a trusting relationship and deliver services such as specialized curricula, therapeutic interventions, and parenting education to parents and children in the family’s home. In addition, home visiting programs operate as a link between families and other community services—not just through referrals but by helping parents understand the value of the services and how to access them.

President Obama’s federal budget request for FY 2010 called on Congress to fund a major new home visiting initiative—$8.6 billion over the next 10 years—to provide states with funding primarily to support home visiting models that have proven, through rigorous evaluation, to have positive effects on critical outcomes for children and their families (Boonstra, 2009).

Some of the most rigorously evaluated home visiting programs include Healthy Families, Healthy Start, Nurse-Family Partnership, Parents as Teachers, and Safe Care. Program evaluations show a range of positive results for home visiting programs. For example, an examination of 60 home visiting programs found small but statistically significant effects on parents’ behaviors, attitudes and educational attainment, and documented a significant reduction in potential child abuse and neglect (Daro, 2007). Nevertheless, several other studies have indicated that home visiting programs are not universally successful. For example, a randomized controlled trial of the Nurse Family Partnership in Elmira, NY revealed that the program did not significantly reduce the reported incidents of child abuse and neglect in families experiencing domestic violence. However, in families where domestic violence was not a confounding factor, the program was effective at reducing child maltreatment (Eckenrode, Ganzel, Henderson, Smith, Olds, Powers, Cole, Kitzman, & Sidora, 2000).

Families in Home Visiting Programs

Promoting the different outcomes of home visiting programs is tied directly to ensuring that families are safe and that their parenting is not compromised. In all the home visiting approaches, the home visitor serves as a bridge across philosophies, policies and procedures, families and agencies, and community concerns. Families that are targeted by home visiting programs, however, often experience a range of problems such as maternal depression, substance abuse, and/or domestic violence. These issues often occur along with poverty, compounding the challenge of delivering effective home visiting services.

Children’s Exposure to Violence

As evidenced in the findings of the National Survey of Children’s Exposure to Violence (NatSCEV), children’s exposure to violence, crime, and abuse are pervasive in the United States (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2010). More than 60% of the children surveyed were exposed to crime, abuse, and violence within the past year, either directly or indirectly. Furthermore, nearly half of the children had experienced at least two different types of victimization and 8% experienced seven or more kinds of victimizations.

The negative impacts of exposure to violence, especially when compounded by instability and uncertainty in the absence of a strong attachment to a caregiver, begin to multiply and can affect every area of a child’s functioning. Cognitive, attention, and emotional resources that are normally devoted to the developmental process are applied instead to coping and survival strategies (Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth, 2009).

Not all exposure to violence has a long-term impact on children. Certain factors can provide a powerful buffer from the intense stress and anxiety that may occur when they are exposed to violence. These factors include the presence of a stable loving adult, positive relationships among family members, communication and good problem-solving capacity between parents, the stability and responsiveness of systems and staff that interact with the child and access to social supports and interventions for parents and other caregivers (Cohen, Kracke, &McAlister Groves, 2009).

This new understanding of the vulnerability of children exposed to violence creates a renewed sense of urgency about intervening early in their lives. Literature reviews and program practice demonstrate that parents who have been exposed to violence themselves and those currently living with domestic violence, may have difficulties performing their parenting tasks and meet their children’s developmental needs (Levendosky & Graham-Bermann, 2001). However, this does not automatically indicate that home visitors can assume that parents living with violence and other traumatic stressors show greater deficiencies in parenting than their non-abused counterparts. Many parents living with violence and other traumatic stressors, including domestic violence, tend to parent adequately and sometimes even compensate through increased nurturing and protection of their children (Lieberman &Van Horn, 2008). Research also underscores that the risk of child maltreatment is reduced once the adult victim achieves safety and that adult victims, despite ongoing abuse, can be effective parents and mediate the impact of their children’s exposure to domestic violence (Holt, Buckley & Whelan, 2008).

Women indicate that offending parents often interfere with their parenting, and that they often make decisions to stay with or leave the perpetrator based on their sense of the best interests of the child (Ritchie & Holden, 1998). As a result of living in constant fear, households with domestic violence may fail to provide opportunities to develop a basic sense of trust and security that is the foundation of healthy emotional development. One-third of abused women experience post-traumatic stress disorder, low self-esteem, depression, and anxiety (Genelle, Sawyer Davis, Hansen, & DiLillo,2004).

In the case of the father or father figures, Guile (2004) found little information about fathers and parenting capacity in households with domestic violence. When compared to their nonviolent counterparts, these fathers are less likely to have been involved with their children, more likely to have used negative child-rearing practices such as slapping, and are more authoritarian and controlling, and less consistent (Bancroft & Silverman, 2002).

Should Exposure to Violence be Reported to Child Welfare?

The question of whether exposure to violence should trig­ger the need for a report to child protective services is one of the most difficult issues for many service providers including home visitors. Home visitors, as others, have an institu­tional and legal mandate to keep children safe. Everyone agrees that there are some situations in which exposure to violence justifies a report to child protection agency. In practice, however, those judgments are much harder to make. A critical question is whether situations of children’s exposure to violence belong in the child welfare system at all or are better handled by voluntary service systems. This is demonstrated in situations when experts arrive at far different con­clusions, using the same hypothetical situations, about when the intervention of the child welfare system is appropriate.

Involvement with the child welfare system should be a last resort for any family. Friends and neighbors, clergy, health professionals, community organizations, and many others should be available as a first line of support and help. Specialists with responsibilities for educating families and community-based organizations, including domestic violence advocates, can assist them in providing better information to the women they serve. Through this educational process, community groups can help clarify the expectations, legal procedures, potential support, and consequences of engagement with the child welfare system.

Suggestions for Home Visiting Programs

The following are a set of recommendations to improve program infrastructure and service delivery that will help home visitation programs to meet their primary goals of ensuring safety of the child and non-abusing parent, improving parenting knowledge, beliefs, expectations, skills and behavior, facilitating the child’s healing and resumption of developmental process, and repairing/rebuilding relationships within the family.

1. Identify children who have been exposed to violence

The most important first step is to identify, as early as possible, children who are exposed to violence. Given what is known about the prevalence of co-occurring domestic violence and child abuse/neglect, programs should have universal screening policies in place and all home visitors should be trained to ask relevant questions and make observations about the possibility of domestic violence.

Home visitors are in a unique position to watch for physical signs (bruises, unexplained changes in behavior, emotional signs such as depression or anxious behavior). Systematically identifying and referring children exposed to violence requires the development and implementation of policies, procedures, and practices that include documenting the presence of children during episodes of violence that result in agency interactions with caregivers in known settings (e.g., at a crime scene, in a domestic violence shelter, in dependency court) and incorporating screening questions into existing intake protocols.

2. Integrate strategies to address exposure to violence and domestic violence into home visiting protocols

Planning for services in families with domestic violence must always take into consideration the child’s experience of violence and its effects as well as the potential danger to the child’s safety. It is critical to develop a safety plan for the adult victim and the child. In domestic violence situations, child safety usually depends upon the safety and protection of the adult victim. The ultimate goal is to end violence against both the children and the abused partner. The child’s need for attachment, safety, and security—which may change over time—should be the constant frame of reference during service planning.

3. Link families with community-based services

Home visitors can provide a variety of opportunities for families with young children exposed to violence or at high risk of exposure to access needed services (for example, health care, early childhood, child protective services and domestic violence professionals) and engage parents/caregivers into needed services for their children and themselves. To be able to do this work, programs must support and foster collaborative partnerships and cross-agency training with child welfare and domestic violence agencies and other providers that serve the families.

4. Include evidence-based strategies in the parenting education activities

Parenting education is provided by most home visiting programs. Key issues related to parenting education include determining the parents’ capacity to protect their children, helping parents understand how their own exposure to violence influences their parenting, and introducing practices that improve the non-offending parent-child bond which is often strained or fractured by the violence.

Parenting classes often have different approaches and philosophies, target audiences, and goals. Effective parent training interventions include Parenting Wisely, Nurturing Parent, STEP, and Project 12-Ways. Most of these programs are not provided in the home or specifically target children’s exposure to violence. An additional consideration is that while these programs have demonstrated a number of positive outcomes, their success in building trauma-related parenting capacity has not been assessed.

Programs designed to provide parenting skills without violence for men who batter have emerged in the last decade. These parenting programs are usually supplementary sessions within existing offending-parent intervention programs or a separate curriculum. The EVOLVE program, for example, integrates six lessons on fatherhood into a larger curriculum for perpetrators (Donnelly, Mederos, Nyquist, Williams, & Wilson, 2000). The Family Violence Prevention Fund developed the Fathering After Violence Project which includes exercises that can be integrated into batterer intervention programs and into curricula for fatherhood programs in other systems (Arean & Davis, 2007).

5. Refer children to specialized services

The kinds of exposure to violence that children, youth, and families in home visiting programs experience are typically not associated with a single event such as an accident or a school shooting. Rather, they are usually interpersonal in nature, intentional, prolonged and repeated, occur in childhood and adolescence, and may extend over years of a person’s life. If untreated, the impact of the exposure can interfere with children’s healthy development and lead to long-term difficulties with school, relationships, jobs, and the ability to participate fully in a healthy life.

Diverse mental health interventions have been developed to increase protective factors and decrease behavioral and emotional symptoms that result from exposure to violence. Child Parent Psychotherapy for Family Violence (CPP-FV), an evidence-based intervention for infants and toddlers, uses a parent-child dyadic model (Lieberman, Ghosh Ippen, and Van Horn, 2006). For school-age children, treatment programs such as Kids Club and Mom’s Empowerment include a child intervention while the non-offending parent simultaneously attends separate sessions to learn how to help their children cope (Graham-Berman, Banyard, Lynch, & DeVoe, 2007). Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) is provided in schools to groups of children to help them develop skills, regulate emotions, and build resiliency (Stein, Jaycox and Karaoka, 2003). Other evidence-based interventions for children for who have been exposed to toxic stress include: Trauma-Focused Cognitive Behavior Therapy (TF-CBT), Abuse-Focused Cognitive Behavior Therapy (AF-CBT); Parent Child Interaction Therapy (PCIT); and Project 12-Ways/Self-Care for Child Neglect (http://www.nctsn.org).

6. Support the mental wellness of home visitors

Adults who work with children exposed to violence may experience significant emotional impact. They are exposed to intense stressors that can have a negative effect on their physical and emotional well-being. Feelings of stress, exhaustion, and sadness are common. Physical symptoms may include headaches, stomach upset, and muscle aches and pains. Exposure to the tragic stories of children can trigger the same feelings of fear and anxiety in the professional that the child is feeling. To prevent burnout and assure quality, adults who work with these children need specific support and supervisory services. Stress management, peer support, and high-quality on-the-job supervision are critical (Rice & Groves, 2005).

Conclusion

Home visitors have an extraordinary opportunity to respond to the needs of children exposed to violence and their families. To support home visitors, the programs must invest in infrastructure building through policy development and training. Whatever the model of home visitation, program impact is dependent upon the skills and sensitivity of the home visitor and providing the home visitor with a framework that provides training, skill development, protocols and support to address domestic violence with the families they serve.

References

Arean, J. D. & Davis, L. (2007). Working with fathers in batterer intervention programs: Lessons from the Fathering After Violence Initiative. In J. L. Edleson & O. J. Williams (Eds.), Parenting by men who batter (pp. 118–130). New York: Oxford University Press.

Bancroft, L. & Silverman, J. (2002). The batterer as parent: Addressing the impact of domestic violence on family dynamics. Thousand Oaks, CA: Sage.

Boonstra, H (2009, Summer). Home visiting for at-risk families: A primer on a major Obama Administration initiative. Policy Review. 12, 3, 11-15.

Cohen, E. , Kracke, K., McAlister Groves, K. (2009). Understanding Children’s Exposure to Violence. Moving from Evidence to Action: The Safe Start Series on Children Exposed to Violence. Issue Brief #1, North Bethesda, MD: Safe Start Center.

Daro D. (2007). Home Visitation: Assessing Progress, Managing Expectations. Chicago, Ill: Chapin Hall Center for Children. Retrieved on February 10, 2011 from http://www.chapinhall.org.

Dore, M. M., & Lee, J. M. (1999). The role of parent training with abusive and neglectful parents. Family Relations, 48, 313–325.

Donnelly, D., Mederos, F., Nyquist, D., Williams, O. J., and Wilson, S. G. (2000). Connecticut’s EVOLVE Program: A 26 & 52 week culturally competent, broad-based, skill-building, psycho-educational curriculum for male domestic violence offenders with female victims. State of Connecticut Judicial Branch: Rocky Hill, Connecticut

Dutra, L., Bureau, J. F., Holmes, B., Lyubchik, A., & Lyons-Ruth, K. (2009). Quality of early care and childhood trauma: A prospective study of developmental pathways to dissociation. Journal of Nervous Mental Disorders, 197(6), 383-90.

Eckenrode, J., Ganzel, B., Henderson, C., Smith, E., Olds, D., Powers, J., Cole, R., Kitzman, J., and Sidora, K. (2000) Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. Journal of the American Medical Association 284, 11, 1385-1391.

Finkelhor, D, Turner, H., Ormrod, R., Hamby, S., & Kracke, K. (2009, October). Children’s exposure to violence” A comprehensive national survey. Juvenile Justice Bulletin. www.ncjrs.gov/pdffiles1/ojjdp/227744.pdf.

Genelle K. Sawyer, C.A. Davis, D.J. Hansen, M.F, & DiLillo, D. (2004, November). Examining the Context of Domestic Violence: Relationship of Current and Past Partner Psychological Aggression and Physical Assault to Parenting. Poster Presented at the 38th Annual Convention of the Association for the Advancement of Behavioral Therapy, New Orleans, LA. Retrieved on February 10, 2011 from http://www.unl.edu/psypage/maltreatment/documents/AABT2004_DomesticViolenceandParentingHandout.pdf

Graham-Bermann S.A., Banyard V., Lynch S., DeVoe E.R. Community-based intervention for children exposed to intimate partner violence: An efficacy trial. Journal of Consulting and Clinical Psychology, 75, 2, 199-209.

Guille, L. (2004) Men who batter and their children: An integrated review. Aggression and Violent Behaviour, 9, 129-163.

Holt, S., Buckley, H.., Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse and Neglect 32 797-810.

Levendosky, A., Graham-Bermann, S.A (2001). Parenting in battered women: The effects of domestic violence on women and their children. Journal of Family Violence, 16, 2, 171-192.

Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press.

Lieberman A.F., Ghosh Ippen C., Van Horn, P.J. (2006). Child-Parent Psychotherapy: Six month follow-up of a randomized control trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 913-918.Rice, K. and Groves, B. (2005), Hope and Healing: A Caregivers Guide to Helping Young Children Exposed to Violence. Washington, DC: Zero to Three.

Ritchie, K. L and Holden, G. W. (1998). Parenting stress in low income battered and community women: Effects on parenting behavior. Early Education and Development, 9, 97–112.

Stein B.D., Jaycox, L.H., Kataoka S.H. (2003). A mental health intervention for school children exposed to violence. Journal of the American Medical Association, 290, 5, 603-611.

]]> http://futureswithoutviolence.org/health/ejournal/2011/04/connecting-the-dots-childrens-exposure-to-violence-and-home-visiting-programs/feed/ http://futureswithoutviolence.org/health/ejournal/2011/04/domestic-violence-within-the-context-of-home-visitingeight-lessons-from-the-dove-intervention/ http://futureswithoutviolence.org/health/ejournal/2011/04/domestic-violence-within-the-context-of-home-visitingeight-lessons-from-the-dove-intervention/#comments Thu, 07 Apr 2011 17:28:32 +0000 vedalyn http://endabuse.org/health/ejournal/?p=466 by Linda Bullock, PhD, RN, FAAN; Phyllis Sharps, PhD, RN, FAAN and the DOVE Research Teams

Linda F.C. Bullock, PhD, RN, FAAN
University of Virginia
School of Nursing
Claude Moore Educational Bldg
P.O. Box800826
Charlottesville, VA 22908-0826
Phone:  (434) 982-1966
Email: lcb2u@virginia.edu

Phyllis W. Sharps, PhD, RN, CNE, FAAN
Dept. of Community Public Health Nursing
Johns Hopkins University
School of Nursing
525 North Wolfe Street - Room 432
Baltimore, MD 21205
Phone: (410) 614-5312
Email: psharps@son.jhmi.edu

Dr. Bair-Merritt’s article in this e-journal issue, Home Visiting Programs’ Response to Intimate Partner Violence: What We Know and Why It Matters for the Health of Our Children,” makes it clear that children exposed to intimate partner violence (IPV) in the home are impacted negatively by the violence. She points out that the impact of this exposure may be minimized if there is a relationship between a supportive caregiver and the child. Historically, one of the main outcomes of home visitation programs has been to strengthen a caregiver’s supportive parenting role through education and role modeling. Addressing issues of partner violence in the home, however, has not traditionally been a part of home visiting services. In a recent NIH/NINR-funded study, Domestic Violence Enhanced Visitation Intervention (DOVE) [R01 NR009093; Dr. Phyllis Sharps, Principal Investigator, Johns Hopkins University, School of Nursing], an empowerment intervention (DOVE) that home visitors can use to reduce the impact of IPV is being tested in rural Missouri and urban Baltimore. The lessons learned from this study provide rich data for other home visiting programs.

My research team (Bullock, Co-Principal Investigator) has been working with home visitors in several different home visitation programs throughout a large area of Missouri. The home visiting programs that are field testing the DOVE intervention include two Missouri Department of Health and Senior Services prenatal home visiting programs: the Nurse Family Partnership® program (Building Blocks) and the Missouri Community-Based Home Visiting program (MOCBHV). The Lutheran Family and Children Services home visiting program also participated in the field testing. Nearly a hundred home visitors of varying backgrounds and licensures have worked with the research team in implementing and testing the DOVE intervention in 24 of the 115 counties in Missouri.

Over the course of the first eighteen months of the grant, many formal and informal training sessions for the home visitors were conducted by the researchers. Even with repeated trainings, we were faced with a huge recruitment problem for the study. Eighteen months into the study, there were few referrals because the home visitors claimed they were not finding any women in their caseloads that were positive for current abuse or abuse in the past year. It appeared as if IPV had disappeared in Missouri. The research team and the State Health Department decided to hold another required intensive training in the state’s capitol city for all home visitors, but this time we would also address the barriers to assessing for IPV that could be occurring. This training used different strategies from those in previous training sessions. First, a male expert in the area of IPV was brought in as a key speaker to address the issue of problems with the male partner being in the home at the time of the visit thus preventing the home visitors from screening. Second, role playing was employed so that every home visitor had an opportunity to assess or be assessed while role playing as a woman who was experiencing abuse. Each home visitor also had the opportunity to observe an assessment and make comments to the assessor and the person being assessed about how they viewed the role play as an outsider looking in on an interview.

As a final step, participants were divided into focus groups of six to eight home visitors to determine what they thought were barriers and facilitators for implementing IPV assessments and interventions within their case loads (Eddy et al, 2008). We learned that one of the main barriers to addressing IPV in the home was a lack of knowledge on how to address IPV in this situation. This fueled stress and fear in the home visitors. The stress came from a feeling of inadequacy and fear of making a fool of themselves when they talked to the women about the violence. Home visitors also discussed feeling stressed in trying to control their own personal feelings when addressing the issue. There were also fears regarding safety; not only for the women but also for themselves. The most important facilitator identified by home visitors was a feeling of having a good rapport with the woman and knowing that the woman trusted her. Being able to talk about these barriers and facilitators seemed to make a difference because after this training, referrals to the DOVE study increased in Missouri.

Through five years of experience in Missouri, many lessons have been learned about how to effectively implement assessments and interventions for IPV during home visits. The home visitors have learned from our expertise in the area, but we have also learned from them. We believe that sharing these lessons can be valuable to others. Critical factors to be considered when implementing protocols within home visiting programs are listed below with excerpts from the focus groups conducted with home visitors.

Lessons Learned and Quotations from the Home Visitor Focus Groups

1. Training is best done in conjunction with local resources such as local women’s shelters, law enforcement agencies, and legal services. The home visitors we have worked with expressed the need to understand the laws in their area and what services are available. As one home visitor said:

So that would have been a good educational piece to know what happens when mom and baby go into shelter what will happen next? Am I going to lose my food stamps, am I still going to get “ will I lose everything because I go to shelter and then I won’t have anything? I am just stuck there and I don’t have any answers for those questions.”

Having representatives from the shelter and law enforcement agencies present at IPV trainings can help answer questions like the one above. Along with wanting to know what happens when a woman decides to seek refuge, other questions the home visitors had included laws for mandated reporting of IPV, child abuse laws, and legal resources that were available and how to refer to those services. It has been our experience that the home visitors not only appreciate being able to ask their questions and receive answers from the experts, but they find it valuable to be introduced to local contacts that they can call on in the future as other questions arise.

2. Role playing in training sessions helps to increase the comfort level and the likelihood of home visitors asking the questions and intervening.

The other thing was practicing the questions and hearing how other people are saying their questions and stuff, because I know personally I am like I am getting all into someone’s business and are they going to tell me the truth or not? Even if I ask these questions or did I just put up another wall or am I still going to have the same ¦ there are certain things you can ask as a home visitor that you wonder if you are putting up a wall and then the next time you come there is that little stand back like what is she going to ask me or do I want to continue to have that strong relationship with a strong foundation. So that scares me, but listening to how others are saying it and constantly saying it and then at the end the one woman was saying if I offended you in any way, I am really sorry. Tell me how it felt when I asked you those questions so you can become a better communicator with the subject.

Another home visitor echoed a similar feeling:

I have never had any training on DV so I had never learned about screening. I had never learned about any of that. Even just doing the role playing scenario upstairs really helped me because I had never been forced to ask those questions before and use that. And it was good to try it out on someone that was not going through it instead of having been placed in it and having to do it.

Although usually met with resistance from training participants, it is well worth pushing the issue of role playing during the training and having facilitators present that can help guide this exercise. It has been our experience that for many home visitors, this is the first time they have ever asked the questions out loud. Practicing in a training session not only improves their skills in assessing and intervening, it provides an opportunity to go beyond the first time to ask step.

3. Before the information being presented can be fully utilized by home visitors, the training needs to address their attitudes and beliefs about violence and their own personal experiences with violence.

I think that concept of stirring the pot and that you are going to make it worse just reminded me that I need to look at the whole box or picture and that the outcome is that they learn and they are safe. If it means that he is mad at me and won’t let me come back but she has the numbers that she needs then I need to get over it cause it is not about me, it’s about her and her baby.

Another home visitor clearly struggled with addressing the issue of violence. When confronted, she found her own experiences with the issue were getting in the way of helping other women:

My stress comes into the point of being able to control my feelings. I worked for a family for 1 ½ to 2 years and didn’t even know that he was abusive and out of the blue one evening she shared her abusive experiences and because of the bond that I shared with her and my sister’s abusive relationship, I wept and I felt bad about that because we are trained not to cry with the family because the concern is that you are going to make her sad. Which in one sense it did make her feel bad but I guess in a good sense it shows her that I am very sympathetic and that I feel her pain in some sense. I am also concerned that as I continue to work with mom if I will be able to handle the emotional part of it.

Other home visitors were more positive in how they were able to handle the issue:

I want to address the idea of frustration and I think that anyone that is going to do this job at some point you have to draw that line of what you can accomplish and then leave it up to them to some point whether it is smoking, abuse or sleeping with their baby or all of those things. You can only give them so much information and then it is up to them. This is the same type of situation. You can’t make them get out of that relationship, but you can give them support and be there for them and that when they are ready you are there for them and will help them.

We all bring our own personal history to any task, but a valuable first step is to acknowledge that history and move beyond that point. Without this crucial step, it is difficult to effectively deal with others experiencing similar problems.

4. The training needs to specifically address communication styles when talking to women about violence.

Over many years of working with vulnerable women, we have come to appreciate their acute abilities to pick up on what we call the phony factor. As one home visitor put it, Making it real, and being real with them, this is what I have heard and this is what I have seen. Home visitors need to understand that they must be totally non-judgmental when talking to women about violence “particularly when addressing the reproductive coercion that may accompany physical and emotional violence. Some home visitors in our training understood their role is to provide information and resources and the woman’s role is to decide what is best for her family. As expressed by this home visitor:

Being careful not to put your personal judgments out there “ making sure you are not prejudging them. What if she does say yes “ what are you going to say? How am I going to make it look like it’s okay, it’s alright and I am glad that you are sharing this with me instead of ‘Girl, how could you’

5. The training should also address concerns the home visitors may have such as whether a requirement to report to authorities such as child protection services will ruin the trust they are trying to build.

We have to consider, do we hotline the situation if we see abuse? It is a little more intrusive with hotline calls and mandating reporting. I think that we think on that end “safety. The duty to warn and safety and I think that is always a concern for us. So, now we have built this relationship with her and if she discloses to us and we hotline her, will that tear down that relationship with her and if she discloses to me that the children in the home might be at risk, that if they pick up the kids, they would have to be in foster care. That is just some of the things that might be going through our heads.

This home visitor clearly struggles with her responsibilities of being a mandated reporter and her role as a helping person for this family. Training should demonstrate how working in partnership with the woman, letting her know that you will not report her without her full knowledge, not only empowers her but also builds trust and confidence so that she can confide her inner thoughts and feelings. This extends to the woman also knowing that what she shares will be confidential, and is of particular importance in rural areas such as Missouri.

6. A huge barrier for home visitors in addressing violence is the presence of the male abuser in the home.

This was a common concern among all the home visitors we have worked with in Missouri, and one that became less of a problem after we brought in a male expert in the area of IPV. Based on his advice and our experiences, we train home visitors to take the woman’s lead on how to deal with her partner. We also recommend the home visitor have brochures in her/his bag that address fathering and/or child development. If the client’s partner appears during the visit, the home visitor can engage him in his role in helping to ensure the child has the best chance of developing to his/her full potential. It seemed that this may not be something home visitors consider, as seen in the following quote,Maybe that is a good idea to bring in some information pamphlets with me in case I have to shift ¦ and he walks into the room one day unexpectedly. During the training, we also suggested that if the home visitor feels uncomfortable discussing IPV in the home for fear of the male partner, then she could meet the woman at another location for one of the scheduled visits. In response, a home visitor stated, I had never thought about meeting her at the WIC clinic or her primary care “you know that is something we can do because they are in the house and I think that is going to have a big impact on our program.

7. Working with families where abuse is occurring is not a happy experience for anyone, particularly when there is a lack of resources in the community for referral. This is reflected in the following statement by a home visitor:

“so it’s like now what do I do because I can’t leave phone numbers to call. I have no way to get you transportation which happens in —which is the site that I am from. I have girls that don’t have a phone and don’t have transportation. I can’t leave phone numbers. I can’t say here is this transportation. So, what do I do? There is my question, because I am stuck.”

Over the five years of working with the DOVE study, we have come to appreciate that, perhaps, the most important thing for any woman is to have the opportunity to discuss her situation with someone, like a home visitor, who will not judge her and who will let her have control of what she needs to do to keep herself and her children safe. In circumstances like these, we have trained home visitors to offer the use of their own cell phone to work out a safety plan with an advocate at either a local shelter or the National Domestic Violence Hotline (1-800-799-SAFE).

When I first started I had that inner sense of ˜Oh my gosh, I have to do something inside me “ you stay calm on the outside and you do the nursing thing “but on the inside I was going crazy. Then I realized that like anything else it has a cycle and that people are not always ready at the same time and in my situation like other programs, I am in their lives for a long period of time. So, I am noticing with these ladies that the more I see these ladies the more they see you, the more they see you caring by connecting them with something. It helps them open up and empowers them “so I just take it just a little bit at a time.

8. Because work in this area is difficult, we recommend frequent team meetings or regularly scheduled meetings with a supervisor for debriefing.

We have found this important in our own work with women experiencing abuse. One of the home visitors expressed the same sentiment:

I think that my struggle is feeling a little inadequate and not knowing what to say. I can encourage them and tell them that what is happening is not okay. I haven’t had a lot of experience with physical abuse but right now I am dealing with verbal and emotional abuse with two of my clients and just thinking that I don’t know the perfect thing to say, and others said taking it home and being so upset and thinking I don’t know how long you can do this type of work since it affects me so much so a variety of emotions.

With Sec 2951 of the 2010 Healthcare Reform Bill, Maternal, Infant, and Early Childhood Home Visiting Programs, calling for home visitation programs to be strengthened by providing comprehensive services to improve outcomes in at risk families, the lessons from DOVE are invaluable. States will be required to measure improvement in rates of IPV, particularly among those women receiving home visitation services. Although IPV is not something that home visitors have ignored when working with families, it is not a health issue that is routinely assessed or addressed in a standardized procedure during most home visits. Not addressing IPV could be one reason that the outcomes home visitors hope to achieve have not been realized.

In summary, it is vital to assess each woman for current IPV so that resources can be offered to improve the health and safety of clients and their children. For assessments to be accurate and for an intervention to be effective, however, very specific training and support must be available for those providing the services. More than how to assess and intervene; the training must include role playing, specific strategies to address barriers that could prevent talking about the issue in the home environment, and last, but not least, the provider’s personal feelings or experiences that may intrude. The DOVE model provides home visiting programs a ready means of implementing this training and intervention. Failure to deal with the elephant in the room will ultimately cause more harm than good.

References

Eddy, T., Kilburn, E., Chang, C., Bullock, L., Sharps, P., and the DOVE Research Team. (2008). Facilitators and barriers for implementing home visit interventions to address intimate partner violence: Town and gown partnerships. Nursing Clinics of North America, 43, 419-435.

Megan H. Bair-Merritt, MD, MSCE

200 North Wolfe Street, Office 2021
Baltimore, MD 21287
Phone: (443) 287-8954
Email: mbairme1@jhmi.edu

Home visiting programs across the United States vary with regard to specific elements of model implementation such as frequency, duration and timing of visits, and educational background of the home visitors. Despite differences in design, however, most home visiting programs target families deemed to be at-risk for adverse outcomes; depending upon the study, ~15-45% of families enrolled in home visiting programs report intimate partner violence (IPV) (Chamberlain, 2007). Additionally, all home visiting programs are united in their goal to optimize maternal and child health. In order to most successfully achieve this overarching goal, home visiting programs should include standardized protocols to assess for IPV and to provide assistance both to women experiencing abuse and to the children exposed to this violence.

The following article describes why inclusion of IPV-specific content is an important component of ensuring excellent child health, what is known in the scientific literature about the impact of home visiting programs on IPV, and what interventions are currently being studied as options for adding IPV- specific content to home visiting models. Finally, recommendations are made for translating research to practice. Complementary information can be found in the Davis, James, & Stewarts’ (2010) guide for policy makers on IPV and home visiting.

Why is the inclusion of IPV screening and response important in ensuring excellent child health?

Childhood exposure to IPV independently predicts poor child health and development. Thus to maximize children’s well-being, IPV must be recognized and addressed, and mothers’ health, safety and positive parenting skills must be supported.

The National Scientific Council on the Developing Child (2005) defines a toxic stressor as “stressful events that are chronic, uncontrollable, and/or experienced without the child having access to support from caring adults” (p. 1); such stressors activate children’s stress response system, with chronic activation of this system potentially leading to permanent physiological changes which have been associated with adverse health outcomes (National Scientific Council on the Developing Child, 2005). Childhood IPV exposure is a particularly potent “toxic stress” for children because it is often chronic and uncontrollable, and it may impact caregivers’ ability to engage in positive parenting practices (Levendosky, Leahy, Bogat, Davidson, & von Eye, 2006).

Childhood IPV exposure has been associated with poor social-emotional child health outcomes from infancy through adolescence (Kitzmann, Gaylord, Holt, & Kenny, 2003; Holt, Buckley & Whelan, 2008). Infants exposed to IPV may exhibit signs of traumatic stress such as frequent crying and inability to comfort, particularly when their mothers have experienced severe abuse and have resultant symptoms of post-traumatic stress disorder (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006). Toddlers display excessive separation anxiety, increased aggression with peers and lower social competence (Howell, Graham-Bermann, Czyz, & Lilly, 2010). School age children frequently blame themselves for the IPV, and are at increased risk for both internalizing (e.g. anxiety, depression) and externalizing (e.g. aggression) disorders (McFarlane, Groff, O’Brien, & Watson, 2003; Hazen, Connelly, Kelleher, Barth, & Landsverk, 2006). Finally, adolescents exposed to IPV are more likely than their peers to engage in risk-taking behaviors such as substance use and abuse, and risky sexual behavior (Holt, et al., 2008). Teenagers exposed to IPV are also more likely to enter into relationships characterized by dating violence (Holt, et al., 2008).

Emerging evidence also supports that children exposed to IPV are at increased risk of a host of physical health problems (Bair-Merritt, Blackstone, & Feudtner, 2006). Boynton-Jarrett, Fargnoli, Suglia, Zuckerman, & Wright (2010) reported that children exposed to “chronic” IPV had an 80% increase in odds of obesity at 5 years of age. Suglia, Enlow, Kullowatz, & Wright (2009) found that IPV-exposed children develop asthma at twice the rate of children not exposed. Interestingly, however, Suglia et al. (2009) found that IPV-exposed children were protected from this increase in asthma incidence if there were high levels of positive maternal-child interaction. This latter finding suggests that interventions that strengthen the relationship between a supportive caregiver and a child, such as home visiting, may help to buffer the adverse impact of IPV on child health.

Finally, children exposed to IPV have altered, and sub-optimal, health care use patterns. These children are less likely to attend regular well-child care with a primary provider, and are more likely than non-exposed peers to be under-immunized (Bair-Merritt, Crowne, Burrell, Caldera, Cheng, & Duggan, 2008). When severe IPV is occurring, they may be more likely to visit the emergency department (Bair-Merritt, Feudtner, Localio, Feinsten, Rubin, & Holmes, 2008). In general, children exposed to IPV incur ~20% higher health care costs than children who are not exposed (Rivara, et al., 2007).

The presence of IPV may limit home visiting programs’ ability to prevent child maltreatment.

The American Academy of Pediatrics states that “identifying IPV may be one of the most effective means to prevent child abuse…” (Thackeray, et al., 2010; p. 1094). This statement is based in part on the common co-occurrence of child maltreatment and IPV. Review studies have estimated that the median overlap in at-risk samples is between 30 and 60% (Appel & Holden, 1998; Edleson, 1999).

Some home visiting programs have had documented success in reducing child maltreatment (Bilukha, et al., 2005). However, an analysis of data from Nurse-Family Partnership in Elmira, New York found that while, in general the home visiting program reduced child maltreatment, rates did not decrease significantly when frequent IPV was present (Eckenrode, et al., 2000). Thus, IPV is the proverbial “elephant in the room.” Without properly addressing violence within the caregivers’ relationship, efforts to prevent child maltreatment may fall short.

What is known in the scientific literature about the impact of home visiting programs on IPV?

The evidence is limited, and existing study findings need to be replicated in other home visiting programs.

A review conducted by Bilukha et al. (2005) examined the relationship between home visiting and the prevention of myriad types of family violence. This review concluded that there was insufficient evidence to determine if home visitation was associated with reduced rates of IPV and called for further research in this area. Several studies, however, have examined the impact of home visiting on IPV. For example, reports from the Nurse-Family Partnership in Denver, Colorado found lower rates of IPV for nurse-visited women when children were four years of age (Olds, et al., 2004), but no program effects on IPV for women in Memphis at 6 or 12 year follow-ups (Olds, et. al., 2004; Olds, et al., 2010).

Bair-Merritt, et al. (2010) recently published a study using data from the Hawaii Healthy Start Program (HSP) to determine whether home visiting was associated with reduced rates of both maternal IPV victimization and perpetration. Results indicated that in the home visiting group, as compared to the control group, rates of IPV victimization decreased and rates of IPV perpetration decreased significantly during the three years of program implementation when children were aged 1 to 3 years. At long-term follow-up when children were 7 to 9 years of age, rates of IPV victimization and perpetration decreased for both intervention and control mothers but there were no longer statistically significant differences between the two groups (Bair-Merritt, et al., 2010).

The recent Hawaii HSP study raises two important issues that warrant further comment. First, measurement and definitions are important if IPV is a primary outcome of interest. It is preferable that IPV not be viewed as “present” or “absent,” but that researchers and program evaluators consider program impact on frequency or rates of IPV; while the ultimate goal is cessation of IPV, reduction in frequency also may be beneficial to maternal and child health. Also, when considering child impact, IPV victimization and perpetration should both be considered.

Second, an association existed between home visiting and reduced IPV even though Hawaii HSP home visitors reported discomfort with their knowledge about IPV, and did not consistently link women experiencing abuse with resources (Duggan, et al., 2004). This reticence to ask women about IPV has been documented in other home visiting studies as well (Tandon, Parillo, Mercer, Keefer, & Duggan, 2008). Reductions in IPV instead may have been related to the home visitors’ encouragement of maternal self-efficacy and to the longitudinal relationship of the mother and home visitor.

Finally, recent evidence suggests that the ability of home visitors to form trusting relationships with mothers, and to potentially reduce IPV, may relate to the mother’s attachment status and depression. Using data from Healthy Families Alaska, Duggan, Berlin, Cassidy, Burrell & Tandon (2009) found that the program had a differential impact on IPV based upon the mother’s baseline depression and attachment status. Specifically, the program attenuated IPV, but only with depressed mothers who scored low to moderate on baseline measures of discomfort with trust/dependence (Duggan, et al., 2009).

What IPV interventions are currently being studied as enhancements to home visiting models?

Recognizing IPV identification and response as a critical part of home visiting, sites across the country are testing the effectiveness of IPV-specific content delivered during home visiting. Two of these projects are detailed here with additional promising programs detailed in the Davis, James, & Stewarts’ Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment. A Guide for Policy Makers” (2010).

With funding from Centers for Disease Control and Prevention through the West Virginia University Injury Control Research Center, investigators from several academic centers are conducting a study to develop and evaluate a model of an in-home IPV intervention for mothers enrolled in the Nurse Family Partnership program (NFP).  For phase 1 of the study– development of the IPV intervention– qualitative case study methods have been used.  The intervention is currently being pilot tested for feasibility and acceptability.  The second phase of the study will involve a cluster randomized controlled trial (RCT) to test the effectiveness of the NFP plus IPV intervention compared with the existing NFP model in improving the client’s quality of life and reducing the recurrence of IPV.  NFP sites are currently being recruited for the RCT; enrollment of participants is planned to start in the fall of 2010.

The DOmestic Violence Enhanced Home Visitation (DOVE) Project is a National Institutes of Health (NIH/NINR) funded research project conducted over 5 years as a collaborative effort between Johns Hopkins University, the Baltimore City Health Department, the University of Missouri, and Missouri Department of Health and Senior Services. The DOVE intervention is a highly-structured public health nurse-administered IPV home visitation program, designed to educate new mothers who screened positive for IPV and reduce their overall risk of continued IPV. To date 257 women have been recruited. Initial results show that, compared to control mothers who did not receive the intervention, women in the DOVE group reported significantly lower physical and sexual IPV scores at delivery (p<.05). At 18 months post- delivery, DOVE participants reported lower overall total IPV scores and lower scores on negotiation and psychological IPV (p<.05) as measured by the Conflict Tactics Scale. These reductions are a promising trend and provide evidence that integrating IPV-specific content into existing home visiting programs may reduce IPV against pregnant and parenting women.

How can research best translate to policy and practice?

To most effectively promote children’s healthy growth and development, home visiting programs should include IPV-specific content.

Although writing such a recommendation is easy, translating research to practice is challenging, and must be done with significant forethought and care. Some flexibility in IPV-specific program content is important to meet the individual needs of the communities that each program serves. However, several general recommendations can be made:

1. Home visitation programs should include explicit, evidence-based content designed to screen for and address IPV. Emerging results from trials such as the NFP study and DOVE should help to inform the use of evidence-based practices. Until results of these trials are disseminated, existing literature about efficacious IPV interventions tested in non-home visiting settings may be a useful guide. For example, Kiely, et al. (2010) reported results from a randomized controlled trial of a tailored IPV counseling intervention that was delivered to women in prenatal clinics. The authors found that women who received the intervention group experienced lower odds of recurrent IPV (Kiely, et al., 2010).

2. Once the IPV-specific content is integrated into home visiting models, an implementation system must be put into place to ensure that home visitors acquire, maintain and apply the skills necessary to enact this content. For example, the ability to successfully implement IPV-specific content may differ based on qualities of the home visitor or the family, and the implementation system needs to specifically address these issues. This likely will take an investment in time and money to train, supervise and coach home visitors, and must include an honest assessment of barriers to screening and management.

3. Programs should routinely assess fidelity. As discussed in #2, a well-conceived implementation plan with quality improvement initiatives may foster model fidelity (Rubin, 2010).

4. If IPV-specific content is delivered with fidelity, programs should consider if this content is effective; however, program evaluators must decide a priori how they will define and measure effectiveness. This likely should include outcomes related to the home visitor (such as knowledge of IPV and its impact on children and awareness of community-based IPV resources) and the caregiver (such as rates of IPV, steps taken toward safety planning, connection with community-based IPV resources). To assess whether IPV is ongoing, one option is administering a validated IPV measure at regular intervals. Repeated screening may be necessary because it is common for caregivers to transition into and out of violent relationships (Bair-Merritt, Ghazarian, Burrell, & Duggan, submitted). Caregiver reporting of frequency, severity and directionality of IPV also may be helpful in evaluating program effectiveness in reducing IPV.

5. A related consideration is whether there are circumstances in which the content is more or less effective, and how the content should be modified to best meet the needs of families for whom it is less effective.

The focus of this issue of the e-journal on the intersection of home visiting and IPV is timely given the recent federal funding of home visitation programs as part of health reform. Moving ahead, close collaboration between researchers, practitioners, advocates and policy makers is needed to optimize the delivery of IPV-specific content as part of the home visitation model.

References

Appel, A., & Holden, G. (1998). The co-occurrence of spouse and physical child abuse: A review and appraisal. J Family Psych, 12, 578-599.

Bair-Merritt, M.H., Blackstone, M., & Feudtner, C. (2006). Physical health outcomes of childhood exposure to intimate partner violence: a systematic review. Pediatrics, 117(2), e278-290.

Bair-Merritt, M.H., Crowne, S., Burrell, L., Caldera, D., Cheng T., & Duggan, A. (2008) Impact of intimate partner violence on children’s well-child care and medical home. Pediatrics, 121(3), e473-480.

Bair-Merritt, M.H., Feudtner, C., Localio, A.R., Feinsten, J.A., Rubin, D., Holmes, W.C. (2008). Health care use of children whose female caregivers have intimate partner violence histories. Arch Pediatr Adolesc Med, 162, 134-139.

Bair-Merritt, M.H., Ghazarian, S., Burrell, L., & Duggan, A.K. (submitted). Intimate partner violence in mothers at-risk for child maltreatment: classes of violence and movement between classes over time. Public Health Reports.

Bair-Merritt, M.H., Jennings, J.M., Chen, R., Burrell, L., McFarlane, E., Fuddy, L., Dugan, A.K. (2010). Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start home visitation program. Arch Pediatr Adolesc Med, 164, 16-23.

Bilukha, O., Hahn, R., Crosby, A., Fullilove, M.T., Liberman, A., Moscicki, E., Snyder, S….Briss, P.A. (2005) The effectiveness of early childhood home visitation in preventing violence: a systematic review. Am J Prev Med, 28, 11-39.

Bogat, G.A., DeJonghe, E., Levendosky, A.A., Davidson, W.S., von Eye, A. (2006) Trauma symptoms among infants exposed to intimate partner violence. Child Abuse Negl, 30, 109-125.

Boynton-Jarrett, R., Fargnoli, J., Suglia, S.F., Zuckerman B., & Wright, R.J. (2010). Association between maternal intimate partner violence and incident obesity in preschool-aged children. Arch Ped Adol Med, 164, 540-546.

Center on the Developing Child at Harvard University (2010). The Foundations of LifelongHealth Are Built in Early Childhood. http://www.developingchild.harvard.edu

Chamberlain, L (2007). Published studies on home visitation with findings relevant to domestic violence. Family Violence Prevention & Health Practice. 6,  http://www.endabuse.org/health/ejournal/archive/1-6/

Davis, L., James, L., & Stewart, K. (2010) Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment. A Guide for Policy Makers http://www.endabuse.org/userfiles/file/Children_and_Families/Realizing%20the%20Promise%20of%20Home%20Visitation%202-10.pdf

Duggan, A.K., Berlin, L.J., Cassidy, J., Burrell, L., & Tandon, S.D. (2009). Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. J Consult Clin Psychol, 77, 788-799.

Duggan, A., Fuddy, L., Burrell, L., Higman, S.M., McFarlane, E., Windham, A., & Sia, C. (2004).

Randomized trial of a statewide home visiting program to prevent child abuse: impact in reducing parental risk factors. Child Abuse Negl. 2004;28(6):623-643.

Eckenrode, J., Ganzel, B., Henderson C., et al. (2000). Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. JAMA, 284(11),1385-1391.

Edleson, J. (1999) The overlap between child maltreatment and woman battering. Violence Against Women, 5,134-54.

Hazen, A.L., Connelly, C.D., Kelleher, K.J, Barth, R.P., & Landsverk, J.A. (2006). Female caregivers’ experiences with intimate partner violence and behavior problems in children investigated as victims of maltreatment. Pediatrics, 117: 99-109.

Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: a review of the literature. Child Abuse Negl, 32, 797-810.

Howell, K.H., Graham-Bermann, S.A., Czyz, E., Lilly, M. (2010). Assessing resilience in preschool children exposed to intimate partner violence. Violence Vict, 25: 150-164.

Kitzmann, K.M., Gaylord, N.K., Holt, A.R., Kenny, E.D. (2003) Child witnesses to domestic violence: a meta-analytic review. J Consult Clin Psych, 71(2), 339-352.

Levendosky, A.A., Leahy, K.L, Bogat, G.A, Davidson, W.S., von Eye, A. (2006) Domestic violence, maternal parenting, maternal mental health, and infant externalizing behavior. J Fam Psychol, 20, 544-552.

McFarlane, J.M., Groff, J.Y., O’ Brien, J.A. & Watson, K. (2003). Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children. Pediatrics, 112, e202-e207.

National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. http://www.developingchild.net

Olds, D., Kitzman, H., Cole, R., et al. Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

Olds, D., Kitzman, H.L., Cole, R.E., Hanks, C.A., Arcoleo, K.J., Anson, E.¦.Stevenson, A.J. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending. Arch Pediatr Adolesc Med, 164, 419-424.

Olds, D., Robinson, J., Pettit, L., et al. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.

Rivara, F., Anderson, M., Fishman, P., Bonomi, A.E., Reid, R.J., Carrell, D., Thompson, R.S. (2007) Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics, 120(6), 1270-1277.

Rubin, D. (2010). Video on http://www.pewtrusts.org/our_work_detail.aspx?id=922

Suglia, S.F., Enlow, M.B., Kullowatz, A., & Wright, R.J. (2009). Maternal intimate partner violence and increased asthma incidence in children: buffering effects of supportive caregiving. Arch Pediatr Adolesc Med, 163, 244-250.

Tandon, S.D., Parillo, K., Mercer, C., Keefer, M., & Duggan, A.K. (2008). Engagement in paraprofessional home visitation: families

reasons for enrollment and program response to identified reasons. Women’s Health Issues, 18, 118-129.

Thakeray, J.D., Hibbard, R., Dowd, M., and The Committee on Child Abuse and Neglect, and the Committee on Injury, Violence, and Poison Prevention (2010). Intimate partner violence: the role of the pediatrician. Pediatrics, 125, 1094-1100.

Home visitation holds great promise as an intervention and prevention strategy for domestic violence (DV). Years ago, I did not make that connection. At the time, I was working for a visionary public health leader who, in the face of consideration resistance, was supportive of me starting a domestic violence training initiative in a maternal and child health program. At the same time, she was considering the potential of home visitation to prevent child maltreatment and asked me to be involved during the initial stages of gathering information and program development. During the implementation phase of the paraprofessional home visitation model that was selected, I urged the program managers to consider expanding their training and protocol to include assessment and intervention for DV but the program followed a specific protocol and the program developers were not supportive of adaptations or changes. I was quickly consumed with our domestic violence initiative and paid little attention to what was happening with this home visitation program as it expanded to several sites.

Less than a decade later, I would be extensively involved with in the intersection between delivering home visitation services and addressing DV both on the national level and in my home state of Alaska. A randomized controlled trial of the Alaska-based home visitation program produced disappointing results and the failure to systemically address domestic violence was identified as one of the key factors limiting program effectiveness. We responded with an intensive plan to provide training and technical assistance. Program management and staff were very receptive but the highly publicized evaluation results and missed opportunities to address prevalent risk factors such as domestic violence put a quick end to funding before changes could be implemented and evaluated. Subsequent analyses of the evaluation data examined how maternal levels of depression, attachment anxiety, and discomfort with trust/dependence moderated program impacts. Interestingly, findings indicated that program impacts were moderated by both maternal depression and attachment insecurity for several outcomes including DV (Duggan et al, 2009).

My next experience of working with programs offering home visitation services truly shaped the work and resource development that I have been doing since on this issue. I joined Rebecca Levenson of the Family Violence Prevention Fund on a nationwide trek to provide training and technical assistance to Healthy Start sites— this federally funded program utilizes a variety of home visitation/case management models to promote their goals and these range from the Nurse Family Partnership and Healthy Families America to Parents As Teachers and other community worker models of care. From Hawaii to Oregon to Pennsylvania to Alabama, we witnessed firsthand the unique window of opportunity that home visitation programs have to promote healthy relationships and the ongoing challenges that home visitors faced working with families experiencing domestic violence. We quickly realized that what worked in clinical settings was not necessarily a good fit for home visits and that training and assessment for domestic violence had to be tailored to the ‘relationship’ based framework of home visitation which looks very different that a clinical checklist during a brief visit. It became clear that all sites needed core competencies to respond to domestic violence benchmarks to measure their progress and to create a universal standard of care in the field.

In this issue of Family Violence Prevention and Health Practice, we hear from leading experts in the field who are evaluating the impact of existing home visitation programs on DV and designing innovative home visitation initiatives to address DV. The challenges of responding to children’s exposure to violence in home visitation programs are examined. This issue also provides the opportunity to highlight new resources that the Family Violence Prevention Fund has developed for home visitation programs. With increased attention and funding to implement home visitation services across the United States, we have an extraordinary opportunity to advocate for integration of screening and intervention for DV into all home visitation services and support both proven and innovative practices that address DV within the context of home visits.

References

Duggan AK, Berlin LJ, Cassidy J, Burrell L, Darius Tandon S. Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. J Consult Clin Pyschol. 2009; 77(4):788-799.

Vicki Breitbart, EdD, LCSW
Vice President of Planning, Research, and Evaluation

Lisa Colarossi, PhD, LCSW
Director of Research and Evaluation

Planned Parenthood of New York City

Correspondence to:  Dr. Lisa Colarossi, Director of Research and Evaluation, Planned Parenthood of New York City, 26 Bleecker Street, New York, NY 10012. lisa.colarossi@ppnyc.org

Acknowledgements
The authors would like to thank the many people who have contributed over time to the work described in this paper, including Drs. Leslie Davidson and Vaughan Rickert at Columbia University, and Anne Robinson, Leslie Rottenberg, and Jini Tanenhaus from Planned Parenthood of New York City. The opinions expressed in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc. Research discussed in this paper were funded by the Centers for Disease Control (U49 CE000731) and the Robert Wood Johnson Foundation.

Implementing Intimate Partner Violence Screening in an Urban Family Planning Center

At Planned Parenthood of New York City (PPNYC), which serves a large number of clients annually from diverse racial, ethnic, and age groups, staff from our three health care centers perceive intimate partner violence (IPV) as a pressing and critical issue.  In 1998 when revisions were being made to medical history forms, PPNYC recognized the importance of incorporating brief standard screening questions to identify clients who had experienced sexual and physical assaults.  The screening questions were chosen from the available research literature about health care and IPV screening.  With this change came a new policy and procedure for screening and referral processes, which included training of health care staff and required universal screening and referral.  All health care clients are screened for IPV, regardless of gender or type of relationship, including marital, dating, and same-sex partnerships.  Since PPNYC’s clients are primarily women (98%), this paper focuses on female clients.

Research to Develop a New Screening Tool

In 2003, researchers from PPNYC and Columbia University began a collaborative investigation into the prevalence and nature of intimate partner violence in young women ages 15 to 24 years.  The focus of this project was to develop an IPV screening approach to identification, management, and referral within health care settings that would be acceptable to younger women, who had not been the focus in previous publications about screening.  It included the development and testing of a comprehensive IPV screening tool and a provider training component focused on working with young women.  Before the project began, PPNYC conducted a brief survey to assess provider attitudes and practices regarding screening for IPV (N = 15).  Eighty-seven percent of providers were overwhelmingly supportive of the need for screening but more than half (60%) were generally concerned about how to incorporate the screening into an already busy schedule.  It was, therefore, critical for the project to develop a new screening tool that would enhance clinical practice and not deter from other tasks and activities of the health care setting. The definition of IPV we used to guide this project was as follows: a pattern of assaultive and coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats.  We looked at these behaviors as perpetrated by someone involved in an intimate relationship where the actions were aimed at establishing control by one partner over another. The initial research project had two phases.

In Phase I of the project (see Zeitler et al., 2006), we conducted an anonymous survey to investigate the attitudes and expectations of young women concerning physical, verbal, and sexual intimate partner violence as well as their attitudes toward screening by health care providers.  Women completed an audio-assisted computer survey that employed the validated Conflict in Adolescent Dating Relationship Inventory (Wolffe, Reitzel-Jaffe, Wekerle, Rasley, & Straatman, 2001). This tool measured self-reported experiences with an intimate partner’s violent behavior and included several open-ended questions.  Of the 645 ethnically diverse women aged 15 to 24 who were family planning patients, 45% (290) reported having EVER been abused by a partner (physical, sexual, or emotional). Of those who had been abused, 55% (159) reported that they had been asked by a provider, but only 20% (58) had disclosed the information when asked.  Ninety percent (580) of women responded positively to being screened, saying that they would not mind answering screening questions in the health care setting. Among the choices for whom they would want to talk to about IPV more women reported that they wanted to speak with a health care provider (95%) compared to their mother (90%) or a counselor (89%).

The survey results were augmented by women’s qualitative comments on the necessity of talking about one’s problems in order to solve them. Women said that screening could serve an educational purpose to help young women recognize different forms of control.  In addition, we found that the language used to ask the questions was of paramount importance.  For example, women reported discomfort with the word “abuse” and said that they preferred responding to descriptions of behaviors rather than labels. Based on the results of Phase I, we developed training for providers and provisional screening tools that were piloted in the same health center six months later.

In Phase II (see Rickert et al., 2009), we piloted three sets of screening questions that were added to the standard medical history form completed by all health center clients as follows: a version that asked about IPV victimization only, a version that asked about a broader range of relationship issues, and one that asked about the woman’s use of violence in addition to her victimization. Young women, 15 to 24 years of age, were randomly assigned to complete one of the three tools for violence screening (N = 799). No significant differences emerged between  the three screening tools for reports of physical and/or sexual abuse ever  or within the last year. We also assessed provider feasibility and acceptability across the three screening approaches and found no significant differences. Providers, on the average, were comfortable talking about IPV with any of the approaches. Overall, the findings from Phase II of the study suggested that brief screening for IPV could easily be incorporated into health care services without interrupting the patient flow.

Policy and Practice Changes Resulting from the Initial Phases of Research

The researchers brought these findings to PPNYC health care providers and administrators for a discussion about how the study could impact their practice.  Additionally, other new studies provided evidence that the use of standardized screening questions increased the frequency of provider discussions with patients about IPV and of higher identification rates among OB/GYN clinics that implemented screening protocols versus those that did not (e.g., Trabold, 2007). This may be due to the “normalizing” of IPV screening questions for both patients and providers by including the questions within the routine context of collecting medical history information (Owen-Smith et al., 2008).  This also signals to patients that abuse is viewed as an important health care issue.

There was overwhelming support for revising the policy for identifying IPV with a new set of questions that would contain language focused more on specific behaviors rather than on abstract labels of “abuse.” Providers also wanted to ensure that the new screening questions would help situate any questions about IPV into the context of the woman’s relationship. Due to the growing body of evidence on the impact of both past and current abuse, providers wanted to screen for both. With this in mind, a committee of health care professionals collaborated with the researchers to develop the new policy and screening tool.  The revised screening tools included the new questions shown in table 1. The revised policy included universal screening of all patients as part of their medical history.  A written and verbal screen is conducted, and patients are referred to an on-site social worker for further assessment and planning and additional referrals to local IPV organizations and hotline numbers. Not only did this research impact the policy and practices of PPNYC, but the umbrella organization for this agency center, Planned Parenthood Federation of America, also developed a policy that encourages IPV screening by all of its affiliates.

Table 1. Screening questions

Evaluation of the New Screening Tool
After the new screening tool and policy were in place for one year, a comparative study was conducted to compare IPV disclosure rates of women who had completed the original older screening tool in 2006 (n=420) and those who completed the new screening questions in 2007 (n=385) (see table 1; Colarossi, Breitbart, & Betancourt, 2009a). Data were collected from chart reviews of randomly selected patients across the three PPNYC health centers. Twenty-two percent (85) of women completing the newer form disclosed current and/or past IPV, compared to 9% (38) of women who answered the older questions. No reporting differences were found by race/ethnicity, health center location, marital status, primary language, payment, or service type. Further logistic regression analyses revealed that after controlling for age, women completing the new screening form were more than 2.5 times more likely to report past and current violence (mutually exclusive) and over 4 times more likely to report experiencing both past and current violence compared to women who reported the original screening form.

We believe that asking only a few more screening questions, which used language about specific behaviors and allowed for more response options (a scale rather than yes/no for most questions), and specifying the time frame provided options for women to report IPV that were not as constraining or stigmatizing as using language such as “abuse” and definitive yes/no responses without a context that were used on the older form.

To further evaluate our updated screening policy for provider barriers to screening, we conducted five focus groups with seventy-five PPNYC health care providers, of whom 65 (87%) also completed written surveys about barriers to screening in family planning clinics (see table 2 for sample questions from the survey).  Providers included certified nurse-midwives, nurse practitioners, physician assistants, social workers, and health care associates. Barriers included lack of time, training, and referral resources. Attitudes toward screening were positive overall, but a number of providers expressed frustration with clients’ lack of follow-up to recommended referrals, were concerned about taking too much time away from other health care matters, and believed that certain job roles were more appropriate for conducting screening than others. Providers also expressed a desire for more training about the connection between IPV and reproductive health as well as for responding to disclosures of violence (Colarossi, Breitbart, & Betancourt, 2009b). As a result, a training session was scheduled with a trainer from the Family Violence Prevention Fund on reproductive control and related counseling techniques.

Future Directions

In the last 10 years, research on IPV and reproductive health has expanded in both breadth and depth from studying the association among IPV and reproductive health outcomes to identifying mechanisms of influence and empirically based screening practices. Evidence for mechanisms of influence, including birth control sabotage, pregnancy manipulation, health care monitoring, and partner refusal to use a condom (Levenson, 2009; Miller, 2007; Williams, Larsen, & McCloskey, 2008; Wingood & DiClemente, 1997) support an expanding role for reproductive health professionals. Future directions for research should include a focus on the ways to reduce pregnancy risks associated with partner control or coercion of birth control such as the provision of long acting contraceptives. We will be considering how to integrate general IPV screening questions with questions focused on reproductive control. Partner control over condom use also presents challenges for new interventions to reduce STI and HIV infections.

In our practice, we believe that universal IPV screening should be implemented in all reproductive health care settings using standardized, empirically tested screening instruments and response protocols. While significant strides have been made in understanding how IPV affects sexual and reproductive health, providers need to be aware that this is a prevalent health care issue that requires universal screening and appropriate follow-up assessment and referral.  This includes improvements in youth-friendly services for teen dating violence and health care, and expanded education and outreach services to immigrant communities with specialized expertise in language and cultural barriers.

PPNYC has also made recent efforts to increase coordinated community responses between health care professionals and IPV specialists by convening an initial discussion group of interdisciplinary providers across New York City. Screening for IPV is only as helpful as the response that follows.  Health care providers can discuss health care needs and safety plans specifically for reducing the risk of reproductive health problems, but bridging social service providers and health care providers is needed to coordinate a full range of services for clients experiencing abuse. Making a referral is not as helpful as facilitating access for a survivor between well-trained health care and social service providers knowledgeable about partner violence. To promote such relationships, increased cross-training is needed about the specific connections between physical and sexual violence, reproductive coercion, and reproductive health, including relationship dynamics that:  inhibit the use of condoms, interfere with birth control methods and lead to unwanted pregnancy; monitor or restrict access to health care; and  impact pregnancy continuation and termination.

Finally, the public must be aware of the range of behaviors associated with partner violence and its effects on reproductive health. Health care recipients who do not have knowledge about the connection between relationship dynamics and reproductive health problems, including increased risk for sexually transmitted infections and HIV, unwanted pregnancy, miscarriage, and urinary tract infections, may not understand why they are being screened for IPV by a reproductive health provider nor be able to take advantage of health care options that may be helpful.  There is a need for more provider training, but also for public campaigns and health center waiting room visual materials to increase knowledge and understanding about the link between reproductive health and intimate partner violence.

Table 2. Examples of questions on the provider survey
Please indicate how much you agree or disagree with each statement

We acknowledge that you follow the PPNYC protocol on partner violence. We would like to know whether you agree or disagree that each factor below makes it more difficult to discuss partner violence with patients.

For the following items, please indicate how much you would like more professional development on each of the topics below.

References

Colarossi, L. G., Breitbart, V., Betancourt G. (2009a). Screening for Intimate Partner Violence in Reproductive Health Settings: An Evaluation Study. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Colarossi, L. G., Breitbart, V., Betancourt G. (2009b). Provider Barriers to Screening for Partner Violence in Reproductive Health Clinics: A Mixed Method Study. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Hathaway, J.E., Willis, G., & Zimmer, B. (2002). Listening to survivors’ voices: Addressing partner abuse in the healthcare setting.  Violence Against Women, 8(6): 687-719.
Levenson, R. R. (2009). Male reproductive control of women who’ve experienced intimate partner violence in the United States:  An unexplored dimention. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Miller, E. Male partner pregnancy-promoting behaviors and adolescent partner violence: Findings from a qualitative study with adolescent females, Ambulatory Pediatrics, 2007; 7(5):360-366.
Owen-Smith, A., Hathaway, J., Roche, M., Gioiella, M.E., Whall-Strojwas, D. & Silverman, J.   (2008). Screening for domestic violence in an oncology clinic: Barriers and potential solutions.  Oncol Nurs Forum, 35(4): 625-633.
Rickert, V.I., Davidson, L.L., Breitbart, V., Jones, K., Palmetto, N.P., Rottenberg, L., Tanenhaus, J., Steven, L. (2009).  A randomized trial of screening for relationship violence in young women.  Journal of Adolescent Health, 45, 163-170.
Trabold, N. (2007). Screening for Intimate Partner Violence within a health care setting: A systematic review of the literature.  Social Work and Health Care, 45, 1-18.
Williams, C. M., Larsen, U., and McCloskey, L. A. (2008).  Intimate partner violence and women’s contraceptive use.  Violence Against Women, 14(12), 1382-1396.
Wolfe, D. A., Reitzel-Jaffe, D., Wekerle, C., Grasley, C., Straatman, A. (2001). Development and validation of the conflict in adolescent dating relationships inventory, Psychological Assessment, 13, 277-293.
Zeitler, M.S., Paine, A.D., Breitbart, V., Rickert, V.I., Olson, C., Stevens, L., Rottenberg, L., Davidson, L.L. (2006). Attitudes about intimate partner violence screening among an ethnically diverse sample of young women. Journal of Adolescent Health, 39, 119.el-119.e8.

Jill Clark, MPH
Massachusetts Department of Public Health, Family Planning Program

Beth Nagy, MPH
Massachusetts Department of Public Health, Division of Violence and Injury Prevention

Background

Massachusetts and national statistics are clear that violence is prevalent in many women’s lives.  In the United States today, one-quarter to one-third of all women report experiencing domestic or sexual violence (Tjaden & Thoennes, 2000), and in Massachusetts, 15% of girls report experiencing dating violence (Massachusetts Departments of Elementary and Secondary Education [MDESE] and Public Health [MDPH], 2008).  Unfortunately, these experiences may be much more widespread than these numbers suggest, since sexual and domestic violence remains heavily underreported.

Sexual and domestic violence are important public health issues that affect many individuals, including those served by all types of public health programs.  In 2002 the Massachusetts Department of Public Health (MDPH) conducted a grant-funded self-assessment of important issues facing a wide variety of maternal and child health programs.  These programs included nutrition programs such as WIC, early intervention, family planning, and home-visiting programs.  Consistent with current knowledge about the prevalence of violence, the survey results showed that 93% of MDPH respondents dealt with issues of domestic violence in their programs, even when violence prevention and response was not the primary goal of the program.

The findings from this self-assessment prompted MDPH to promote the integration of violence prevention and screening into a variety of public health programs.  These efforts were bolstered by the Massachusetts Safe Families project, part of a collaboration of the Association of Maternal Child Health Programs (AMCHP) and the Family Violence Prevention Fund (FVPF).  The Safe Families Project brought together a wide variety of partners to work on integrating sexual and domestic violence prevention and response into maternal and child health programs, and provided a natural springboard for launching a training program for family planning providers and others.

Development of the Family Planning Training

MDPH staff, in close collaboration with the FVPF, provided trainings on sexual and domestic violence screening in the family planning setting.  The MDPH Family Planning Program funds clinical family planning and reproductive health services—including medical exams, contraception, testing and treatment for sexually transmitted diseases, and client-centered counseling—throughout Massachusetts.  Twelve agencies are funded to provide these services in more than 80 clinical locations.  Annually, these agencies provide important services to over 98,000 clients (MDPH, 2008), many of whom are low-income and un- or under-insured.

The training was developed with the intention of reaching as many family planning providers as possible—both clinical providers (e.g., nurses and nurse practitioners) as well as non-clinical providers (e.g., family planning counselors).  In order to reach the greatest number of providers and be as relevant as possible to the family planning setting, a number of key elements were critical to the success of the training.

First, to maximize the number of providers who could attend, as many trainings as possible were held locally or onsite at the family planning agency.  The trainings were also scheduled in conjunction with the agencies to ensure convenient timing, to minimize conflicts with clinic scheduling, and to ensure minimal impact for clients.

Prior to the trainings, each agency was asked to complete the Family Violence and Reproductive Health Program Assessment Tool to establish a baseline of violence screening practices at each agency.  The tool, which is available at www.endabuse.org, asks detailed questions about policies and procedures for sexual and domestic violence screening, staff roles, types of sexual and domestic violence for which clients are screened, intervention and referral strategies, training, and data collection.  This tool was helpful to document the starting point of each agency with respect to violence screening, but it also had two important secondary roles.  First, the information provided by completing the assessment tool allowed each training to be tailored to the specific characteristics of the individual agency, making the training more relevant and more effective.  Second, completing the assessment tool was also informative for the family planning agencies, as it suggested leverage points where violence screening could be incorporated into the flow of the family planning visit.  Some sample questions from the assessment tool are shown in Box I.

Each training session also included staff from local sexual and domestic violence resources.  This was a critical component that facilitated networking, collaboration, and the development of referral resources.  Key personnel from domestic violence agencies, rape crisis centers, sexual assault nurse examiner programs, and shelters attended the trainings.  This allowed family planning and sexual and domestic violence staff to make face-to-face connections with one another, improving referral relationships for clients in the future.  Instead of referring clients to an agency, providers could now make a specific referral to an individual whom they knew.  Including staff from sexual and domestic violence programs in the training also allowed for peer education among providers, increasing each others’ competency in their areas of expertise.

Key Training Concepts

Although each of these structural factors was important to the success of the trainings, the key component was the training content.  Providers in a busy clinical setting needed to understand the importance of violence screening to their work, and to develop strategies for including sexual and domestic violence concepts into their existing clinical practice.  The key concepts that helped to make the case for the importance of sexual and domestic violence screening in family planning settings were the linkages between the experience of violence and health, and the concept of reproductive coercion.

The Connection between Sexual and Domestic Violence and Health

Research has demonstrated strong linkages between a lifetime experience of violence/trauma and adverse health outcomes.  The landmark Adverse Childhood Experiences (ACE) study by Felitti and colleagues (1998) demonstrated profound connections between early traumatic experiences and an increased risk of adult chronic disease and death.  This research provided some of the most compelling evidence that violent experiences can have an effect on health outcomes.  Other work has documented connections between violence experiences and health behaviors; that is, people who have experienced violence are more likely to engage in behaviors that put their health at risk.  This connection was explored in depth at the trainings for family planning providers.  For example, providers learned that:

• Girls who were sexually abused were twice as likely to have their first sexual intercourse before 16 years (Fergusson, Horwood, & Lynskey, 1997)
• One out of two girls who experienced sexual abuse had more than five sexual partners by age 18 (Fergusson et al., 1997)

These risky behaviors, and others like them, were much more common among clients who had experienced abuse and were also associated with negative sexual and reproductive health outcomes.  Examples of the type of information that was shared with providers included:

• Women disclosing physical abuse were three times more likely to experience a sexually transmitted infection than women not disclosing abuse (Coker, Smith, Bethea, King, & McKeown, 2000)
• 40% of pregnant women experiencing abuse reported that the pregnancy was unwanted (vs. 8% of non-abused pregnant women) (Hathaway  et al., 2000)
• Women presenting for a third or subsequent abortion were more than two and a half times more likely to report a history of violence compared to women seeking their first abortion (Woo, Fine, & Goetzl, 2005)

Educating providers about these statistics during the trainings energized and empowered family planning providers.  Providers quickly grasped that understanding the effects of violence on their clients’ lives and discussing the impact of violence with individual patients was not an “extra” task to be added on to an already busy clinical visit.  Instead, effectively screening for sexual and domestic violence would allow them to identify clients at greater risk for engaging in unsafe sexual behavior and to work with these clients to offer resources and strategies for improving their reproductive health as well as to address the violence in their lives.  In order to fully grasp the impact of sexual and domestic violence—especially experiences of violence in a client’s current relationship—providers needed to understand their client’s experiences through a lens of reproductive coercion.

The Concept of Reproductive Coercion

Reproductive coercion is a dimension of inter-personal violence related to reproductive health.  Reproductive coercion is an attempt to control or manipulate another person through their reproductive health.  Examples of reproductive coercion include, but are not limited to:  intentionally exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a woman against her will; intentionally interfering with a partner’s birth control, or threatening or acting violent if she does not comply with the perpetrator’s wishes regarding sexual activity, contraception, or the decision whether to terminate or continue a pregnancy.

Family planning providers were already familiar with the effects of reproductive coercion.  Many had worked with clients who repeatedly reported unprotected sex and unsuccessful use of contraception despite extensive counseling on safer sex methods and contraceptive use.  However, viewing a client’s health behaviors with an understanding of the impact of violence on sexual and reproductive health behaviors, and with a reproductive coercion lens, allows previously invisible experiences of violence to suddenly become visible to reproductive health providers.  Clients that repeatedly request emergency contraception may be unable to effectively use other contraceptive methods because of a controlling or violent partner.  Clients with unintended pregnancies may have become pregnant against their wishes.  Clients who do not practice safer sexual behaviors may have a history of violent experiences and relationships.  Using a lens of reproductive coercion, each of these clients becomes a priority for sexual and domestic violence screening and, if she discloses violence in her past or present relationships, she receives support and collaborative referrals to appropriate services.

This knowledge constituted a fundamental shift in the way family planning clients’ behaviors are understood, and energized family planning providers to do more for their clients.  Family planning providers began to understand quality, sensitive, and appropriate sexual and domestic violence screening as integral to their success as providers of family planning services.  Without screening for violence, family planning providers might never elicit the root causes of many sexual and contraceptive behaviors that prevent many clients from staying healthy, successfully preventing pregnancy, and having healthy relationships.  This results in missed opportunities for contraceptive counseling, education on reducing risk behaviors, and referrals to supportive services.

Furthermore, the experiences that many clients had disclosed to family planning providers were eye-opening to domestic violence and rape crisis staff.  Although sexual and domestic violence program staff were used to hearing about the direct effects of violence, many had never asked their clients questions about their reproductive health or barriers that they experienced to safe sex and effective contraception.  Hearing about family planning clients’ experiences of reproductive coercion educated the sexual and domestic violence program staff about these issues and suggested new questions they might ask their clients.  These connections also encouraged support and referral of sexual and domestic violence provider clients to family planning programs.  Sexual and domestic violence providers learned about strategies for successful contraception in the context of a relationship characterized by reproductive coercion, such as “invisible” contraception like injectables, implants, or IUDs.

To support enhanced screening in the context of the connections between violence and health and reproductive coercion, family planning providers requested specific tools for use in a clinical setting.  In close partnership with the Family Violence Prevention Fund, tools were developed with provider input and disseminated at a follow-up training.  Providers were offered “scripted questions” that gave concrete examples for asking clients about violence in ways that were normalizing, non-judgmental, and relevant to the client’s present clinical concerns.  These materials were presented in many different formats—as detailed scripts, in list format, and on “flash cards” that could be carried in a pocket—in order to be helpful and relevant to the widest possible array of providers and clinical settings.  Some examples of the scripted questions and scripted responses appear in Box II.

Training Outcomes

Providers were enthusiastic both at the initial training and the follow-up training where the tools were introduced.  Nearly all participants in the first round of training felt that the training was helpful and that their assessment skills were enhanced by the training.  Participants’ feedback described how the training had influenced their screening practices.  Comments included that screening for sexual and domestic violence is “totally relevant to the work that I do,” and that “repeat pregnancy tests and terminations could be red flags for DV, not necessarily teens trying to get pregnant.” Providers also reported that they were “able to think of questions in a new way, with an understanding of the purpose.” After the second trainings focused on the provider toolkits, participants were similarly positive, reporting that exercises and materials were helpful and that the training provided them with new knowledge and skills.  Participants also appreciated the focus on usable tools.  One participant commented that the best thing about the training was the focus on “how to talk to patients and language to use.  I have been to several trainings but none have done so until now!”

The 12 MDPH-funded family planning agencies are periodically reviewed by MDPH staff for compliance with the Family Planning Program Standards.  An expectation for routine sexual and domestic violence screening of all family planning clients is included in the Program Standards.  Since the completion of the trainings, three agencies have been reviewed; at all three agencies, counselors were observed conducting appropriate and relevant sexual and domestic violence screening.  Site reviews will continue and additional sites will be assessed.  Most importantly, implementation of the training has raised awareness about the importance of sexual and domestic violence screening among both MDPH staff as well as providers, ensuring that violence screening is assessed as one of the key aspects of good family planning counseling.

Lessons Learned and Future Directions

Although the trainings appear to have been successful in increasing awareness among providers and increasing screening for sexual and domestic violence in family planning settings, some aspects of the program could be improved in subsequent trainings or in implementation in other states.  First, the trainings described above were a collaborative work-in-progress between MDPH and FVPF.  The toolkit materials and trainings on practical skills emerged over time with input from both organizations as well as the family planning agencies themselves.  With the benefit of hindsight, providing some of the practical skills and toolkit materials earlier would have reinforced the important training messages as well as given providers tangible tools to use immediately following the completion of training.

Second, there are many opportunities to provide additional tools and technical assistance to the family planning providers that could be utilized.  Providers and administrators may need assistance to update documents such as medical record forms, counseling protocols, and referral documentation in order to complete the transition to new approaches to violence screening.  Especially at larger, more complex agencies, support and technical assistance may be needed to overcome administrative barriers that can delay the implementation of sexual and domestic violence screening indefinitely.

Finally, provisions for ongoing sustainability of screening must be addressed.  Staff turnover is a very important issue to address, resulting both in loss of trained staff at family planning agencies as well as loss of personal referral connections between family planning and sexual and domestic violence programs.  Institutionalizing the expectation of both violence screening and relationship building among community-based programs is critical.  One way that relationship building has been institutionalized in Massachusetts is a programmatic standard that family planning programs and rape crisis center programs meet for cross-training at least once a year.  This standard has been incorporated into the standards for both MDPH-funded family planning programs as well as MDPH funded rape crisis center programs.

However, even if expectations for ongoing training and relationship building have been institutionalized, resources are needed for refresher trainings to ensure that new staff are familiar with the connections between sexual and domestic violence and reproductive health and coercion.  One option may be developing a training curriculum that can be delivered to provider agencies and conducted in-house for new hires.  Ensuring that violence screening is expected by funding agencies (in this case, the MDPH Family Planning Program) is also critical to monitoring performance and ensuring sustainability.  Standards about sexual and domestic violence screening should be explicit, informed by the latest scientific evidence, specific, and enforced.

Ultimately, implementation of violence screening in family planning settings can be accomplished with limited resources.  The key is the providers themselves:  offering compelling evidence that violence screening enhances client outcomes, both directly and indirectly related to reproductive health, and encouraging providers to offer screening in an environment where they will be supported both personally and with effective referral resources for their clients.  Offering training and support to providers that achieves these goals can increase violence screening and improve outcomes for family planning clients.

References

Coker, A.L., Smith, P.H., Bethea, L., King, M.R., & McKeown, R.E. (2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9(5), 451-457.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. & Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245-258.

Fergusson, D.M., Horwood, L.J. & Lynskey, M.T. (1997). Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child Abuse and Neglect, 21(8), 789-803.

Hathaway, J.E., Mucci, L.A., Silverman, J.G., Brooks, D.R., Mathews, R., & Pavlos, C.A. (2000). Health status and health care use of Massachusetts women reporting partner abuse. American Journal of Preventive Medicine, 19(4), 302-7.

Massachusetts Department of Public Health Family Planning Program. (2008). Family Planning Program Summary of Service Data from 12 Program Annual Reports, Fiscal Year 2007. Boston, MA.

Massachusetts Departments of Elementary and Secondary Education and Public Health. (2008). Health and Risk Behaviors of Massachusetts Youth, 2007. Boston, MA.

Tjaden, P. and Thoennes, P. (2000). Extent, Nature, and Consequences of Intimate Partner Violence. Findings From the National Violence Against Women Survey.  Washington, DC: National Institute of Justice, Centers for Disease Control and Prevention.

Woo, J., Fine, P., & Goetzl, L. (2005). Abortion disclosure and the association with domestic violence. Obstetrics and Gynecology, 105, 1329-1334.