Catalyst for Health and Safety: Strategies to address intimate partner violence in community health centers

National Health Resource Center on Domestic Violence Free technical assistance and tools including: Patient and provider resources Training curricula Clinical guidelines State reporting law information Documentation tools Model policy and protocols Model programs in multiple states For more information, please visit the National Health Resource Center on Domestic Violence website. Notes to Trainer: Explain that the National Health Resource Center on Domestic Violence provides free technical assistance and health materials. To order materials, visit: https://secure3.convio.net/fvpf/site/Ecommerce/15587835?FOLDER=0&store_id=1241

Learning Objectives As a result of today's activity, learners will be better able to: Understand the health impact of intimate partner violence (IPV) and what works to identify and respond to abusive relationships Apply at least 3 strategies to embed a response to IPV into other initiatives addressing social determinants of health Notes to Trainer: Read the learning objectives aloud. 3) Describe at least 3 approaches other primary care centers are using to create and measure sustainable responses to IPV

AZ Alliance well positioned to as a model PCA AZ has a strong history working on successful models Project Connect Trainings for providers at over 20 family planning clinics across the state, many in rural and frontier communities PATHS: testing in an intervention in three health centers in AZ (Williams, Kingman and Lake Havasu) HRSA Project Catalyst: Phase one trained the Mariposa clinic, expanding into multiple settings in Arizona

Why a Health Care Response is needed Ever growing body of research on health impacts of D/SV Many victims/survivors access health care more often than they seek other services Patients support health response Health providers are well positioned to identify, help and refer patients!

Prevalence of Intimate Partner and Sexual Violence 3.9 million women physically abused annually in the United States 1 in 4 women and 1 in 7 men report lifetime prevalence #1 for homicide of women More prevalent among women than diabetes, breast cancer, and cervical cancer Instructor Script: DV is much more common than most health care providers, managers, administrators and policy-makers realize. The prevalence of DV and the adverse health effects are staggering. DV is virtually impossible to measure with absolute precision for a number of reasons, including the societal stigma that inhibits victims from disclosing their abuse and the varying definitions of abuse used from study-to-study. The estimates range from 960,000 incidents of violence against a current or former spouse, boyfriend, or girlfriend per year to 3.9 million women raped and/or physically assaulted by an intimate partner annually. (NVAW Survey, 1993) Nearly one-third of American women (31%) report being physically or sexually abused by a husband or boyfriend at some point in their lives, according to a 1998 Commonwealth Fund survey. (Commonwealth Fund, 1999) DV crosses all demographic groups, including educational, racial, and socioeconomic. In 1999, there were 1,642 murders a year by intimates, of those 74% (1,218) were women. (Bureau of Justice Statistics Special Report, 2001) Domestic violence is more prevalent among women than diabetes, breast cancer, and cervical cancer, all health problems routinely assessed for in clinical settings. (CDC: National Diabetes Fact Sheet, 1998) National Cancer Institute(SEER 1994 and 1997).

The Cost of IPV The medical cost burden within the 12 months after victimization ranges from $2 to $7 billion nationally. Without intervention, higher health care costs persist even 3 to 5 years after DV exposure has ended. DV exposure increases the need for mental health services. A large and growing body of evidence indicates that DV elevates health care utilization and costs, but current estimates are considered to underestimate the true cost of DV due to undisclosed and/or undiagnosed abuse. http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=17269&lid=3

Support for Screening as a Prevention Strategy The USPSTF recommends screening for women of childbearing age (up to age 46) for IPV and conducting a follow up with any woman with a positive screen. Notes to Trainer: The January 2013 recommendations state that there is sufficient evidence to support domestic violence screening and interventions in health settings for women “of childbearing age.” (14-46 years). There was “insufficient evidence” for elderly or vulnerable adults and that more research is needed on elder abuse and neglect.

Clinical Preventive Services for Women 2011 Institute of Medicine released Clinical Preventive Services for Women: Closing the Gap IPV screening is one of eight preventive services that would ensure women’s health and well being Currently a covered benefit in the ACA Notes to Trainer: The 2011 Institute of Medicine (IOM) Recommendation: Screening and counseling involve the elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems. One of the great eight covered preventive screenings as a result of the 2011 IOM’s recommendations includes a well-woman visit: http://iom.nationalacademies.org/Reports/2011/Clinical-Preventive-Services-for-Women-Closing-the-Gaps.aspx

Governmental and Professional Organizations Endorse Screening Professional health association endorse an IPV response AMA, AAP, AAFP ACOG etc. Joint commission Committee opinion no. 554: reproductive and sexual coercion. Obstetrics and gynecology, 121(2 Pt 1), 411-415. 3, 2013 Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults policy, 2013.

Growing national support for an IPV response ”When health center leadership commits to the system-wide integration of care, including developing formal partnerships with community based social service organizations to address intimate partner violence, we find they are better positioned to improve health outcomes for the patients they serve.” -Judith Steinberg, MD, MPH, Chief Medical Officer, Bureau of Primary Health Care, Health Resources and Services Administration

Addressing IPV Benefits Your Health Center and Your Patients IPV interventions are low cost Interventions are evaluated to be effective Improving response increases provider satisfaction Offers a solution for an underlying risk impacting at least 25% of women

Women who talked to their health care provider about abuse were… Healthcare providers can make a difference! Women who talked to their health care provider about abuse were… 4 times more likely to use an intervention 2.6 times more likely to exit the abusive relationship Narration: The research has shown that just having the opportunity to talk to a health care provider about domestic violence can increase access to domestic and sexual violence services. In this study by McCloskey et al. (2006), 132 women outpatients who disclosed domestic violence in the preceding year were recruited from multiple hospital departments and community agencies. Abused women who talked with their health care providers about the abuse were more likely to use an intervention and exit the abusive relationship. Women who were no longer with their abuser reported better physical health than women who stayed. McCloskey LA, Lichter E, Williams C, Gerber M, Wittenberg E, Ganz M. Assessing Intimate Partner Violence in Health Care Settings Leads to Women’s Receipt of Interventions and Improved Health. Public Health Reporter. 2006;121(4):435-444. Additional studies in reproductive and adolescent health programs find that women and girls who receive a health based intervention report leaving the relationship because it was unhealthy and unsafe. (ADD CITATION)

Health Impact of Domestic, Sexual and Intimate Partner Violence

Injuries Among IPV/SA Victims bruises, broken bones, burns, spinal cord injuries, lacerations, knife wounds etc. TBI: 71% of women experiencing IPV have incurred traumatic brain injury (TBI) due to a physical assault Strangulation More than two-thirds of IPV victims are strangled at least once the average is 5.3 times per victim This self-reported data is from the 1995 National Violence Against Women Survey. While most physical injuries are fortunately minor, the emotional toll and the long term health consequences are damaging. (Arias & Corso, 2005, Chrisler & Fergun, 2006) Chrisler & Ferguson, 2006 Abbott et al, 1995; Coker et al, 2002; Frye et al, 2001; Goldberg et al, 1984; Golding et al, 1999; McLeer et al, 1989; Stark et al, 1979; Stark & Flitcraft, 1995)

Beyond Broken Bones and Black Eyes: Long-term health impact of violence Overwhelming? You bet! But reality. Words from Wordle directly from CDC. Women who have experienced domestic violence are 80% more likely to have a stroke, 70 percent more likely to have heart disease, 60 percent more likely to have asthma and 70 percent more likely to drink heavily than women who have not experienced intimate partner violence. Just to name a few… Health problems associated with a history of forced sex by an intimate partner include: Chronic headaches Depression Pelvic inflammatory disease Vaginal and anal tearing Bladder infections Sexual dysfunction Pelvic pain Gynecological problems Survivors of rape are 13 times more likely to attempt suicide compared to those who have not been victims of crime, and 6 times more likely to attempt suicide than those who have been victims of other crimes. 35 According to the Center for Disease Control and Prevention, 31.5% of female and 16.1% of male adult victims of rape reported physical injury as a result. More than 1/3 of injured females, or approximately 105,187, received medical treatment in emergency rooms between the years of 2004 and 2006.14 In addition to immediate and/or acute injury, experiencing sexual and interpersonal violence can have long term emotional and physical health effects.   The negative physical and emotional health effects of sexual and interpersonal violence and trauma can interfere with a victim’s successful college career and can continue to affect them throughout their lives. Data from a 2005 Behavioral Risk Factor Surveillance System (BRFSS) report linked high cholesterol, stroke and heart disease with a history of rape among both males and females; “Female victims of non-consensual sex were more likely to report heart attack and heart disease compared to non-victims.” 14 The health impacts of SA/IPV disproportionately affect female victims. According to According to a 2010 survey conducted by the Center for Disease Control and Prevention (CDC), among female victims of rape, physical violence, or stalking by an intimate partner, 72.2% were fearful, 62.6% experienced at least one post-traumatic stress and 41.6% were injured as a result of the violence, while among men 18.4% were fearful, 16.4% experienced PTSD and 13.9% were injured as a result of the violence.14 http://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html http://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html, 2010

IPV and impact on chronic health conditions Heart disease Overweight/Obese Stroke Depressed immune function Irritable bowel syndrome Poor perinatal health outcomes Arthritis Asthma Headaches and migraines Back pain Chronic pain syndromes Genitourinary problems High cholesterol (Black & Breiding,2008; Campbell et al, 2002; Coker et al, 2000; Constantino et al, 2000; Follingstad, 1991; Kendall-Tackett et al, 2003; Letourneau et al, 1999; Wagner et al, 1995; Coker et al, 2000; Drossman et al, 1995; Lesserman et al, 2007; Kernic et al, 2000; Talley et al, 1994; Black & Breiding, 2008; Bailey, 2012)

Behavioral Health Impacts Anxiety/Panic Attacks Sleep problems Memory loss Post-traumatic stress disorder (PTSD) Depression, poor self-esteem Insomnia Suicide ideation/actions Alcohol, drug, tobacco use Narration: Domestic and sexual violence also have psychological effects: including anxiety, sleep problems, memory loss, ptsd, depression, poor self esteem, insomnia, and risk of suicide. (Bergman & Brismar, 1991; Coker et al, 2002; Dienemann et al, 2000; Elsberg et al, 2008; Kernic et al, 2000; Stark & Flitcraft, 1995; Sato-DiLorenzo & Sharps, 2007; Lemon et al, 2002; Ackard et al, 2003; Weinsheimer et al, 2005; Kaysen et al, 2007; Miller et al, 1989; Plichta, 1992) (Bergman & Brismar, 1991; Coker et al, 2002; Dienemann et al, 2000; Elsberg et al, 2008; Kernic et al, 2000; Stark & Flitcraft, 1995; Sato-DiLorenzo & Sharps, 2007; Lemon et al, 2002; Ackard et al, 2003; Weinsheimer et al, 2005; Kaysen et al, 2007; Miller et al, 1989; Plichta, 1992)