1. Innovative Strategies for Dealing with Interpersonal Violence Phyllis W. Sharps, PhD, RN, FAAN Professor and Associate Dean for Community and Global Programs

2. 1. Discuss the importance of universal screening in maternal and child health care settings. 2. Identify barriers for screening and intervening. 3. Describe new strategies for screening and connecting families with resources for decreasing risks related to interpersonal violence. Session Objectives

3. VIOLENCE AGAINST WOMEN  Across lifespan female children and women are more vulnerable  Female victims of violence suffer significant health consequences  Dynamics of violence against women is different compared to men 3

4. ALARMING STATISTICS  1 in 3 women globally, have experienced some kind of assault:  Sexual  Physical  Psychological ( UNFAP, 2000)  1 in 4 women in USA report experiencing violence by a current or former partner (National Crime Victimization Survey: 2007-2008, US Dept. Justice, Bureau of Statistics – http://www.ojp.usdoj.gov/bjs/pub/pdf/cv07.pdf http://www.ojp.usdoj.gov/bjs/pub/pdf/cv07.pdf 4

5. ALARMING STATISTICS Women are much more likely to be victimized than men  Women = 84% of spouse abuse victims  Women = 86% of victims of abuse by BFs or GFs  75% of perpetrators of family violence are male 5

6. ALARMING STATISTICS  In the U.S., 32.7% of femicides were committed by intimate partner vs. 3.1% male homicides were IPV-related (Fox & Zawitz, 2006)  50% of women who were victims of intimate homicide had been seen in the health care system in the year before their death (Langford, 1998; Sharps et al, 2002) 6

7. CDC NISVS Survey Results on IPV Victimization (weighted prevalence) Health Outcomes -2011 Disproportionately higher among AI/AN, African American & Multiracial Women www.cdc.gov/ViolencePrevention/NISVS Females lifetime Females Past Year Males Lifetime Males Past Year Physical violence32.9428.24.7 Rape 9.4.6** Stalking10.72.82.1.5 Rape, physical violence, &/or stalking35.65.928.55 With IPV-related impact (fear, PTSD Sx, Injury, pregnancy, STI, missed work, need for services) 28.8-9.9- Severe physical violence (vs. push/shove/slap) 24.32.713.82 Any psychological aggression (expressive or coercive control) 48.813.948.418.1 Injury/needed medical care from IPV *Cell size too small or standard error too large 14.8/7.94/1.6

8. Cost Of Violence Against Women Cost of non-fatal injuries  1995 = $5.8 M  2012 = > $5.8 B Costs are  Direct medical/mental health care  Lost productivity from paid work & household duties – 13.6 M days of lost productivity 8

9. It’s Important UNIVERSAL SCREENING 9

10.  Routine Screening & Brief Counseling mandated by 2012 Affordable Care Act – for primary care women’s health covered services  Recommended by 2011 IOM report (www.iom.edu )www.iom.edu  Office of women’s health at DHHS (www.OWH.gov)www.OWH.gov 10

11.  USPTF 2013 recommends screening for IPV – ALL women of childbearing age (ACOG ’90 & ’13; Nursing Outlook ’13)  Part of home visitation programs for pregnant women – DOVE intervention (Sharps, Bullock & Campbell NINR) UNIVERSAL SCREENING 11

12. Challenges for Screening and Intervening BARRIERS 12

13.  Fear – asking might make it worst for women  Personal safety – what if the abuser comes in or finds out!  Fear – women and her children might not come back for care or drop –out of program  Lack of training - not aware of all health care outcomes, myths,  Frustrations – why do they stay, why they don’t use services  Not sure – how to ask questions, what to say or do PROVIDER CONCERNS 13

14.  Embarrassment – to reveal  Victimization – if abuser finds out  What happens to my disclosure – who else knows  Judgmental attitudes – of professionals and other helping professionals WOMEN’S CONCERNS 14

15. Screening and Intervening STRATEGIES 15

16.  Important Strategies  Universal Screening  Danger Assessment  Safety Planning  Referrals (shelters, legal) 16 Violence Against Women

17.  Privacy  Frame as routine part of practice  Ask direct questions  Ask at very visit  Listen and be sensitive to her story  Avoid minimizing her experience 17 Asking Questions

18.  Abuse Assessment Screen (AAS)  RADAR  ASSERT 18 Assessment Tools

19. Abuse Assessment Screen 1. 1. Have you ever been emotionally or physically abused by your partner or someone important to you? 2. Within the last year, have you been hit, slapped, kicked, pushed or shoved, or otherwise physically hurt by your partner or ex-partner? If YES, by whom Number of times 3. Does your partner ever force you into sex? 4. Are you afraid of your partner or ex-partner? Helton & McFarlane, 1986 Mark the area of any injury on body map. 19

20. Assessment Tools 20 R: Remember to ask A: Ask directly D: Document findings A: Assess for safety R: Review options, refer (F:) Follow-up A: Ask S: Sympathize S: Safety E: Educate R: Refer T: Treat

21.  Developed in 1985 to increase battered women’s ability to take care of themselves (Self Care Agency; Orem ‘81, 92)  Modified – now 20 items - 2001 based on results from homicide study  Interactive, uses calendar - aids recall plus women come to own conclusions - more persuasive & in adult learner/ strong woman/ survivor model  Intended as lethality risk instrument versus re-assault (e.g. SARA, K-SID) - risk factors may overlap but not exactly the same 21 Danger Assessment (Campbell ’86, 2001)

22.  Routine assessment at EACH prenatal care visit by regular provider (McFarlane & Parker ‘92)  If abuse during pregnancy, alert for child abuse  Understand particular tendency for hope for relationship during pregnancy  Careful assessment at post partum 22 PROVIDER ROLES: ABUSE DURING PREGNANCY

23. One Love App – Danger Assessment APP for women aged 16-26 www.joinonelove.org or www.dangerassessment.org www.joinonelove.org www.dangerassessment.org 23 Campbell et al JIPV 2009

24. “Coaching Boys Into Men” Futures Without Violence (www.futureswithoutviolence.org)www.futureswithoutviolence.org Also Beyond Title Nine – Campus Violence; Start Strong; More!! RCT Miller et al, J of Adolescent Health 2012

25.  Important Strategies  Coordinate Community Response  Integrated systems  Missed Opportunities  Empower Women  Listen to her story  Increase her awaren ess 25 Violence Against Women

26. Patient SurvivorsDV Advocates LegislativeMilitaryPhysicians Prevention Intervention Treatment Society Education Social Services Governance Health Religious Nurse Professionals 26 Community Team Process

27. NATIONAL DOMESTIC VIOLENCE HOTLINE 1-800-799-SAFE (7233) 27

28. Phyllis W. Sharps, PhD, RN, FAAN psharps@son.jhmi.edu 410-614-5312 28 THANK YOU