Domestic Violence It is Everyone’s Business Leah Rosenthal, PhD Jennifer Brown, MFT Claudia Kruse, MFT Kaiser Permanente Employee Assistance Program

It Can Happen to Anyone… KP physician and employees victims of domestic homicide Stephanie Zalot 1966-2003 Quality Outcomes Cassandra Floyd, MD 1966-2001 OB/GYN Lisa Munoz 1976-1999 Optical Services “An Equal Opportunity Destroyer” 3

Overview Establishing DV as a Critical Workplace Issue Prevalence, health effects and costs Why employers are getting involved The important role of EAPs Building an Effective Workplace Program Education - training staff and managers Partnership - raising awareness Prevention - promoting materials Responding to DV at the Workplace Partnerships Policies EAP role

Kaiser Permanente by the Numbers A healthy workforce requires a healthy workplace. 8.7 million members 156,000 employees 13,729 physicians 416 medical offices 32 medical centers 80% female workforce

Kaiser Permanente by the Numbers KP Employee Assistance Program is a division of KP Healthy Workforce and a National Shared Service. External: Colorado Georgia Mid-Atlantic States Ohio Internal / Onsite: Northern California Southern California Oregon / Washington Hawaii

DV is Common New cases of breast cancer: 211,000 Number of women dying from cardiovascular disease: 484,000 Number of women who are victimized by DV each year: 1,500,000 Victims of physical DV during their lifetime (USA): 1 in 4 women 1 in 14 men Breast Cancer Facts & Figures. 2005-2006, American Cancer Society: Atlanta, GA. Heart Disease and Stroke Statistics. 2006, American Heart Association. Tjaden, P. and N. Thoennes, Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women survey. National Institute of Justice Centers for disease Control and prevention (NIJCDC), 1998. Domestic violence is the leading cause of injury to women aged 15 to 44. Can Fam Physician, 1999. 45: p. 2317, 2322. 7 7

A Look at National Statistics: DV Leads to High Morbidity & Mortality 1 in 4 women, 1 in 14 men are the victims of DV at some point in their lives. DV is the leading cause of injury to American women ages 15-44. DV is a leading cause of pregnancy-associated mortality. Thompson, R., et al., Intimate Partner Violence: Prevalence, Types, and Chronicity in Adult Women. Am J Prev Med, 2006. 30(6): p. 447-457.

Prevalence of DV has been Significantly Under-Estimated Group Health Cooperative assessing physical, sexual and emotional abuse (2006 data): Among 3,429 Seattle women 18-65 years: 8% are currently experiencing DV 15% experienced DV in last 5 years 44% lifetime prevalence Highest prevalence occurs in working age and parenting women Associated with 4 times higher risk of severe depression+ +Thompson, R., et al., Intimate Partner Violence: Prevalence, Types, and Chronicity in Adult Women. Am J Prev Med, 2006. 30(6): p. 447-457 Thompson, R., et al., Intimate Partner Violence: Prevalence, Types, and Chronicity in Adult Women. Am J Prev Med, 2006. 30(6): p. 447-457. 2006 Bonomi, A. E., Thompson, R. S., Anderson, M., Reid, R. J., Carrell, D., Dimer, J. A. and Rivara, F. P. Intimate partner violence and women's physical, mental, and social functioning. Am J Prev Med, 2006. 30(6)p 9

A Look at National Costs $5.8 billion per year. $4.1 billion in direct medical and mental health expenses. $900 million in lost productivity. $900 million in lost earnings by victims of homicide. $18 billion per year for costs associated with law enforcementand criminal justice system.

Contributes to Future Health Care Costs Witnessing physical abuse of mother is strongly associated with health risk factors and conditions. Unintended pregnancy Sexually transmitted disease Smoking as an adolescent Becoming victims or perpetrators of DV as adults Poorer health outcomes as adults: cardiovascular disease emphysema depression Based on CDC/Adverse Childhood Experiences studies conducted at KP San Diego http://www.cdc.gov/NCCDPHP/ACE

DV is a Costly Workplace Issue Hidden costs: Abuse related absenteeism: 54% missed an average of 3 days or more per month.* Decreased productivity: 37% report job performance affected.+ Increased cost of DV + employees $2,200/yr direct health care costs+ $990/yr in productivity (CDC estimate)+ Workplace security and liability In a survey of EAP programs, 83% had employees with restraining orders. *Laurence, L. and R.Spalter-Roth, Measuring the Costs of Domestic Violence Against Women and the Cost-Effectiveness of Interventions. 1996, Institute for Women’s Policy Research. +Cost of Intimate Partner Violence Against Women in the United States. 2003, National Center for Injury Prevention and Control, CDCP *Laurence, L. and R.Spalter-Roth, Measuring the Costs of Domestic Violence Against Women and the Cost-Effectiveness of Interventions. 1996, Institute for Women’s Policy Research. +Cost of Intimate Partner Violence Against Women in the United States. 2003, National Center for Injury Prevention and Control, CDCP

Health Effects More than physical injuries… Headaches Insomnia, fatigue Chest pain, palpitations Chronic pain syndromes Substance abuse or relapse

Mental Health Effects Major depressive disorder Occurs in 63-81% of abused women compared to 7% in controls. Generalized anxiety Occurs in 38-47% of abused women compared to 6% of controls.

DV is Closely Associated with Other Health Risks Smoking Sexually transmitted infections Not obtaining preventive care (breast and cervical cancer screening, immunizations) Sub-optimal control of chronic health conditions (diabetes, asthma, hypertension) Unintended pregnancy, complications during pregnancy Other chronic health problems Centers for Disease Control (CDC), Feb 2008

Aiding Recovery The majority of women end abusive relationships. On average, it takes about 5 years. On average, leave 3-5 times. Most do not have another abusive relationship. Financial resources and economic stability are extremely important. Focus on safety.

“The Systems Model” Health Care Approach to DV Prevention “Kaiser Model” Inquiry and Referral On-site Resources Leadership and Quality Improvement I Supportive Environment Community Linkages 17

Engaging Leadership How to engage leadership: Identify a “Champion.” Begin a DV Prevention Task Force. Build the business case for prevention by: - examining prevalence. - presenting financial and human costs.

KP Domestic Violence Champions Brigid McCaw, MD, MS, MPH Medical Director for Domestic Violence Services Kaiser Permanente Northern California Brigid.McCaw@kp.org Tammy Jones Senior Vice President Healthy Workforce, National Human Resources Tammy.Jones@kp.org Jerry O’Keefe, MFT, CEAP Director, Kaiser Permanente National EAP Services Jerry.O’Keefe@kp.org

Why are Employers Getting Involved? A healthy workforce: contributes to organizational prosperity. fosters workplace safety (OSHA). reduces risk of legal and liability issues. enhances community improvement and positive business identity. decreases expenses associated with health care.

Building a Workplace Program Raising awareness at work… Where to focus? - Prevention How to prevent? - Education, partnership and promotion Tjaden, P. and N. Thoennes, Extent, Nature, and Consequences of Intimate Partner Violence. 2000, U.S. Department of Justice: Washington, DC. Adult Female Victims of Intimate Partner Physical Domestic Violence, in Data Points. 2001, California Women's Health Survey, Office of Women's Health, California Department of Health Services: Sacramento, CA. 41.Felitti, V.J., et al., Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, 1998. 14(4): p. 245-58. Dube, S.R., et al., Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services. Violence Vict, 2002. 17(1): p. 3-17. Anda, R., et al., Childhood abuse, household dysfunction and indicators of impaired worker performance in adulthood. The Permanente Journal, 2004. 8: p. 30-38. Rivara, F. P., Anderson, M. L., Fishman, P., Bonomi, A. E., Reid, R. J., Carrell, D. and Thompson, R. S. Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics, 2007. 120(6):1270 21

When to Promote Health at Work? Healthy and Productive Risk Factors Develop Early Clinical Disease Prevention and Health Promotion Raising Awareness at Work Raising awareness at work… Full Blown Clinical Disease Chronic Care Management Severe Disease and Disability 22 22

Domestic Violence at Work… Who is Affected? Victims 12 months, affects 8% of female and 3% of male employees. Frequently associated with other conditions that reduce work performance. Co-workers Increased workload. Concern about safety. Perpetrators 20% of employees report they have known co-worker who perpetrated DV on work time.

EAP and Employers Education, Partnership, Prevention Religious Leaders Advocates Police Health Professionals Employers Friends Judges & Legal Professionals Policy Makers Educators

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