Building Effective Programs: Coping with the Patchwork Quilt of Women's Health Issues

Domestic Violence

Presenter: Jeffrey Coben, M.D., Director, Center for Violence and Injury Control, Allegheny General Hospital, PA; Senior Scholar in Residence for Domestic Violence, Center for Outcomes and Effectiveness Research, Agency for Healthcare Research and Quality (AHRQ).

Estimates indicate that each year more than 2.5 million women are victims of domestic violence. About one in every six women seeking health care has sustained domestic violence injuries in the past 12 months. Abused women are significantly more likely than those not abused to have visited an emergency department, been hospitalized, and in contact with the health care system in the prior year. Abused women are also more likely to suffer from back pain, headaches, gynecological problems, unintended pregnancy, alcohol dependence, HIV, and sexually transmitted diseases (STDs) than non-abused women. With all these adverse consequences that have been linked to domestic abuse, there have been calls for increasing the role of the health care system in identifying and intervening for victims of domestic violence.

Dr. Coben summarized the findings of research conducted in the past 10 years on domestic violence and the health care system in the following areas: screening and detection, risk factors, and effectiveness of health care training programs. He then suggested promising examples of State initiatives to address the issue.

Screening and detection research has found that:

• Over 90 percent of women support routine inquiry by health care providers around domestic violence.
• Most abused women present with non-traumatic complaints, indicating that routine or universal screening needs to be considered in order to identify these women.
• Screening with direct questions increases disclosure, but may take several visits and attempts before women will admit to being victimized.

Factors that place women at increased risk for domestic violence include:

• Young age (16-25 years).
• Low socioeconomic status.
• Recent separation from partner.
• Young children in the home.
• Homelessness.

Evaluations of the effectiveness of health care training programs have demonstrated that:

• Educational programs have a positive impact on providers' beliefs and attitudes around domestic violence.
• System-change programs (e.g., educational materials, policies and procedures on domestic violence screening) have a positive impact on improving hospital culture and environment.
• Universal screening programs increase victim identification, but institutional and administrative support is required to institute, carry out, and maintain these programs.

Model program and a model legislative initiative were presented that both aim to improve the health care system's response to domestic violence. The National Health Resource Center Initiative, coordinated by the Family Violence Prevention Fund in San Francisco, has the goal of training health care providers, systems, and community partners as it relates to dealing with victims of domestic violence in the health care setting.

In 1995, the Initiative was piloted in 12 hospitals in California and Pennsylvania. Compared to hospitals which did not implement the training program, those that did were found to have experienced a positive change in provider behaviors, hospital culture, and moving towards implementing universal screening in the hospital setting. Based on its initial success, the program has now been implemented in over 150 settings in four States.

Common goals of these programs include:

• Training health care providers about domestic violence.
• Establishing a domestic violence task force or team within the hospital setting, to carry forward policies and procedures related to domestic violence.
• Establishing domestic violence policies and procedures.
• Environmental modifications to make hospitals more user-friendly for victims of domestic violence.
• Increasing screening for victimization.
• Providing intervention services.

The 1999 Pennsylvania Domestic Violence Healthcare Response Act was presented as an example of a legislative initiative that has had a positive effect. The Act established a program to support domestic violence medical advocacy projects across the State of Pennsylvania. Each project was required to:

• Demonstrate collaboration between a community-based domestic violence program and a health care organization.
• Develop and implement domestic violence policies and procedures (including universal screening) for all staff of the health care organization.
• Develop and implement an ongoing domestic violence training program for health care organization employees.
• Provide onsite services and educational materials to inform domestic violence victims about services available in their community.
• Evaluate the effectiveness of the program. Long-term studies are still needed on the effect of this program on women's health and safety outcomes.

An independent review process selected 12 of the 31 project proposals submitted to receive funding. The majority involved multiple hospital sites so that while only 12 projects were funded, 37 new hospitals participated. Dr. Coben highlighted the following impacts that the program has had on providers and patients in the first year of implementation:

• The program provided 358 hospital-based trainings.
• Over 8,500 health care staff were trained throughout the State.
• An additional 98 community-based trainings were conducted, reaching over 1,900 more professionals.
• A 490 percent increase in training was documented compared with FY 1998-1999.
• Nearly 800 victims were provided with onsite services in the first year of the program.
• A 190 percent increase was observed in the number of women served in the first year as compared to FY 1998-1999.

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