Rural Women's Health Conference Summary Report Summary Report  (PDF File, 1.82 Mb) August 13 -15, 2007 Omni Shoreham Hotel, Washington DC

Closing Plenary

Domestic Violence: Trends, Best Practices, and Rural Challenges

Linda Chamberlain, Ph.D., M.P.H., opened her presentation by noting that in Alaska, rates of sexual assault, abuse, and violence are extremely high. However, she noted that the exact numbers are difficult to report, because the majority of Alaska's communities are small and tightly knit, which makes the stigma around the issue very high.

Dr. Chamberlain went on to note that when she started this project, it was called the Domestic Violence Training Project. However, when she started talking about domestic violence, Dr. Chamberlain received questions about whether she would talk about child abuse and elder abuse, too. Dr. Chamberlain explained that this proves family violence is a continuing cycle.

Dr. Chamberlain explained that another part of family violence is animal abuse. She said animal abuse is an indicator of other problems. In fact, she noted, the numbers are overwhelming.

Dr. Chamberlain then explained that the discussion cannot be isolated with domestic violence. Instead, the issue needs to be discussed within the context of lifetime exposure. For example, Dr. Chamberlain met one woman who had been abused, but within the context of what the woman had experienced growing up, she did not believe the abuse she suffered was that severe—because she did not have broken bones like her mother. Dr. Chamberlain stated that this example illustrates why the issue of domestic violence must be addressed in terms of lifetime exposure to violence.

Dr. Chamberlain went on to explain that the issue of domestic violence must also be considered in the context of rural culture. She noted that in rural culture, building trust is a big issue. For example, it took Dr. Chamberlain eight visits to meet with one Eskimo community before they would let her talk to the community members. Dr. Chamberlain described how there is also a code language of abuse. For example, "acting funny" is often equated with abuse. She noted that communities and cultures, especially those that are rural, develop their own languages.

Dr. Chamberlain described several rural challenges that have a significant impact on the issue of family violence. She stated that some of these challenges include confidentiality and isolation. In addition, she said people must deal with a high prevalence of firearms and a rollout of violent offenders from other communities. She explained that people from Montana and other States often flee to Alaska when the law enforcement in their town finally comes calling. Dr. Chamberlain noted that one additional challenge is the remoteness of rural communities.

Dr. Chamberlain described strategies for overcoming some of the challenges associated with addressing domestic violence in rural communities. She noted that traditional domestic violence training pushes the provider to ask direct questions. In contrast, in Alaska, Dr. Chamberlain noted they often have to use less direct questions, such as, "If you knew someone," and incorporating code words such as "acting funny." She explained that when everyone gets more comfortable, it often opens the door to discuss current victimization. She also noted that depression and substance abuse can be a part of victimization. Screening for domestic violence does not capture sexual abuse. She emphasized that scripted screening is also important. She explained that turnover of care providers is high, and so it is important to script all questions, including sexual assault questions, physical abuse, etc.

Dr. Chamberlain then explained that using integrated locations is very important. She explained it is hard to hide a domestic violence shelter in a remote location. She said one effective strategy is integrating services to the point that no one can be sure why a woman is walking through the door.

Dr. Chamberlain also noted that the Association of Maternal and Child Health Programs has been looking at domestic violence as a prenatal disparity. She said this perspective—looking at domestic violence as a health disparity—is breakthrough thinking.

In closing, Dr. Chamberlain emphasized that the solution to dealing with the cycle of family violence is to create a community safety net. To illustrate her point, Dr. Chamberlain showed a picture of a traditional blanket toss—the more people you have around the blanket, the safer it is. She explained that for family violence, we need to work together to see the answer. In the final analysis, what that takes is a team. You can go much further with a team than you can go alone.

Women's Health Issues

America Bracho, M.P.H., CDE, began her presentation by noting that she recently attended a California Healthcare Leadership Training, where she learned about a book called Leadership on the Line, published by the Harvard Business School Press. The book is about being a leader and dealing with issues without becoming the issue. Dr. Bracho stated that when we consider an issue, we need to think collaboratively. She illustrated her point with the issue of HIV in the Bronx, where there is a high rate of infection among Latina and black women, higher than the combined infection rate of 45 other States. People say the issue is sex. But the truth is that the issue is connected with issues of substance abuse, literacy, and economics. Because the system ignores those issues, we are left to deal with survivor issues.

Dr. Bracho went on to explain that we have a system of services in which we tell people what to do. People are disposable. The solution is to bring people into leadership roles. She noted that it is not just about having a CPA in the office—it is about having the people that are infected. It is about training the people so that when the money goes away, the help does not. The passion, the activism, the combination, the world perspective is the way out. It has to go beyond just telling someone to stop with domestic violence. It has to go further.

Dr. Bracho stated that when women learn something, communities improve. Investing in women is investing in community health. Women continue the culture. No matter how poor they are, they will continue giving to the community. Disparity does not mean difference. It is not a difference between one ethnic group and another. It is a disparity when it has to do with cause.

Dr. Bracho noted that in rural women, there are higher rates of poverty and lower rates of insurance. Poverty is an indicator for a lot of other issues. Poverty does not mean that you are bad, but it does mean that you will not have the same opportunity—the same access. From the adaptive point of view, you will deal with poverty; you will deal with the lack of an education; and so on. Every article talks about poverty, but how many articles talk about economic development for women?

Dr. Bracho stated that we need comprehensive interventions. These are problematic for people to design, emulate, and measure. One illustration that comprehensive interventions can happen is to think of a single mother with three children. She explained that a mother never just thinks about one thing, such as, "my son is not taking his medication." Instead, the mother thinks about a number of issues intertwined. Problems are connected; solutions are connected. Nutrition in the school is connected to an unsafe neighborhood, and they are both connected to obesity.

Dr. Bracho emphasized that we need to go the extra mile. She said, "We need to get to the adaptive side. We have it in our hearts and minds. We need to deal with our own egos and our own inability to cooperate. We need rural women at the center of this strategy."

Dr. Bracho also noted that we need to transform rural women into community workers. The "compañeras," which means "friends" in Spanish, will do the rest. She explained that people may think they want a doctor to do it all, but at the end of the day, they will depend on that person. For example, if a neighbor named Sabina begins exercising and improving her health, other women may say, "If Sabina can do it, so can I." That is not true with the doctor. People will not say, "If the doctor can do it, so can I."

Dr. Bracho discussed how when providers are looking at how to train lay people to be community health workers (building capacity), there is a model to follow. She noted that to really train the community, the workers need to be trained in every area. She explained that the most important aspect of this training is communication. When Dr. Bracho's program works with promotoras, they work with the community twice. She explained that the women they hire live in the community, so they are dealing with the same issues. These women offer a perspective that no one else can.

Dr. Bracho noted that a parallel is the story of Dell Computers. Michael Dell says that the reason they are successful is that the sales force tells the engineers what consumers are saying—the sales force and the engineers communicate with each other. Dr. Bracho noted that in Harvard's strategy, the concept is called "crafting strategy." In the healthcare world, it is called improvising. The promotoras work in all areas—everything is intertwined. The women learn how to cook their parents' food. They learn how to use medication. She also noted that it is also extremely important that volunteers receive payment for their work.

Dr. Bracho went on to explain that the data that is collected from the community needs to go back to the community—not just to inform them but to create change.

Dr. Bracho illustrated this point with the story of a woman with diabetes who was unable to afford preventive treatment, and ended up losing her sight. She asked the promotoras if they had to pay a large amount of money to avoid blindness, would they? She received a range of responses. One woman said she would sell her furniture, or whatever it took. Then one woman said she would do it even if she had to sell tamales. In Mexico, this phrase is equivalent to Americans saying they would sell apple pies.

The thought stuck. Dr. Bracho's group decided they needed a healthcare community, even if they had to sell tamales, so they started selling tamales to raise money for eyesight screenings. They worked together to develop a master recipe (and a healthy recipe), and they ended up receiving national press.

Since then, Dr. Bracho's group has also created a children's initiative—they have a group of over 100 child promotoras. She noted that children are an example of "the extra mile." She explained that women are more likely to take their children into a healthcare clinic than themselves. When the woman brings her child to a clinic, this is a perfect opportunity to talk to her about her health as well. That is going the extra mile.

In closing Dr. Bracho noted that the key message is to follow the path that the people show you. She said you may start working with diabetes... then you follow the path to housing...and so on. The solution is in the collaboration.

Next Steps: Where Do We Go From Here?

Marcia Brand, Ph.D., Associate Administrator for Health Professions and Director, Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services, was the final presenter.

1. Reaffirmation—to learn whether they are on the right track and up to date
2. A new way—to find new strategies and techniques
3. A takeaway—to have something to take home and share with coworkers
4. Inspiration—to reflect and re-energize

As evidenced by this report, the HHS OWH Charting New Frontiers in Rural Women's Health Conference provided all four of these opportunities for participants—and much more. Participants heard success stories and lessons learned from rural women all over the country.

From California, participants learned the importance of going the extra mile. And from Alaska, they heard the story of one woman who did just that by making eight separate trips to a community to build trust in order to address domestic violence.

From Wyoming, participants learned that women multitask and are the glue that holds things together. And from Texas, they heard the story of promotoras who banded together to bring access to care and other services to two rural colonies.

From New Hampshire, participants learned that women aren't substance abuse treatment-resistant—treatment is women-resistant. And from Georgia, Indiana, Virginia, Maine, and more, they learned new strategies for overcoming rural barriers and providing gender appropriate substance abuse treatment and care.

Finally, from a story that spanned the desert mesas of New Mexico to the tree-capped mountains of New Hampshire, participants learned about the interconnectedness of health. Body, mind, and spirit are part of a family; which, in turn, is part of a work environment; which, in turn, is part of a community; which, in turn, is part of a global environment. Illness can occur on any of these levels, and health care must consider all of them.

From all of these success stories and lessons learned, the key takeaway message was that rural communities can lead. Rural communities are a manageable size. In Philadelphia, PA, it might be hard but in a Philadelphia in another state—it is possible. And in this effort, Dr. Brand stated, "Rural women will lead the way."

Current as of October 17, 2008