EMERGING PUBLIC POLICY ISSUES
AND
BEST PRACTICES

Rhonda M. Johnson, MPH, CFNP

August 30, 2000

Federal Office of Rural Health Policy
Order No. # 99-0545(P)

EXECUTIVE SUMMARY

Domestic violence is an increasingly recognized public health problem, and its impacts are likely to be particularly devastating in our nation’s rural areas. This paper provides a brief overview and synthesis of recent efforts to improve the health care response to domestic violence in our rural communities.

A review of the recent academic and professional literature establishes both the background and significance of this pervasive public health concern. Several key emerging public policy issues identified from both the literature and key informant interviews are then presented. These include:

• Universal Screening by health care providers
• Appropriate Training for health care providers
• Mandatory Reporting by health care providers
• Documentation/Coding by health care providers
• Employee Assistance Programs for health care providers experiencing Domestic Violence
• Integration of health services into community response
• Funding for expanded and improved health response

If identified, model practices and/or programs are presented for each of these key policy issues, with contact information for additional information if available.

Two broad-based national efforts (the National Health Initiative sponsored by the Family Violence Prevention Fund, and the joint Department of Health and Human Services/Department of Justice Agenda for the Nation) are also briefly described.

Finally, there are recommendations for next steps and an updated resource list likely to be of value to rural health care providers and policymakers working to improve their own health care response to domestic violence, as well as literature and individuals/organizations consulted in the drafting of this report.

INTRODUCTION AND OVERVIEW

The Federal Office of Rural Health Policy often takes the lead in identifying and addressing the unique and complex challenges implicit in the delivery of quality health care services in rural areas of our nation. In late 1987, Congress charged the Office with informing and advising the Department of Health and Human Services on matters affecting rural hospitals and health care, co-ordinating activities within the department that relate to rural health care, and maintaining a national information clearinghouse. The Office works both within government at federal, state and local levels, and with the private sector -- with associations, foundations, providers and community leaders -- to seek solutions to rural health care problems.

As domestic violence has edged its way into the health care arena and onto the national health agenda, it is perhaps not surprising that little attention has been paid to the unique rural challenges and potential solutions to this perplexing and pervasive social concern. Rural health care providers and policy makers are increasingly accountable for their actions in the area of domestic violence, yet little effort has been made to provide them with the appropriate tools to improve their practice and programs. This report is an effort to provide such attention and tools.

After a brief overview of why rural health practitioners and program managers should be concerned about domestic violence, this paper will briefly highlight several emerging policy concerns that are confronting the rural health community in the arena of domestic violence response, and describe some encouraging local, regional and national efforts to address them.

And finally, a brief list of Recommendations and a more extensive Resource list are provided to assist both the direct service provider and the program planner to develop improved health care responses to rural domestic violence.

BACKGROUND AND SIGNIFICANCE

Rural Battered Women as a Vulnerable Population

Partner violence, particularly the battering of women, is an increasingly recognized public health problem in the United States. An estimated two to four million women are physically abused every year, which translates into a woman being battered every 18 seconds in the US¹. The National Crime Victimization survey, which collects data about incidents reported as crimes, reported the 1992-3 rate of physical attacks by family members for women as 9.3 per 1000². Population based surveys, however, suggest the rate of adult violence may be much higher; the National Family Violence Surveys, for example have reported an annual rate of 116 per 1000 women for a violent act by an intimate partner, and 34 per 1000 for "severe violence" by an intimate partner³.

More recently, the National Institute of Justice (NIJ) and the Centers for Disease Control and Prevention (CDC) jointly sponsored the National Violence against Women Survey (NVAWS), which was a nationally representative survey conducted from November 1995 to May 1996. Results of this telephone survey of 8000 women and 8000 men confirm that physical assault is still widespread among American women. Using a definition of physical assault that included a range of behaviors, from slapping and hitting to using a gun, 52 percent of surveyed women said they were physically assaulted as a child by an adult caretaker, and/or as an adult by any type of perpetrator; 1.9 percent of surveyed women said they were physically assaulted in the last 12 months. Female victims averaged 3.1 assaults per year, which equates to about 5.9 million physical assaults perpetrated against women in the 12 months preceding the survey⁴. This combination of past and recent experience with violence is not uncommon among currently battered women.

Battering is a syndrome of control and entrapment that may accompany the use of physical force in intimate relationships, and has been defined as "a staged experience that involves injury, illness, isolation and complex psychosocial problems"⁵.

Very few data-based studies of rural battered women exist, but the already significant problems of battered women are likely exacerbated by rural factors. Poverty, lack of public transportation systems, shortages of health care providers, under-insurance or lack of health insurance, and decreased access to many resources (such as advanced education, job opportunities and adequate child care) all make it more difficult for rural women to escape abusive relationships^{6, 7}. In addition, rural health care providers may be acquainted with or related to their patients and their families, creating a barrier to disclosing abuse confidentially and thus further isolating these women^{8, 9}. Geographical isolation and cultural values, including strong allegiance to the land, kinship ties and traditional gender roles also increase the challenges faced by rural women when they attempt to end the abuse in their lives¹⁰. The increased availability of weapons (such as firearms and knives) common in rural households also increases both the risks and lethality of domestic attacks upon rural women¹¹.

Limitations of Existing Data: A Case In Point

The paucity of reliable and useful data about the extent of domestic violence experienced by rural women in the United States is remarkable. The experience of Alaska in this regard seems to be common around the country, and can thus serve as a case study of sorts. Very little representative data exist about the incidence or prevalence of female partner abuse in Alaska. In 1986, a questionnaire was mailed to a random selection of women aged 18 or older from the master jury list for the State of Alaska, to assess the prevalence of partner abuse; the response rate was 42.5% (n=795). Abuse was measured on a continuum of violence that resembled the physical aggression sub-scale of the Conflict Tactics Scale, with some added items for psychological abuse and sexual assault¹². Slightly more than ten percent (10.2%) of adult women reported physical abuse by their spouse or live-in partner at sometime during their life. Nearly two-thirds (63.3%) of women reporting abuse had experienced it at least once a month. Rural Alaskans were under-represented in this sample, but the results have been frequently cited in official documents¹².

The Pregnancy Risk Assessment Monitoring Surveillance System (PRAMS), a mail and phone survey of new mothers randomly identified from birth certificates, is the only population-based source of data on female partner abuse¹². This survey, which over-sampled for Alaska Natives and women without prenatal care in 1991-2, asked two separate questions about physical abuse-one specific to partner abuse, the other to physical abuse by "someone close" to the respondent. Response rate was 75 percent (n=2,975). Nearly 15 percent of respondents reported being hurt by someone close to them in the last two years; 27 percent of recent mothers less than 18 years of age had experienced physical abuse¹².

Court cases and police reports are often used as indirect measures of abuse prevalence. Alaska is among five states with the highest levels of domestic violence filing on a per capita basis¹³. According to the State of Alaska Department of Public Safety (1992), fifty percent of female murder victims were killed by their husbands or boyfriends in 1991¹⁴. The Alaska State Troopers reported that 67 percent of all homicides that they investigated during 1995 were related to domestic violence¹⁵.

Domestic Violence program statistics are also often used as an indirect measure of female partner abuse. In state fiscal year 1997, 12,072 females were new or continuing (unduplicated) clients at one of the state’s 21 domestic violence shelters or safe houses¹⁵. In 1996, there were 290,669 women of all ages living in Alaska, which means that approximately 1 out of every 25 women sought services at a domestic violence program¹⁶. Of these, a disproportionately high percentage, 36 percent, were Alaska Native, compared to their 16.5% representation in the state’s population.

Thus, imperfect studies done to date and indirect measures both suggest rural rates of domestic violence are high, but no truly representative data yet exist. Alaska is unfortunately not unique in this absence of reliable data. States with significant rural populations must face the problem of rural domestic violence with very little documentation of the prevalence and/or incidence rates of violence within their rural communities. This policy review acknowledges these incomplete but no longer invisible rates, and explores how rural communities can develop a comprehensive and integrated approach to improving the primary health care response to this pervasive public health issue.

Increased Demand for Primary Health Care Services

Women in violent relationships frequently sustain injuries and experience illnesses that require medical attention. Domestic violence is one of the most powerful predictors of increased health care utilization^{17, 18, 19}.

Such increased utilization is predictable, because it is the frequency, not the severity, of injuries that is the hallmark of violence against women⁵.

This increased demand for services is particularly important in rural areas where prevalence of family violence may be higher, and adequate health services may already be limited.

Prevalence studies of intimate partner violence in clinical settings suggest that a significant minority of patients experience domestic violence in their lives, with some estimates as high as 20-40% of all women presenting for health care services ^{20, 21, 22}. Clinician identification of battered women is consistently low, with at least one study suggesting clinicians mis-diagnose and/or inappropriately treat almost 95% of such women in their care²³. Thus battered women are seeking health care services, but they are rarely identified or appropriately assisted. This deadly oversight is probably more common in rural areas, where recruitment and retention of health care providers is a consistent problem and those providers that are available are often overworked.

Primary care has been defined as the delivery of first contact medicine, and includes the assumption of longitudinal responsibility for the patient regardless of the presence or absence of disease, and the integration of physical, psychological, and social aspects of health to the limits of the capability of the health personnel²⁴.

Domestic Violence and Primary Care In 1995, Elliot and Johnson conducted structured interviews with 42 women in a mid-western primary care clinic. Their findings are worth noting: Forty-five percent of this sample reported experiencing physical, social and/or emotional abuse from an intimate partner; Of the 36% who reported being physically abused, 38% presented to the clinic for health maintenance reasons25. Elliot, B. and Johnson, M. (1995). Domestic violence in a primary care setting: patterns and prevalence. Archives of Family Medicine, 4: 113-119.

This comprehensive care is usually provided in ambulatory settings such as family practice clinics, both public and private, by providers such as physicians, nurse practitioners and physician assistants.

Rural areas are often disproportionately served by these providers, often in conditions of high stress and minimal resources, particularly in isolated and remote communities. Overworked and exhausted providers may be even more likely to miss important clues to domestic violence, particularly if such clues are not obvious.

In the largest study published to date of female partner abuse conducted in a primary care setting, slightly more than twenty-one percent (21.4%) of the 1,952 women surveyed suffered physical and/or sexual abuse from an intimate male partner in their adult lives.

Health Care Response to Domestic Violence

The number of domestic violence training programs for young clinicians is increasing around the country, as more providers join professional pioneers in recognition of the need to improve the institutional response to battered women^{26, 27, 28, 29, 30, 31}. In recent years, advocates for an improved health care response to domestic violence have directed their attention away from the academic training grounds, and taken on the more formidable challenge of changing entrenched daily practice within busy, clinical settings³².

The Alaskan efforts, and recent national demonstration projects, are examples of these newer efforts to change average clinical practice. Changing professional norms are reaching even the most isolated communities. Rural providers are increasingly held accountable to these emerging standards of practice, even in the absence of appropriate resources and training.

In recent years, there has also been a shift in research focus from documenting the poor performance of health professionals with battered women, to documenting and exploring these emerging efforts to improve health care professional response^{33, 34, 35, 36, 37, 38, 39, 40, 41}.

Rural providers and programs could benefit from review of these recent efforts, adapting lessons learned elsewhere to their own communities.

Residential training programs and post-graduation continuing education focusing on domestic violence are becoming more common, but implementation of improved policies and procedures within the clinical setting remains problematic at most sites^{35 42, 43}.

Studies specifically investigating barriers to clinician identification of battered women have recently emerged as well ^{44, 45, 46, 47}. In these studies, clinicians typically state that they are reluctant to open the "Pandora’s Box" of universal screening, without institutional support and appropriate referral networks in place⁴⁸. Yet very few programs in rural areas have even been described in the literature, and fewer still have been studied in depth.

Several recent national and local efforts specifically designed to address these clinical concerns may be of interest to rural providers, and will be briefly described below. Sharing the burden of care seems to be one practical solution.

One recent study demonstrated increased program success when multi-disciplinary collaboration, including the development of referral and resource networks, supplemented the otherwise limited medical model⁴⁹. Still, such studies are rare. Unique rural concerns and/or successful strategies for improved care to rural battered women are still relatively unknown and both are virtually absent from the research literature.

Qualitative studies, including interviews and site visits, are becoming more common in this area of changing practice and policy, perhaps because they frequently focus on "real world" questions and answers that may seem more interesting and applicable to the community-based practitioner. ^{50, 51, 52, 53, 54, 55, 56, 57}. Figuring out what works in the field, and spreading the word are two important roles for this newer kind of study.

EMERGING RURAL HEALTH POLICY ISSUES

Several emerging rural health policy issues have been identified by key informant survey and telephone interviews during spring and summer 2000. Domestic violence agencies, rural health specialists and others were queried to identify these key issues; see listing of agencies and individuals consulted at the end of this report. Policy issues that were frequently cited by those surveyed include:

• Content and Impact of DV Screening Protocols and Policies
• Appropriate Training and Support for Health Care Providers
• Mandatory reporting of domestic violence by health professionals (raises conflicting issues of confidentiality, safety and support)
• Employee Assistance Programs (EAP) for hospital/clinic employees experiencing DV
• Documentation/Coding Issues for Health Care Providers

• Conflicting issues of confidentiality, safety and support
• Integration of Health Services into Community Response

• Funding to Support Expanded and Improved Health Care Response

UNIVERSAL SCREENING

Screening for domestic violence in a clinical setting provides an excellent opportunity for secondary prevention: early identification of and intervention with individuals at risk for the health consequences of violence in the home. It provides an otherwise absent opportunity for disclosure and provides a woman and her health care provider the chance to collaborate in developing a plan to protect her safety and improve her health. Such routine screening is particularly important in rural communities, where providers may be overworked and women may be reluctant to disclose without an obvious opening.

Universal screening presents a shift in clinical practice from the more familiar professional norm of targeted screening, which involves asking only those individuals perceived by clinicians as high risk. Recent research confirming both the prevalence of violence in many women’s lives and the failure of current efforts to effectively identify battered women, cast serious doubts on the efficacy of such targeted screening. Many prominent professional organizations, including the American Medical Association and the American Nurses Association, now recommend that health care practitioners routinely screen for domestic violence.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also strongly supports universal screening for victims of abuse. This private, not-for-profit organization evaluates the performance of nearly 10,000 health care organizations, and through a voluntary accreditation process, educates, consults on, and evaluates structures, processes and outcomes that enable the delivery of quality health care. Since 1992, JCAHO has included physical assault and "domestic abuse of elders, spouses, partners" with existing standards for child abuse, rape and sexual molestations. These standards were initially confined to the Emergency Department, consistent with the Healthy People 2000 goal to establish protocols to address domestic violence in at least 90% of the nation’s hospital’s Emergency Departments. By the mid 1990s, these standards expanded to become organization wide across all departments and functions.

To earn full JCAHO sanction, policies had to address procedures for "victim identification, patient consent, examination and treatment, the hospital’s responsibility for the collection, retention and safeguarding of specimens, photographs, and other evidentiary material, and legally required, notification and release of information to the proper authorities." These standards are particularly relevant to small rural hospitals that may be the only primary and urgent care source for a geographically dispersed population, but they also apply to home health care, ambulatory care, health care networks, mental health and long term care facilities. In fact, in many rural communities, the hospitals provide ALL these services, so rural hospitals desiring JCAHO accreditation may be accountable to many different and overlapping standards. These standards have evolved to be descriptive rather than prescriptive, but they carry significant weight within the health care community, including both providers of care and third party payers.

Compliance with the standards affords a coordinated approach to victims who seek help through the health care system, and is consistent with evolving professional norms of appropriate practice. However, the seal of accreditation represents only one approach for rural settings because accreditation is not universal in rural areas. Currently, only about one-third of rural hospitals are JCAHO accredited. In many cases, rural hospitals have not gone through the approval process because of concerns over costs, administrative burden and the relative benefits of receiving the JCAHO seal of approval. There is also a perception by some rural hospital administrators that the JCAHO process is geared towards the urban setting and fails to take into account the special circumstances faced by rural facilities. As a result, relying on JCAHO standards to improve the response to domestic violence concerns will not reach all of the rural communities.

Cultural competence refers to "the process by which the provider combines general knowledge with specific information provided by the victim about his/her culture, incorporates an awareness of one’s biases, and approaches the definition of culture with a critical and open mind." This recommendation may be particularly important in rural settings, where some cultural norms may foster self-reliance and a hesitancy to seek outside help, and geographic distance prevents frequent interaction with the health care system. Universal screening decreases both the isolation of the victim, and also the possible stigma attached to targeted screening. This seems particularly important in rural areas where providers play many roles, and are likely to see clients outside of the clinic setting.

The Family Violence Prevention Fund (FUND) is working with many national health and medical organizations to encourage the widespread implementation of these screening guidelines. These guidelines were an integral part of their own National Health Initiative demonstration project, and are currently being adapted in many diverse settings, including rural sites.

APPROPRIATE TRAINING FOR RURAL HEALTH CARE PROVIDERS

Appropriate training has not always kept pace with evolving professional standards of care, and ensuring access to the continuing education that does exist has often been difficult for rural health care providers. Thus it becomes particularly important that rural health facilities take the lead in developing and providing such training to its staff.

Recent research confirms that most practicing health care providers received little or no education about family violence during their professional schooling, and/or post-graduate training. This is changing for current students and recent graduates, but the need for effective and comprehensive continuing education in this area is very real. Some states have gone so far as to mandate minimum continuing education in domestic violence as a requirement for professional licensure, although this is certainly not yet the norm, and may not even be desirable.

Such measures certainly reflect a concern about the adequacy of the current preparation of health care providers to deal with domestic violence in their daily workplace, but they may not acknowledge the fact that rural providers already have a difficult time accessing existing continuing education, let alone training that is not yet fully developed.

Clinicians themselves consistently report lack of appropriate training as a major barrier to appropriate screening in their own practices, yet little consensus exists as to the content, duration and frequency of such training.

MANDATORY REPORTING BY RURAL HEALTH CARE PROVIDERS

Consensus on the best and most appropriate roles for the health care professionals in the response to domestic violence is still emerging, but perhaps no issue remains as contentious as mandatory reporting. Most observers now agree that providers need to routinely screen for violence, provide sensitive and nonjudgmental support, address patient safety, document the abuse and provide information about options and resources. What is not so clear is under what circumstances providers should be mandated to bring cases of domestic violence to the attention of state authorities, usually law enforcement, and/or if such well intentioned mandates actually create dangerous and unintended consequences for the victims.

Currently, several states have mandatory reporting laws that specifically address domestic violence or abuse; these provisions often supplement existing deadly weapon or illegal act reporting requirements. Five states mandate reporting in certain instances of domestic violence (California, Colorado, Kentucky, New Mexico and Rhode Island), while one exempts victims of abuse from its general mandate to report certain injuries (New Hampshire).

Ariella Hyman, JD recently reviewed existing practices for the Family Violence Prevention Fund; the result is Mandatory Reporting of Domestic Violence by Health Care Providers: A Policy Paper (1997). She notes

Several ethical issues familiar to health care providers are also raised with the issue of mandatory reporting. Such mandated reporting undermines patient autonomy, compromises expectations of confidentiality within provider-patient relationships and severely challenges the medical norm of ensuring informed consent. It also perpetuates harmful stereotypes of battered women as passive and helpful, when empowering responses by providers have been shown to be more effective interventions. For these reasons, mandatory reporting may create more harm than good, particularly in rural areas.

DOCUMENTATION BY RURAL HEALTH CARE PROVIDERS

Mandatory reporting to law enforcement is but one of the challenges faced by rural health care providers working to improve their health care response to domestic violence. In times of fiscal constraint and sustained efforts to maximize reimbursement for rural health care services, another emerging policy issue is how efforts to accurately track domestic violence encounters in the clinical setting may have unintended financial consequences, unless such efforts are cautiously implemented and continuously evaluated for financial impact upon both the provider and the patient.

Reimbursement for health care services is usually dependent upon the International Classification of Disease (ICD-9) codes assigned by administrative staff to medical records. Ideally, these codes accurately reflect the provider-patient encounters within a clinical setting, and thus can also be used as a reliable source of incidence and prevalence statistics. In recent years, domestic violence advocates have lobbied for more accurate coding of domestic violence in clinical settings, for just these reasons. Unfortunately, such diligent coding rarely results in improved reimbursement rates, and in some cases, may actually decrease the amount received by the provider. This sets up a possible conflict between program planners in need of accurate data, and providers in need of maximum reimbursement for services provided. These issues are just beginning to be addressed, and have implications for financially struggling rural providers.

The 995-81 code is the primary code that identifies each incidence of domestic violence. It has been recently supplemented with four additional codes to add specificity: 995-82 adult emotional/psychological abuse, 995-83 adult sexual abuse, 995-84 adult neglect (nutritional) and 995-85 other adult abuse and neglect.

In addition to the generic 995.8_ code, each medical record must contain a primary diagnosis (PDX) code as to why hospitalization is necessary. In general, these codes represent the abuse of violent act suffered by the victim in each individual case. Here, 995 codes are classified under symptoms and signs and have lower reimbursement levels than specific acts of abuse.

E-codes, which provide details about the violence useful to planners, researchers and epidemiologists, are not required codes, and since they do not add to the reimbursement level of a claim, they are rarely included by clinical staff.

V-codes, which represent the history of abuse codes, are similarly useful for administrative purposes, but do not usually translate into increased reimbursement levels, either. Another interesting dilemma is that according to coding rules a history code cannot be used if a condition is still present, so if the abuse is still present, the V-code is inappropriate and cannot be used on the medical record.

These coding subtleties confuse even the well trained, and medical records staff often struggle to remain current on appropriate coding norms. The paucity of appropriately trained staff, and the frequency of staff turnover common in rural areas may only exacerbate this confusion.

Since many reimbursement schedules, like Medicaid and Medicare, only include the primary diagnosis and one secondary code for reimbursement, it is rarely efficient or profitable for hospitals to include additional codes. Yet, hospitals are increasingly called upon to do just that. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began more strictly enforcing the new domestic violence codes in 1997, and in 1998, clinic coding guidelines mandated that domestic violence should be coded as a primary and not a secondary code. As noted earlier, this may be counterintuitive for many healthcare administrators because most 900 level codes have low reimbursement values.

THE POTENTIAL FOR DISCRIMINATION

Ironically, more accurate and complete coding may also have potential negative consequences for the patient as well, unless existing legislation against insurance discrimination is closely monitored and strictly enforced. Some insurance companies deny victims of domestic violence access to insurance by using domestic violence as an underwriting criterion (i.e., a basis of determining who to cover, what to cover and how much to charge). They also may deny coverage on the basis of abuse-related medical conditions and claims. An unintended consequence of more diligent documentation of domestic violence by health care providers is that more medical records now reveal abuse information. When applying for insurance, individuals often sign a release to permit insurers access to such medical records. Until very recently, no laws specifically outlawed discrimination by insurance carriers against survivors of domestic violence. An informal survey in 1994 by the staff of the Subcommittee on crime and Criminal Justice of the United States Senate Judiciary Committee revealed that 8 of the 16 largest insurers in the country used domestic violence as a factor when deciding whether to issue insurance and how much to charge. This could have an even greater impact on rural communities, which typically have higher rates of uninsured and underinsured and lower incomes. That makes purchasing insurance in rural areas more difficult and the prospect of being denied coverage due to new underwriting criterion may only exacerbate the problem.

Many recent laws and legislative proposals prohibit insurers from using domestic violence as a basis for underwriting or rating insurance, but the matter is far from settled. The advent of managed care has already contributed to the instability of health care coverage in many rural areas, as third party payers have abandoned entire communities in pursuit of profits. Possible insurance discrimination only complicates an already complex financial picture for rural residents.

EMPLOYEE ASSISTANCE PROGRAMS FOR HEALTH STAFF

Efforts to improve provider screening and training practices have not only greatly increased the quality of services to the general population. They have also reinforced the value of a previously under-utilized resource: employee assistance programs (EAP) for health care providers experiencing violence in their own lives. When healthcare providers receive training about domestic violence, often it can trigger emotions related to personal experiences with violence, either in the past or the present. In addition to providing care to patients, health care staff may find that colleagues and coworkers experiencing domestic violence need support as well. The development of an appropriate workplace policy regarding domestic violence and programs to assist employees are essential. These lifelines are likely to be particularly valuable in rural areas where supportive resources may be minimal, and confidentiality may be harder to maintain.

The Family Violence Prevention Fund included the development of Employee Assistance Programs as a key component of its National Health Initiative. Interviews in summer 2000 with Initiative participants in several states confirmed that such programs met a real need that frequently surfaced when facilities attempted to improve their institutional response to violence. Several sites realized that the problems in-house had to be effectively addressed before staff could effectively respond to patients experiencing domestic violence. Particularly in rural areas where hospitals and medical centers may be major employers, appropriately addressing domestic violence in the workplace sets a community standard that other employers may eventually adopt.

The federal government, under President Clinton’s direction, has also implemented an Employee Awareness Campaign on Violence Against Women. In October 1997, the Vice President announced new guidelines, created at the President’s direction to help federal departments and agencies create a safer work environment. These new guidelines explain how to develop programs to respond to violence against federal employees, including domestic violence as well as threatening, harassing, and intimidating behavior. To address domestic violence concerns among its own employees, a Department of Health and Human Services human resources task force compiled an action guide entitled "Understanding and Responding to Domestic Violence in the Workplace." The guide assists HHS employees in understanding the nature of the problem, finding help and developing safety plans, and also addresses potential concerns of co-workers and supervisors. Such guidelines might be particularly helpful to federal employees working in rural areas. More information can be obtained from the Department of Health and Human Services web site http://www.dhhs.gov.

INTEGRATION OF HEALTH INTO RURAL COMMUNITY RESPONSE TO VIOLENCE

Coordinated community response to domestic violence is not a new idea, but in many settings, health care providers are new participants in such cooperative efforts. Effectively integrating the health care response into the larger community response is another policy challenge, that may not seem new to many rural providers. Wearing multiple hats and sharing limited resources are familiar experiences for most rural providers.

The recent efforts of the Illinois Family Violence Coordinating Council are typical of such efforts to pool resources and coordinate efforts. While its origins are in the criminal justice system, its scope and impact certainly includes the health care system. With leadership from the Illinois Supreme Court and The Illinois Council for the Prevention of Violence, the Family Violence Coordinating Council was launched in 1994, with more than 100 members in attendance. It is funded by the State Justice Institute, with match provided by the following state entities: Illinois Department of Public Aid, Illinois Department of Children and Family Services, Illinois Department on Aging and the Illinois Attorney General’s Office.

According to its mission statement, the Coordinating Council "utilizes a multi-disciplinary, multi-system approach…and works across the health, justice and social services systems to promote a more coordinated justice system and community approach to family violence and to foster effective family violence prevention, education and intervention strategies." The Health Systems Committee, which is chaired by the Violence Prevention Planner at the Illinois Department of Public Health, has several specific goals, including

Such a coordinating council provides a mechanism for sharing information, resources and ideas as communities develop their own policies and procedures for dealing with domestic violence. Such a statewide effort provides economies of scale that could benefit small rural providers who lack resources to investigate model programs and practices on their own. It also serves as a conduit for thoughtful discussion as alternative legislative and policy ideas are presented and reviewed. Rural participation in such discussions are critical to the development and implementation of rural-sensitive policies at the state, regional and local level.

FUNDING FOR IMPROVED RURAL HEALTH CARE RESPONSE

Significant change in professional norms and practice requires sustained effort, and ideally, reward for improved performance. Financial resources for training and expanded programs are essential, and incentives for improved practice are often preferred to sanctions for poor practice. The funding stream for addressing domestic violence is limited and fragmented, particularly at the rural community level. At the Federal level, there are several sources of financial support.

While federal Violence Against Women Act (VAWA) funds have been a recent source of funding for expanded health programs, many rural sites have not benefited from the limited dollars, and fewer still can realistically compete for such funds.

In fiscal year 2000, Congress appropriated $223.6 million for Department of Health and Human Service (HHS) programs to prevent violence against women, including $2 million for the National Domestic Violence Hotline. For HHS programs under the Violence Against Women At, the department has been allocated $101.1 million for grants to states for battered women’s programs, $15 million for programs to reduce sexual abuse among runaway, homeless, and street youth, $44.1 million for grants to states for rape prevention and educational programs, and as noted above, $5.9 million for coordinated community responses to violence against women. In addition, $7 million from the Preventive Health and Health Services Block Grant is earmarked for rape prevention programs. The President’s fiscal year 2001 budget includes an additional $23.2 million to continue a department wide initiative to prevent violence against women from occurring and to provide services for its victims. In total, in fiscal year 2001, HHS is requesting $246.8 million for programs to prevent violence against women. Yet at the time of this report, the Violence Against Women Act had not yet been re-authorized, and future funding streams are unclear. In an uncertain funding climate, rural planners and policy makers may be wise to seek and maximize non federal sources of funding for their domestic violence programs.

State funding is more variable and somewhat indirect, although some innovative program have been developed to address the problem of domestic violence.

A few years ago, the Pennsylvania Coalition against Domestic Violence (PCADV) created a program at the state level that may be useful model for some rural sites hoping to expand their funding options. In fiscal year 1993/94, in response to accreditation requirements of JCAHO, the Commonwealth of Pennsylvania funded the PCADV to develop three medical advocacy demonstration projects. A fourth project was added in fiscal year 1995/96 and a fifth in fiscal year 1996/97 through small grants provided by the Pennsylvania Department of Health. These medical advocacy projects are collaborative partnerships of community-based domestic violence programs and local hospitals. Essential elements of the projects include ongoing training on domestic violence for all health care providers and allied staff; institutionalization of a comprehensive response to patients experiencing domestic violence through the formal adoption of domestic violence protocols and policies; the identification of battered women through routine screening, and the provision of domestic violence services within the health care setting.

Each of these projects, including at least one rural site, have been successful, and the Governor’s fiscal year 1999 budget included $500,000 to fund up to 10 medical advocacy projects lasting approximately 12 months. Priority in these grants is given to projects designed to address underserved ethnic and rural populations; populations including recipients of welfare and/or the working poor, and communities not currently served by PCADV medical advocacy projects. Successful applicants are also required to participate in PCADV Medical Task Advocacy Task Force meetings every six weeks, and costs associated with attending Task Force meetings are encouraged to be included in the budget for the project. Funds are distributed through a standard Request for Proposal process conducted by the PCADV Health Projects Coordinator and staff.

NATIONAL INITIATIVES ON DOMESTIC VIOLENCE

THE NATIONAL HEALTH INITIATIVE: Family Violence Prevention Fund National Demonstration Project

A 1993 survey of California and Pennsylvania hospitals’ emergency departments conducted by the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence (PCADV) asked respondents to 1) identify their institution’s willingness to serve as test-sites, to evaluate the utility of a domestic violence resource manual, 2) assess the implementation strategies suggested in the manual and 3) examine the manual’s adaptability to various settings. Nearly 250 hospitals volunteered to be test sites, but only six hospitals from each state (California and Pennsylvania) were chosen representing a diversity of characteristics: size, location (urban, ultra-urban, rural, suburban), type of ownership, type of facility (trauma center, teaching hospital, HMO, general) and diversity of population⁵⁸.

Each of the twelve pilot hospitals recruited a multi-disciplinary team made up of an emergency department physician, nurse, social worker and administrator and a domestic violence advocate from the local domestic violence program. The site teams received two days of training and six months of technical assistance free of charge but received no funding for implementing and creating a comprehensive health response to domestic violence.

In addition to providing training on clinical skills in identifying and assisting victims of domestic violence and addressing issues related to institutionalizing a comprehensive response, time was also allotted during the training for team members to

• Identify obstacles, strengths and solutions in organizing their hospital’s response to domestic violence;
• Identify ways for practitioners to begin working together across disciplines;
• Identify their disciplines’ roles within the team in bringing about institutional change;
• Develop an action plan and assign specific responsibilities; and
• Identify additional staff recruits to the team from within the hospital (hospitals expanded their teams; some include drug and alcohol, ob-gyn, security, pediatrics, clergy, mental health, hospital board of directors and others

In addition, many of the hospitals and the domestic violence programs made plans to visit and spend time in each other’s facilities to better understand each other’s work, constraints, and strengths⁵⁸. An evaluation conducted after three years of this pilot program indicated both positive trends and areas for improvement. Lessons learned from this initial effort were incorporated into the development of the National Health Initiative, which expanded to include an average of fifteen site teams trained in each of ten states. This national demonstration project specifically targeted the need for institutional change, and recognized that rural communities might have different needs than non-rural ones. As Warshaw and Ganley note in the Training Manual for National Health Initiative participants,

• Prioritizing issues that (while perhaps not alien to nursing and social work) have traditionally been considered outside the purview of medical practice;
• Utilizing models that recognize the social context in which symptoms develop;
• Valuing the quality as well as the content of clinical interactions and fostering interactions that facilitate rather than direct change;
• Creating training environments that encourage clinicians to be able to address complex issues with skill and compassion;
• Developing interdisciplinary teams within the health care setting that model mutual respect and support, and
• Creating collaborative partnerships between the domestic violence advocacy community and the health care system⁵⁸ (p. 111-112).

Thus, the National Health Initiative targets change that is both complex and difficult to measure. The original ten states involved in this national project were Alabama, Alaska, California, Florida, Iowa, Nevada, New Hampshire, New Mexico, Texas and West Virginia. Of these states, several have significant rural participation in the demonstration projects. The challenge in rural areas is putting together a multi-disciplinary team that takes into account the traditional workforce limitations in rural communities. These teams may not have the diversity of professions that the urban models have. However, the key for rural communities is linking the existing resources in a way that shares the burden and improves communication across professional settings. It is also worth noting that several of the model practices and programs detailed in this paper come from this national demonstration project which is still ongoing, and recently expanded to include additional states and sites.

DHHS/DOJ National Advisory Council on Violence against Women: Agenda for the Nation

The National Advisory Council on Violence Against Women, co-chaired by Attorney General Janet Reno and Secretary of Health and Human Services Donna Shalala has been charged with developing an agenda for the nation to address violence against women. The Agenda for the Nation on Violence Against Women will be a call to action, a guide to specific strategies, and ideally, a widely used tool that leads to change. It will be a multi-faceted vehicle designed for these ends:

• "to provide the nation’s policymakers (at the local, county, tribal, state and federal levels) with specific recommendations concerning actions they should take to eliminate violence against women
• to demonstrate the leadership and commitment of the Federal Government through financial support and policy initiatives
• to stimulate public conversation and generate community-driven responses to address the causes of violence against women, the needs of victims, and the behavior patterns of the perpetrators.
• to compile a directory of recommendations, strategies, resources, and action plans developed by various groups around the country
• to build on existing promising practices and highlight the results of over 25 years of achievement".

Although the Agenda involves the collaboration of HHS, DOJ and CDC, the major staff work will be carried out by the Center for Effective Public Policy. Originally slated for completion by late 1999, the Agenda was released to the public October 11, 2000.

The Agenda for the Nation on Violence Against Women is a 12 page document that provides a framework for ending violence against women, and serves as a standard for its accompanying Toolkit. There are fifteen areas of focus including: the workplace, health care systems, the justice system, service centers for victims, the media, the sports community, university and college campuses, faith communities, international issues, the military, community education, housing and economic security, children and youth, sovereign nations and challenges to policymakers.

Both the Agenda and Toolkit should be available after October 11, 2000 on the web at http://www.ojp.usdoj.gov/vawo/advisory.htm.

A 10 point summary of the Health Care Systems section of the Agenda is outlined below

• CONDUCT PUBLIC HEALTH CAMPAIGNS
• ESTABLISH NATIONAL TASK FORCE ON HEATLH AND MENTAL HEALTH CARE SYSTEMS' RESPONSE TO SEXUAL ASSAULT
• EDUCATE ALL HEALTH CARE PROVIDERS ON VIOLENCE AGAINST WOMEN
• CREATE PROTOCOL AND DOCUMENTATION GUIDELINES FOR HEALTH CARE FACILITIES AND DISSEMINATE WIDELY
• PROTECT VICTIM HEALTH RECORDS
• ENSURE MANDATORY REPORTING REQUIREMENTS PRTOECT THE SAFETY AND HEALTH STATUS OF ADULT VICTIMS
• CREATE INCENTIVES FOR PROVIDERS TO RESPOND TO DOMESTIC VIOLENCE
• CREATE OVERSIGHT AND ACCREDITATION REQUIREMENTS FOR DOMESTIC VIOLENCE AND SEXUAL ASSAULT CARE
• ESTABLISH HEALTH CARE OUTCOMES MEASURES
• DEDICATE INCREASED FEDERAL, STATE AND LOCAL FUNDS TO IMPROVING THE HEALTH AND MENTAL HEALTH CARE SYSTEMS' RESPONSE TO VIOLENCE AGAINST WOMEN.

To sum, health policy issues of interest to rural communities struggling with domestic violence are becoming more visible, both in the professional literature and in public discussions evolving around this growing public health concern.

RECOMMENDATIONS ON NEXT STEPS

• An assertive model of pro-action by health professionals, consistent with emerging professional norms and particularly important in rural communities, is needed to improve the health care response to domestic violence. Rural health policy must support such growing professional efforts.
• Rural providers should review Preventing Domestic Violence: Clinical Guidelines on Routine Screening (1999) developed by the Family Violence Prevention Fund when establishing local policies and protocols.
• Rural providers should take the lead in providing appropriate domestic violence training to their staff on an ongoing and consistent basis.
• Rural providers should examine existing (and proposed) state law regarding mandatory reporting, and determine the answers to the following questions before supporting such policy changes:
1. Who is required to report?
2. Who receives the report?
3. Who is required to the report?
4. What are penalties for failure to report?
5. Is there provider immunity from liability?
6. How is provider-patient privilege protected?
7. What is the purpose of the reporting?
8. How will this impact rural communities?
• Rural providers should support efforts to increase accurate documentation of domestic violence, but also consider possible unintended consequences of such documentation (such as insurance discrimination) and seek appropriate legal guidance to protect staff and clients
• Rural providers should implement model workplace policies (including Employee Assistance Programs) that set and maintain a high community standard for dealing with domestic violence among both staff and clients
• Rural providers should actively participate in (and/or initiate if absent) coordinated community responses to domestic violence, working closely with other community sectors in planning, implementing and evaluating services
• Rural providers should maximize existing funds and actively develop additional funding streams by effective collaboration with community partners, at local, state, regional and national levels

APPENDIX

Editor’s Note: The appendix includes a range of resources on domestic violence issues, some of which are rural specific. It also includes various community examples of current projects and initiatives in this field.

RESOURCES TO IMPROVE THE HEALTH CARE RESPONSE TO DOMESTIC VIOLENCE

Training Examples and Resources:

For more information on the Nurse Midwife Project, contact Patricia A. Paluzzi, Project Director, DVEP, American College of Nurse-Midwives, 8403 Colesville Road, Suite 1550, Silver Spring, MD 20910. Telephone: (Main) 240-485-1800 Fax 240-485-1818. Email: info@acnm.org.

• The Domestic Violence Education Project (DVEP) of the American College of Nurse Midwives (ACNM) has the potential to impact the health care response to rural domestic violence. This continuing education program for advanced practice nurses (many of whom practice in rural areas) is a national educational initiative for women’s health care providers, particularly certified nurse midwives. The goal of the DVEP is to provide education regarding assessment, clinical impact, intervention and referral, and to promote universal screening for domestic violence among women presenting for obstetrical care. Training is offered in the form of continuing education during regional workshops and as a pre-course prior to the ACNM annual meeting. The curriculum emphasizes the concepts of "zero tolerance" for domestic violence, and assistance with incorporating DVEP into clinical practice is an additional component of this program.

For more information on the Alaska Family Violence Prevention Project, contact, Linda Chamberlain, PhD, MPH, Project Director, Alaska Family Violence Prevention Project (AFVPP). Section of Maternal, Child, and Family Health. 1231 Gambell St., Anchorage, AK 99501. Telephone: 907-269-3454 Fax 907-269-3497. (800) 799-7570 (toll free within Alaska). Email: lachambe@health.state.ak.us, or Jo Gottschalk, Project Coordinator, bjgottsc@health.state.ak.us.

• A project in Alaska is using funding from its Maternal and Child Health Block grant to raise awareness and provide education, training and technical assistance to health care providers in Alaska, many of whom practice in remote and isolated communities. The Alaska Family Violence Prevention Project (AFVPP) puts an emphasis on on-site, culturally and geographically appropriate domestic violence education through its "train the trainer" module for rural outreach workers. The program also maintains a resource center to assist providers on an ongoing basis.
• Another innovative project is the Family Violence Prevention Fund’s Rural Immigrant Women’s Leadership Project, funded by the Violence Against Women Office/Office of Justice Programs. Three-day trainings in Iowa and Texas assisted domestic violence survivors and others from extremely isolated rural areas to learn to speak out and become leaders and advocates in their own communities. In late 1999, seventy women, all Spanish speakers, were trained in leadership skills and community organizing around abuse. They discussed barriers that hinder rural immigrant women from escaping violent homes, including lack of resources in native languages, fear of deportation, cultural insensitivity and discrimination by police and service providers. Project partners included the Iowa Coalition Against Domestic Violence, Las Americas Immigrant Advocacy Center, Lideres Campesinas, Mujeres Unidas y Activas, the San Francisco District Attorney’s Office and the National Immigration Project of the National Lawyers Guild. The Rural Leadership Project Manual discusses how to create an immigrant leadership project, from resource assessment to women’s group development to bringing women together for the training. The Rural Leadership Project Manual is now available at the Family Violence Prevention Fund’s publication line at 414-252-8089.
• Elaine J. Alpert, MD, MPH, (1997) of the Family Violence Prevention Fund provides some guidelines regarding such training, a synopsis of which is excerpted below:

A well-thought-out policy on education and training must acknowledge the cultural diversity of the United States and the values and beliefs of those who live and work in the communities served by each health care setting or institution. Moreover, at every level of planning, implementation, and evaluation, input from people representing the spectrum of cultures and lifestyles of the community served, and particularly from survivors of abuse, should be actively solicited. Key elements of this policy include:

1. 1. Universal education and training of all health professionals and ancillary staff as an expected and integral component of basic education and continuing in-service training within each profession and field

2. 2. Secure and reasonable funding for the development, implementation, evaluation and dissemination of culturally appropriate and sensitive educational curricula and training

• The Health Resource Center of the Family Violence Prevention Fund, with support from The California Endowment, has recently instituted a program that is working with diverse community health centers throughout California. The California Clinic Collaborative on Domestic Violence works with 20 "leadership" centers, many in rural areas, to implement screening for domestic violence, improve their response to patients identified as victims, implement community outreach and education campaigns, and focus on policy issues impacting low income and ethnically diverse communities. For more information, contact anna@fvpf.org.
• A NEW COMMITTEE ON TRAINING NEEDS: A more recent national effort that may also be of interest to rural practitioners is the launch of the Committee on the Training Needs of Health Professionals to Respond to Family Violence, which took place in January 2000. This committee is an initiative of the Board on Children, Youth and Families of the Institute of Medicine and the National Academy of Sciences. Mandated by Congress by the 1998 Health Care Professions Education Partnership Act (PL 105-392), the committee will determine what training health professionals need to better detect and refer victims of family or acquaintance violence. The study is funded by the Centers for Disease Control and Prevention, and will review and synthesize available research on training needs, examine the appropriateness of current training, the effectiveness of available curricula and outcomes associated with these interventions. At the end of its work, the committee will produce a report summarizing its work and indicating future directions for policy and programs. Information about the committee’s work, meetings and workshops will be available on the Board’s website at: http://www.nationalacademies.org/cbsse/bocyf. This will enable rural advocates interested in training issues can keep informed about and involved in the ongoing debate. For more information, contact Felicia Cohn, PhD, Study Director, Committee on the Training Needs of Health Professionals to Respond to Domestic Violence. Board of Children, Youth, and Families, National Research Council, 2101 Constitution Avenue, NW, Washington, DC, 20418. Telephone: 202-334-2034 Fax: 202-334-3829 Email: fcohn@nas.edu

STATE BY STATE REPORT CARD
ON HEALTH CARE LAWS AND DOMESTIC VIOLENCE

One additional resource likely to be of value to rural policy makers and planners is newly available from the Family Violence Prevention Fund in summer 2000. The State-By-State Report Card on Health Care Laws and Domestic Violence is an at-a-glance evaluation of state activity in passing laws to improve the health care response to domestic violence. The Report Card grades each state based on whether it has enacted effective laws as of June 30, 2000. As the FUND staff notes in its introduction to the Report Card, "policy is constantly evolving. The "best" laws on the books today may be eclipsed by better, more creative, efficient and cost effective laws tomorrow. This Report Card provides a snapshot of where the states stand today, based on the best laws that exist right now." Rural policy makers can determine at a glance the status of the local legislation, and also compare it to other states.

To compile the Report Card, FUND staff contacted advocates, state leaders and others about specific laws regarding domestic violence and health care from October 1999-July 2000. They sent surveys to every state and investigated state statutes to identify what each state had done to improve its response to domestic violence in health care settings. State domestic violence coalitions then reviewed the data, to ensure the conclusions were accurate.

The Report Card covers five policy areas: training, screening, protocols, reporting and insurance. Detailed scoring criteria for each area, as well as complete state by state results are available at no charge on the website of the Family Violence Prevention Fund at http://www.fvpf.org/statereport/.

SELECTED NATIONAL ORGANIZATIONS:

AMA has produced comprehensive diagnostic and treatment guidelines for domestic violence, child physical abuse and neglect, child sexual abuse, and elder abuse and neglect. Copies are available at no cost. AMA is also the host organization to the National Advisory Council on Family Violence, a coalition of physicians representing virtually every specialty. ACOG Past President Richard F. Jones III, MD, FACOG, is a founding member and serves on the National Steering Committee. For more information, contact Martha Witwer at the AMA.

The Fund has a wide variety of nationally recognized educational materials and resources, including its recently released resource manual for health care providers. A major project operated by the Fund includes the Health Resource Center on Domestic Violence.

Funded by the US Department of Health and Human Services, the Center is a project of the Family Violence Prevention Fund, the Center provides specialized materials designed to strengthen the health care systems’ response to domestic violence, as well as technical assistance and library services to support health care-based domestic violence training and program development.

This rural organization is a leader in the production of culturally appropriate materials for migrant families experiencing family violence. Recent projects include Family Violence Bilingual Training Video "La Vida Mia" and Curriculum, Women’s Print and Audio Project (including public service announcements for radio, posters and a photonovella), and Women’s Family Violence Leadership Training.

Operated by a consortium of organizations: The American Public Welfare Association, the National Association of State Units on Aging, the University of Delaware College of Human Resources, and the National Committee for the Prevention of Elder Abuse. The Center serves as a clearinghouse, provides training and technical assistance, and conducts research and demonstration projects.

NCADV is the oldest national organization representing grassroots organizations and individuals working to empower women and their children. The Coalition publishes a national directory of approximately 2,500 domestic violence programs throughout the country, provides information and referral services, compiles a resource packet about Domestic Violence prevention Month, and publishes a quarterly newsletter. They also produced a 45 page Rural Task Force Resource Packet-Reflection on Rural Realities in 1991.

The Public Policy Office of the NCADV is a national leader in the effort to create and influence federal legislation that positively impacts the lives of battered women. They lobby Congress, monitor state and federal legislative developments, and provide information on pending federal policy initiatives. For more information, contact Public Policy Office, NCADV, PO 34013, Washington DC, 20043-4103. Telephone: 202-638-6388.

This hotline is both privately and publicly funded, and intended for both provider and client use. Through use of ATT language line, services can be provided to non-English speakers as well.

Funded by the US Department of Health and Human Services and operated by the Pennsylvania Coalition Against Domestic Violence, the Center provides comprehensive information and resources, policy development and technical assistance designed to enhance community response to and prevention of domestic violence. It also supports the CDC-funded National Electronic Violence Against Women Resource Network (VAWnet), which provides access to databases, publications, resource listings, and research, connects state coalitions and other network members by electronic mail and provides areas of on line discussion among network members.

RECENT RURAL-SPECIFIC RESOURCES

Correia, A. (1999). Innovative Rural Responses to Domestic Violence: A Description of Nine Programs. Iowa City, IA: University of Iowa, Iowa School of Social Work.

Dykshoorn, S. (1998). Tri-State Rural Collaboration Project. Funded by the Federal Department of Justice through North Dakota Council on Abuses Women’s Services for Rural Needs in Wyoming, Montana and North Dakota.

Florida Coalition Against Domestic Violence. (1999). Domestic Violence in Rural America: A Resource Guide for Service Providers. Tallahassee, FL: The Rural Coalition Against Domestic Violence.

Gero, A, Cuscino, V and Sullivan, C. (2000). Determining the Needs of Battered Women in Rural Pennsylvania. Final Report-February 2000. Rural Domestic Violence Project. Harrisburg, PA: National Resource Center on Domestic Violence.

Murty, S. and Schechter, S. (1999). Reaching Rural Communities: A National Assessment of Rural Domestic Violence Service Needs. Iowa City, IA: University of Iowa School of Social Work.

National Resource Center on Domestic Violence. (1999). Getting the Word Out: Domestic Violence Awareness in Rural Communities. Harrisburg, PA.

Websdale, N. (1998). Rural Woman Battering and the Justice System: an Ethnography. Thousand Oaks, CA: Sage Publications.

OTHER USEFUL RESOURCES ON THE INTERNET

American Bar Association Commission on Family Violence
http://www.migrantclinician.org/excellence/familyviolence

This site includes basic information about domestic violence, important phone numbers, hot links to related sites and updates about legal issues, confidentiality issues and policies regarding domestic violence.

American Medical Women’s Association Online Education Website
www.dvcme.org

This site is homepage for online education course designed for health care professionals. The course provides basic knowledge of domestic violence required to recognize, treat and prevent such violence in health care setting. It is divided into 8 units that can be taken for continuing medical education (CME) credit.

Domestic Violence: A Practical Approach for Clinicians.
http://www.sfms.org/domestic.html

This site maintained by San Francisco Medical Society addresses background of domestic violence, including risks for and forms of abuse, screening, diagnosis, clinical findings, interventions, patient safety issues, continuity of care and documentation.

Domestic Violence Information Center
http://www.feminist.org/other/dv/dvhome.html

This site offered by the Feminist Majority provides links to other sites, including phone numbers to each state’s Coalition Against Domestic Violence offices, information about the Violence against Women Act, facts about domestic violence and general references.

Family Peace Project
http://www.family.mcw.edu/d_FamilyPeace.htm

This Medical College of Wisconsin maintained site provides clinical protocols for screening interviews, intervention options, and suggestions for working with survivors of partner violence. It also suggests proper SOAP note documentation and patient safety assessments, and includes discussion rooms concerning issues related to domestic violence.

Minnesota Center Against Violence and Abuse
http://www.umn.edu/mincava

This University of Minnesota-St. Paul maintained site includes extensive bibliographies, course curricula and training resources, news groups and discussion lists, legal reports, scholarly papers, funding agencies, and written exercises with links to many other sites.

Nursing Network on Violence Against Women, International,NNVAWI, PMB 165,1801 H Street B5, Modesto, CA 95354-1215. Phone: 1-888-909-9993.
http://www.nnvawi.org

The Nursing Network on Violence Against Women(NNVAW) was formed to encourage the development of a nursing practice that focuses on health issues relating to the effects of violence on women's lives. NNVAW was founded in November of 1985 during the first National Nursing Conference on Violence Against Women held at the University of Massachusetts/Amherst, and has recently expanded to include international members.

Specialty Medical Organizations

Several medical specialty organizations maintain professional and public information on domestic violence on their websites, including practice and policy statements and available resources. These include, but are not limited to

US Department of Justice
http://www.ojp.usdoj.gov/vawo/

This site also includes up to date links to local resources as well as research and legislation pertaining to violence against women. The full text of its monthly newsletter and its Domestic Violence Awareness Manual are also available at this site. Also copies of Extent, Nature and Consequences of Intimate Partner Violence (the results of the National Violence Against Women Survey released in July 2000) are available on the National Institute of Justice web site, http://www.ojp.usdoj.gov/nij/. Click on "What’s New" and then Publications.

Women’s Rural Advocacy Programs
http://www.letswrap.com/

This site includes the programs of 4 counties in southwest Minnesota addressing the needs of rural battered women.

ADDITIONAL RESOURCE AGENCIES:

Advocates for Immigrant Women, 3094 Kaloaluiki St., Honolulu, HI 96822.
Phone: 808-988-6026.

American Indian Women’s Circle Against Domestic Violence, 1929 S. 5^th St., Minneapolis, MN 55454. Phone: 612-933-7433.

Another Way/End Violence Now, 192 Sarann Ct, Lilburn, GA 30247. Phone 770-717-9447; Fax: 770-729-1224.

Asian Taskforce Against Domestic Violence, PO Box 120108, Boston, MA 02112. Phone: 617-338-2350.

Austin Center for Battered Women, PO Box 19454, Austin, TX, 78760. Phone: 512-385-5181.
http://www.austin-safeplace.org

Center for Nonviolence, 235 W. Creighton Ave, Fort Wayne, IN 46807.

Center for the Prevention of Sexual and Domestic Violence, 936 N. 34^th St., Suite 200, Seattle, WA 98103. Phone 206-634-1903. Fax (206) 634-0115.
http://www.cpsdv.org

Center on Battered Women’s Legal Services, 105 Chambers St, New York, NY 10007. Phone: 212-349-6009.

Clearinghouse on Femicide, PO Box 12342, Berkeley, CA 94701-3342. Phone: 510-845-7005.

Clothesline Project, Box 727, East Dennis, MA 02641. Phone: 508-385-7004.

Community United Against Violence, 973 Market St., #500, San Francisco, CA 94103. Phone: 415-577-5500; Fax: 415-777-5565.
http://www.xq.com/cuav/index.html.

Commission for Prevention of Violence Against Women, 915 Cedar St., Santa Cruz, CA 95060. Phone: 408-454-2772.

Defensa De Mujeres, 406 Main St., #326, Watsonville, CA 95076. Phone: 408-722-4532.

Domestic Violence Initiative/Women with Disabilities, PO Box 300535, Denver, CO 80203. Phone: 303-839-5510.

Domestic Violence Training Project (Project SAFE) c/o Ms. Kate Paranteau, 900 State Street, New Haven, CT, 06511. Phone: 203-865-3699.

Family Violence and Sexual Assault Institute.211 Commerce Blvd-No. 103, Roundrock, TX 78644. Phone: 512-255-1212 or 1-800-460-7233. Fax 512-248-3246.

Legal Aid Society Domestic Violence Victim Assistance, 322 E. 300 S., Suite 230, Salt Lake City, UT 84111. Phone: 801-355-2804.

Manavi (advocates for battered Asian women), PO Box 614, Bloomfield, NJ 07003. Phone: 908-687-2662.

Mending the Sacred Hoop, 202 East Superior Street, Duluth, MN 55802. Phone: 218-722-2781

National Battered Women’s Law Project, 799 Broadway, Room 402, New York, NY 10003. Phone: 212-674-8200.

National Clearinghouse for the Defense of Battered Women, 125 S. 9^th St., Suite 302, Philadelphia, PA 19107. Phone: 215-531-0010.

National Clearinghouse on Child Abuse and Family Violence, 1155 Connecticut Ave, NW, Suite 400, Washington, DC 20036. Phone: 202-505-3422.

National Clearinghouse on Domestic Violence, PO Box 2309, Rockville, MD 20852.

National Coalition of Physicians Against Domestic Violence, c/o AMA, 515 State Street, Chicago, IL 60610. Phone: 312-464-5000.

National Network to End Domestic Violence-Administrative Office
C/O Texas Council on Family Violence, 8701 North Mopac Expressway, Suite 450, Austin, TX 78759.

National Network to End Domestic Violence-Policy Office, 701 Pennsylvania Ave, NW, Suite 900, Washington, DC 20004.

National Organization for Victim Assistance, 1757 Park Road NW, Washington, DC, 20010. Phone: 202- 232-6682.

Nicole Brown Simpson Charitable Foundation, 15 Monarch Bay Plaza, Box 380, Monarch Beach, CA 92629. http://www.nbcf.org/lobby.htm

NOW Legal Defense and Education Fund, 99 Hudson St, Suite 12^th Floor, New York, NY 10013. Phone: 212-925-6635.
http://www.nowldef.org/

Physicians for a Violence-free Society, PO Box 35528 Dallas, TX 75235-0528. Phone: 214-638-4200. Fax: 214-638-4225.

Powerful Choice, PO Box 30918, Seattle, WA 98103. Phone: 206-782-5662.

PrePARE (Protection, Awareness, Response, Empowerment), 147 W. 25^th, New York, NY 10001. Phone: 800-442-7273; Fax: 212-225-0505.

Purple Ribbon Project, 6053 Mooretown Rd, Williamsburg, VA 23185. Phone: 757-220-9274.

Refugee Women’s Alliance, 3004 S. Alaska St., Seattle, WA 98108. Hone 206-721-6243.

Saheli (advocates for battered Asian women), PO Box 3665, Austin, TX 78704. Phone: 512-703-8745.

Silent Witness National Initiative, 7 Sheridan Ave, S. Minneapolis, MN, 55405. Phone: 612-377-6629.

Standing Together Against Rape, 1057 W. Fireweed Ln, #230, Anchorage, AK 99503. Phone: 907-276-RAPE.

Women Against a Violent Environment (WAVE), PO Box 15650, Rochester, NY 14615. Phone: 716-234-9709.
http://www.rochesternow.org/wave.html.

Women’s Law Project, 125 S. Ninth, Ave, Suite 401, Philadelphia, PA 19107. Phone: 215-928-9801.

SELECTED HEALTH PROFESSIONAL RESOURCES

Domestic Violence: A Guide for Health Care Providers. (1991). Colorado Department of Health and The Colorado Domestic Violence Coalition. Denver, CO.

Domestic Violence: A Guide for Health Care Professionals (1990). State of New Jersey, Department of Community Affairs. Trenton, NJ.

Domestic Violence: Identification, Intervention and Nursing Documentation. (1996). Austin Center for Battered Women. Austin, TX.

Osattin, A. and Short, L.M. (1998). Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Health Care Providers. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Salber, Patricia and Taliaferro, Ellen. (1995). The Physician’s Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse…Another Way to Save a Life. Volcano, CA: Volcano Press.

Start the Healing Now: What You Can Do About Family Violence. (1992). Texas Medical Association and the Texas Council on Family Violence. Austin, TX.

Stark, Evan and Flitcraft, Anne (1996). Women at Risk: Domestic Violence and Women’s Health. Thousand Oaks, CA: Sage Publications.

Warshaw, C. and Ganley, A. (1998). Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. Produced by Family Violence Prevention Fund in collaboration with Pennsylvania Coalition Against Domestic Violence. San Francisco, CA: Family Violence Prevention Fund.

OTHER RECENT PROFESSIONAL RESOURCES OF INTEREST

Caralis, P.V. and Musialowski, R. (1997). Women’s experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. Southern Medical Journal, 90, (11): 1075-1080.

Commonwealth Fund, (1996). Prevention and Women’s Health: A Shared Responsibility. Policy report of the Commonwealth Fund Commission on Women’s Health. New York: The Commonwealth Fund.

Friedman, L., Samet, J., Roberts, M., Hudlin, M. and Hans, P. (1992). Inquiry about victimization experiences: a survey of patient preferences and physician practices. Archives of Internal Medicine, 152, 1186-1190.

Gin, NE, Rucker, L, Frayne, S, Cygan, R and Hubbell, FA (1991). Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. Journal of General Internal Medicine, 6: 317-322.

Hamberger, L.K., Saunders, D.G., and Hovey, M. (1992). Prevalence of domestic violence in community practice and rate of physician inquiry. Family Medicine, 24: 283-287.

Hamilton, S. (1998). Alaska Domestic Violence Training Project Final Evaluation Report. Juneau: C and S Management Associates.

Hotch, D., Grunfeld, A.F., Mackay, K., and Ritch, L. (1996). Policy and procedures for domestic violence patients in Canadian emergency departments: a national survey. Journal of Emergency Nursing, 22(4); 278-282.

Johnson, M. and Elliott, B.A. (1997). Domestic violence among family practice patients in midsized and rural communities. Journal of Family Practice, 44, (4): 391-400.

McCauly, J., Kern, D., Kolodner, K., Dill, L., Schroeder, A., DeChant, H., Ryden, J., Bass, E. and Derogatis. (1995). The "battering syndrome" prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Annals of Internal Medicine, 123(10): 737-746.

McFarlane, J., Parker, B., Soeken, K. and Bullock, L. (1992). Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. Journal of the American Medical Association, 267(23): 3176-3178.

McNutt, L.A., Carlson, B.E., Gagen, D., and Winterbauer, N. (1999). Reproductive violence screening in primary care: perspectives and experiences of patients and battered women. Journal of the American Medical Women’s Association, 54(2): 85-90.

National Research Council (1998). Violence in Families: Assessing Prevention and Treatment Programs. Washington, DC: National Academy Press.

Plichta, S. (1992). The effects of woman abuse on health care utilization and health status: a literature review. Women’s Health Issues, 2(3): 154-163.

Plichta, S., Duncan, M., and Plichta, L. (1996). Spouse-abuse, patient-physician communication, and patient satisfaction. American Journal of Preventive Medicine, 12, (5): 297-303.

Plichta, S. and Weisman, C.S. (1995). Spouse or partner abuse, use of health services, and unmet need for medical care in US women. Journal of Women’s Health, 4, (1): 45-53.

Rath, G.D., Jarrett, L.G., and Leonardson, G. (1989). Rates of domestic violence against adult women by men partners. Journal of the American Board of Family Practice, 2: 227-233.

Rodriguez, M.A., Quiroga, S.S., and Bauer, H.M. (1996). Breaking the silence. Battered women’s perspectives on medical care. Archives of Family Medicine, 5, (3): 153-158.

Saltzman, L.E., Salmi, L.R., Branche, C.M and Bolin, J.C. (1997). Public health screening for intimate violence. Violence Against Women, 3: 319-331.

Smith, P., Tessaro, I. and Earp, J. (1995). Women’s experiences with battering: a conceptualization from qualitative research. Women’s Health Issues, 5(4): 173-181.

Tudiver, F. and Permaul-Woods, J. (1996). Physician perceptions of and approaches to woman abuse: does certification in family medicine make a difference? Canadian Family Physician, 42: 1475-1480.

US Department of Health and Human Services (1991). Violent and abusive behavior. Healthy People 2000: National Health Promotion and Disease Prevention Objectives (226-247). US Public Health Service: Washington, DC. DHHS Publication No. (PHS) 91-50212.

Wagner, P.J., Mongan, P., Hamrick, D., and Hendrick, L.K. (1995). Experience of abuse in primary care patients. Racial and rural differences. Archives of Family Medicine, 4(11): 956-962.

Websdale, N. (1998). Rural Woman Battering and the Justice System: An Ethnography. Sage Series on Violence Against Women. Thousand Oaks, CA: Sage Publications.

OTHER BOOKS/PUBLICATIONS

Bart, Pauline and Moran, Eileen (1993). Editors, Violence Against Women: The Bloody Footprints. Sage Publications.

A broad based anthology that analyzes violence against women in the home, in the workplace and in the streets. Covers types of violence, structural supports for violence, and the politics of institutional response to violence.

Jones, Ann (1994). Next Time, She’ll Be Dead: Battering and How to Stop It. Beacon Press.

Analyzes the attitudes and institutions in society which contribute to domestic violence. Chapters deal with how the legal system leaves women unprotected, how language contributes to blaming the woman, and what can be done by different sectors of society to address this problem.

Kilgore, Nancy (1992). Sourcebook for Working with Battered Women. Volcano Press.

Written by a formerly battered woman who is now an educator on domestic violence, this manual offers suggestions for working with battered women and facilitating support groups, and provides additional supplementary materials.

Mousseau, Marlin and Artichoker, Karen (1997). Domestic Violence Is Not Lakota/Dakota Tradition. Medicine Wheel: South Dakota Coalition Against Domestic Violence and Sexual Assault Project.

Pleck, Elizabeth (1987). Domestic Tyranny: the Making of American Social Policy against Family Violence from Colonial Times to the Present. Oxford University Press.

Documents the attention given to domestic violence from the first American laws against family violence in 1641 to the more recent, feminist-led, battered women’s movement, and the forces that have shaped social reform.

Salber, Patricia R and Tallaferro, Ellen. (1995). The Physicians Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse. Volcano Press.

Written by the co-founders of Physicians for a Violence-Free Society, this is a how-to manual for clinicians, caregivers and trainees. Package is available for training groups.

Stark, Evan and Flitcraft, Anne. (1997). Women at Risk: Domestic Violence and Women’s Health. Sage Publications.

Presenting major findings of studies conducted over 15 years, authors maintain that the medical, psychiatric, and behavioral problems exhibited by battered women stem from a so-called "dual trauma" in which the coercive strategies used by their partners converge with discriminatory institutional practices. This volume explores the theoretical perspectives as well as health consequences of woman abuse and considers clinical interventions to reduce the incidence of health problems associated with battering.

Wilson, K J (1997). When Violence Begins at Home. Hunter House Publishers.

A combined project of the Austin Center for Battered Women and the National Domestic Violence Hotline, this book written by a survivor of domestic violence, provides overview of domestic violence, and then focuses on the responsibilities -and limitations- of health care providers as well as others in addressing this pervasive community problem.

KEY INFORMANTS AND REFERENCES

State Coalitions

Alabama Coalition Against Domestic Violence, Montgomery, AL
Alaska Network on Domestic Violence and Sexual Assault, Juneau, AK
Arizona Coalition Against Domestic Violence, Phoenix, AZ
Arkansas Coalition Against Domestic Violence, North Little Rock, AR
Colorado Coaliton Against Domestic Violence, Denver, CO
Florida Coalition Against Domestic Violence, Tallahassee, FL
Hawaii State Coalition Against Domestic Violence, Aiea, HI
Iowa Coalition Against Domestic Violence, Des Moines IA
Kentucky Domestic Violence Association, Frankfort, KY
Mississippi Coalition Against Domestic Violence, Jackson, MS
Montana Coalition Against Domestic and Sexual Violence, Helena, MT
Nevada Network Against Domestic Violence, Reno, NV
New Mexico Coalition Against Domestic Violence, Albuquerque, NM
North Carolina Coalition Against Domestic Violence, Durham, NC
North Dakota Council on Abused Women's Services, Bismarck, ND
Oklahoma Coalition on Domestic Violence and Sexual Assault, OK City, OK
Pennsylvania Coalition Against Domestic Violence, Harrisburg, PA
South Dakota Coalition Against Domestic Violence &Sexual Assault, Pierre, SD
Tennessee Task Force vs Domestic Violence &Sexual Assault, Nashville, TN
Texas Council on Domestic Violence, Austin, TX
Utah Domestic Violence Advisory Council, Salt Lake City, UT
Vermont Network Against Domestic Violence &Sexual Assault, Middlebury, VT
West Virginia Coalition Against Domestic Violence, Charleston, WV
Wyoming Coalition Against Domestic Violence &Sexual Assault, Laramie, WY
Nursing Network against Violence Against Women, Portland, OR
Rural Health Roundtable, Washington, DC
Sacred Hoop, MN

Individuals

Judith Berman, Silver Springs, MD
Peggy Brown, Juneau, AK
Doris Campbell, Tampa, FL
Polly Campbell, Muskie School of Public Service, Portland, ME
Nancy Carlson, Illinois Attorney General's Office, Chicago, IL
Bonnie Carew, MS
Gene Carnicum, Parker, AZ
Linda Chamberlain, PhD, MPH, Anchorage AK
Susan Derk, Morgantown, WV
Tom Ellison, MD, Birmingham, AL
Nancy Fishwick, FNP, PhD, Bangor, ME
Joe Florence, MD, Hazard, KY
Deborah Hack, Denver, CO
Jackie Hallum, Asheville, NC
Lisa James, San Francisco, CA
Bonnie Lehew, IA
Denise McInnis, GA
Jan Mickish, Denver, CO
Rachel Rodgriguez, PhD, RN, San Antonio, TX
Jan Rueb, Austin, TX
Annette Siemens, FNP, MSN, MPH, Seward, AK
Milly Trevino-Sauceda, Pomona, CA

ENDNOTES

2. Bachman, R., and Saltzman, L.E. (1995). Violence against Women: Estimates from the Redesigned Survey. NCJ-154348. Washington DC: Bureau of Justice Statistics.

3. Straus, M.A. and Gelles, R.J. (1990) Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. New Brunswick, NJ: Transaction.

4. Tjaden, P. and Thoennes, N. (1998). Prevalence, incidence and consequences of violence against women; findings from the National Violence Against Women Survey. Research in Brief. Washington, DC: Office of Justice Programs, National Institute of Justice. 1-16.

5. Flitcraft, A. (1995). Clinical violence interventions: lessons from battered women. Journal of Health Care for the Poor and Underserved, 6, (2): 187-195.

6. Bushy, A. (1998). Health issues of women in rural environments: an overview. Journal of the American Medical Women's Association, 53, (2): 53-56.

7. Derk, S. and Reese, D. (1998). Rural health care providers' attitudes, practices and training experience regarding intimate partner violence: West Virginia, March 1997. MMWR, 47, (32): 670-673.

8. Adler, C. (1996). Unheard and unseen: rural women and domestic violence. Journal of Nurse Midwifery, 41, (6), 463-466.

9. Goeckermann, C.R., Hamberger, L.K., Barber, K. (1994). Issues of domestic violence unique to rural areas. Wisconsin Medical Journal, 93, (9): 473-479.

10. Fishwick, N. (1993). Nursing care of rural battered women. AWHONNS Clinical Issues in Perinatal and Women's Health Nursing, 4 (3): 441-448.

11. Butowsky, E. (1991). Battered women and rural realities. Unpublished master's thesis. Department of Maternal and Child Health, University of North Caroline-Chapel Hill.

12. Chamberlain, L. (1998). Research and Evaluation on Violence against Women in Alaska. Unpublished grant proposal.

13. National Center for State Courts (1993). As quoted in Chamberlain, L. (1998) Unpublished grant proposal.

14. Alaska Department of Public Safety (1992). Unpublished annual report.

15. Alaska Council on Domestic Violence and Sexual Assault (1993, 1998). Unpublished annual reports.

16. Alaska Department of Health and Social Services, (DHSS, 1998). Alaska Bureau of Vital Statistics, unpublished report.

17. Pakesier, R.A., Lenaghan, P., and Muelleman, R. (1998). Battered women: where they go for help. Journal of Emergency Nursing, 24: 16-19.

18. Parsons, L.H., Zacarro, D., Wells, B, and Stovall, T.G. (1995). Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. American Journal of Obstetrics and Gynecology, 173(2): 381-387.

19. American Medical Association. (1992). Diagnostic and Treatment Guidelines on Domestic Violence. American Medical Association: Chicago, IL.

20. McCauly, J., Kern, D., Kolodner, K., Dill, L., Schroeder, A., DeChant, H., Ryden, J., Bass, E. and Derogatis. (1995). The "battering syndrome" prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Annals of Internal Medicine, 123 (10): 737-746.

21. Capps, J., Given, J., and Makarushka, C. (1996). Responding to Domestic Violence: A Guide for Local Health Departments. Raleigh, NC: Injury Control Section, Department of Environmental Health and Natural Resources.

22. Dearwater, S., Coben, J., Campbell, J., Nah, G., Glass, N., McLoughlin, E. and Bekemeier, B. (1998). Prevalence of intimate partner abuse in women treated at community hospital emergency departments. Journal of the American Medical Association, 280: 433-438.

23. Chescheir, N. (1996). Violence against women: response from clinicians. Annals of Emergency Medicine, 27: 766-768.

24. Starfield, B. (1979). Measuring the attainment of primary care. Journal of Medical Education, 54(4):361-369.

25. Elliot, B. and Johnson, M. (1995). Domestic violence in a primary care setting: patterns and prevalence. Archives of Family Medicine, 4: 113-119.

26. Dickstein, L.J. (1997). Practical recommendations for supporting medical students and faculty in learning about family violence. Academic Medicine, 72(1Suppl): S105-109.

27. Reid, S.A., and Glasser, M. (1997). Primary care physicians' recognition of and attitudes toward domestic violence. Academic Medicine, 72(1): 51-3.

28. Short, L.M., Johnson, D., and Osattin, A. (1998). Recommended components of health provider training programs on intimate partner violence. American Journal of Preventive Medicine, 14(4): 283-288.

29. Alpert, E., Tonkin, A.E., Seeherman, A.M., and Holtz, H.A. (1998). Family violence curricula in US medical schools. American Journal of Preventive Medicine, 14(4): 273-282.

30. Tabak, N. and Ehrenfeld, M. (1998). Battered women: dilemmas and care. Medical Law, 17(4): 611-618.

31. Kripke, E.N., Steele, G., O'Brien, M.K., and Novack, D.H. (1998). Domestic violence training program for residents. Journal of General Internal Medicine, 13(12): 839-841.

32. Hadley, S., Short, L., Lezin, N., and Zook, E. (1995). Womankind: an innovative model of health care response to domestic abuse. Women's Health Issues, 5(4): 189-198.

33. Tilden, V.P., Schmidt, T.A., Limandri, B.J., Chiodo, G.T., Garland, M.J., and Loveless, P.A. (1994). Factors that influence clinician's assessment and management of family violence. American Journal of Public Health, 84(4): 628-633.

34. McFarlane, J., Greenberg, L, Wettge, A., and Watson, M. (1995). Identification of abuse in emergency departments: effectiveness of a two-question screening too. Journal of Emergency Nursing, 21: 391-394.

35. Hotch, D., Grunfeld, A.F., Mackay, K., and Cowan, L. (1996). An emergency department-based domestic violence intervention program: findings after one year. Journal of Emergency Medicine, 14(1): 111-117.

36. Olson, L., Anchl, C., Fullerton, L., Brillman, J., Arbuckle, J., and Sklar, D. (1996). Increasing emergency physician recognition of domestic violence. Annals of Emergency Medicine, 27: 741-746.

37. Feldhaus, K., Koziol-McLain, J., Amsbury, H., Norton, I., Lowenstein, S., and Abbot, J. (1997). Accuracy of three brief screening questions for detecting partner violence in the emergency department. Journal of the American Medical Association, 277: 1357-1361.

38. Varvaro, F.F. and Gesmond, S. (1997). ED physician house staff response to training on domestic violence. Journal of Emergency Nursing, 23(1):17-22.

39. McFarlane, J., Parker, B., Soeken, K, Silva, C., and Reel, S. (1998). Safety behaviors of abused women following an intervention program offered during pregnancy. Journal of Obstetrical, Gynecological and Neonatal Nursing, 27: 64-69.

40. McGrath, M.E., Peipert, J.F., and Hogan, J.W. (1998). A prevalence survey of abuse and screening for abuse in urgent care patients. Obstetrics and Gynecology, 91: 511-514.

41. Muelleman, R.L. and Feighny, K.M. (1999). Effects of an emergency department-based advocacy program for battered women on community resource utilization. Annals of Emergency Medicine, 33(1): 62-66.

42. Allert, C.S., Chalkley, C., Whitney, J.R., and Librett, A. (1997). Domestic violence: efficacy of health provider training in Utah. Prehospital Disaster Medicine, 12(10: 52-56.

43. Sugg, N.K., Thompson, R.S., Thompson, D.C., Maiuro, R., and Rivara, F.P. (1999). Domestic violence and primary care. Attitudes, practices, and beliefs. Archives of Family Medicine, 8(4): 301-306.

44. Loring, M.T., Smith, R.W. (1994). Health care barriers and interventions for battered women. Public Health Reports, 109, (3): 328-338.

45. Cohen, S., DeVos, E., and Newberger, E. (1997). Barriers to physician identification and treatment of family violence: lessons from five communities. Academic Medicine, 72(1Suppl): S19-25.

46. McGrath, M.E., Bettacchi, A., Duffy, S., Peipert, J., Becker, B and St. Angelo, L. (1997). Violence against women: barriers to intervention in emergency departments. Academy of Emergency Medicine, 4: 297-300.

47. Bates, L. and Brown, W. (1998). Domestic violence: examining nurses' and doctors' management, attitudes and knowledge in an accident and emergency setting. Australian Journal of Advanced Nursing, 15(3): 15-22.

48. Sugg, N.K. and Innui, T. (1992). Primary care physicians' response to domestic violence. Journal of American Medical Association, 267: 3157-3160.

49. Sheilds, G., Baer, J., Leininger, K., Marlowe, J., and DeKeyser, P. (1998). Interdisciplinary health care and female victims of domestic violence. Social Work and Health Care, 27(2): 27-48.

50. Gerbert, B., Johnston, K., Caspers, N., Bleecker, T., Woods, A., and Rosenbaum, A. (1996). Experiences of battered women in health care settings: a qualitative study. Women & Health, 24, (3): 1-17.

51. Rodriquez, M.A., Bauer, H.M., Flores-Ortiz, Y., and Szkupinksi-Quiroga, S. (1998). Factors affecting patient-physician communication for abused Latina and Asian immigrant women. Journal of Family Practice, 47(4): 309-311.

52. McCauley, J., Yurk, R.A., Jenckes, M.W., and Ford, D.E. (1998). Inside "Pandora's box": abused women's experiences with clinicians and health services. Journal of General Internal Medicine, 13(8): 549-555.

53. Rodriguez, M.A., Craig, AM, Mooney, D.R., and Bauer, H.M. (1998) Patient attitudes about mandatory reporting of domestic violence. Implications for health care professionals. Western Journal of Medicine, 169(6): 337-341.

54. Gerbert, B., Caspers, N., Bronstone, A., Moe, J., and Abercrombie, P. (1999). A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Annals of Internal Medicine, 131(8): 578-584.

55. Hamberger, L.K, Ambuel, B., Marbella, A and Donze, J. (1998). Physician interaction with battered women: the women's perspective. Archives of Family Medicine, 7(6): 575-582.

56. Gerbert, B., Abercrombie, P., Caspers, N., Love, C., and Bronstone, A. (1999). How health care providers help battered women: the survivor's perspective. Women & Health, 29(3): 115-135.

57. Rittmayer, J. and Roux, G. (1999). Relinquishing the need to "fix it": medical intervention with domestic abuse. Qualitative Health Research, 9(2): 166-181.

58. Warshaw, C. and Ganley.A. (1998). Improving the Health Care Response to Violence: A Resource Manual for Health Care Providers. San Francisco, CA: Family Violence Prevention Fund.