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.
"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."
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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
relationships6, 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
women8, 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.
"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."
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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 utilization17,
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.
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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 women26,
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 response33,
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 sites35
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.
"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."
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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.
The Family Violence Prevention Fund
(FUND), a national domestic violence advocacy organization has
been an early leader in calling for universal screening, and
with support from the Conrad N. Hilton Foundation and the US
Department of Health and Human Services, recently published
Preventing Domestic Violence: Clinical Guidelines on Routine
Screening (1999).
The FUND recommends:
- Routine screening for domestic violence
victimization for all female patients over the age of fourteen
in primary care, obstetrics/gynecology and family planning,
emergency department, in-patient, pediatrics and mental
health settings. Routine screening means that inquiry about
domestic violence occurs with all women over the age of
fourteen, whether or not symptoms or signs are present and
whether or not the provider suspects abuse has occurred.
- That all practitioners and health organizations
within these settings implement culturally competent programs
to ensure routine screening of all female patients
- That screening be carried out in private
settings and through use of straightforward, nonjudgmental
questions in a culturally competent manner, preferably asked
verbally by the practitioners in ways that increase safety
of abused patients and respect their autonomy.
- Confidential documentation of screening
outcomes.
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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.
Universal Screening In Rural WV
The Women's Health Advocacy Project of the Family Refuge Center,
in Lewisburg, W.V. places domestic violence advocates in rural,
primary care clinics and provides shelter, transportation, legal
advocacy and court accompaniment to abused women. The advocates
educate clinic staff on domestic violence so that they can better
identify associated health problems. All female patients, age
18 and up, are screened to determine how issues of violence
affect their health. Program partners include the West Virginia
School of Osteopathic Medicine, the West Virginia School of
Osteopathic Medicine Clinic, Inc, Monroe Health Center and Rainelle
Medical Center. For more information, contact Ms. Debbie Sizemore,
Program Coordinator, 117 E. Washington St., PO Box 249, Lewisburg,
WV, 24901. Telephone: 304-645-6334. Fax: 304-645-7368.
Email: oma00020@mail.wvnet.edu
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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.
RESOURCES:
- The National Center for Injury Prevention
and Control recently published Intimate Partner Violence
and Sexual Assault: A Guide to Training Materials and Programs
for Health Care Providers, 1998. Executive summary is available
on line. For more information, contact National Center for
Injury Prevention and Control, 4770 Buford Highway, NE Mail
Stop K65, Atlanta, GA 30341. Telephone: 770-488-1506. Fax:
770-488-1667.
- Several community-based examples are
explained in more detail in the resource section of this
paper, including initiatives by the American College of
Nurse Midwives, the Alaska Family Violence Prevention Fund.
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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
"The goals potentially served by mandatory
reporting include enhancing patient safety, improving health care
providers’ response to domestic violence, holding batterers accountable,
and improving domestic violence data collection and documentation
will not necessarily accomplish these goals. Further, the implications
of mandatory reporting for patient health and safety as well as
ethical concerns raised by such a policy argue against its general
application."
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.
For more information, and complete
reprint of Ms. Hyman's policy paper, contact the Family
Violence Prevention Fund. Telephone: 415-252-8900 Fax: 415-252-8991
Email: fund@fvpf.org.
Web: http://www.fvpf.org.
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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.
Domestic violence ICD-9 codes
(divided into four major areas)
- Adult maltreatment and abuse (995-81)
- The primary diagnosis (PDX-underlying
reason for admittance)
- Modifier codes that provide details (E-codes)
- History codes that provide information
on previous incidents (V-codes).
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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.
Resources and Examples:
Discrimination risks are real. A 1998 joint
report developed by the Pennsylvania Coalition Against Domestic
Violence (PCADV) and the Women's Law Project reported that
a woman from rural Minnesota was beaten severely by her ex-husband.
After remarrying, she applied for health insurance and was
told that should would not be covered for treatment relating
to the abuse-related pre-existing conditions of depression
and neck injury.
For more information on these issues, contact
Terry Fromson, Esq, Managing Attorney, Women's Law Project,
125 South 9th St, Suite 401, Philadelphia, PA,
19107, phone 215-928-9801, and/or Nancy Duburow, Health Projects
Coordinator, PCADV, 6400 Flank Dr, Suite 1300, Harrisburg,
PA, 17112, phone 800-932-4632 (in PA), and 800-537-2238 (outside
PA).
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Rural providers should be aware of their own
state laws, and seek appropriate guidance when developing their own
policies and procedures regarding documentation of domestic violence.
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.
Council Development
For more information about the development and use of such Coordinating
Councils, contact Lynda Dautenhahn, Violence Prevention Planner,
Division of Health Promotion, Illinois Department of Public
Health, 535 West Jefferson, Springfield, IL 62761. Phone 217-785-2060.
Fax 217-782-1235. TDD 800-537-0466.
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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.
Coordinated Community Responses
to Prevent Intimate Partner Violence is another program
that has been recently funded by the Centers for Disease Control
and Prevention. For fiscal year 2000, $5.9 million was appropriated
to support 10 projects administered by the CDC. Since its inception
in 1996, this program has funded at least 3 projects designed
for rural and Native American communities to develop and evaluate
a coordinated community response.
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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,
"Despite the well documented prevalence
of partner abuse among women seeking medical services in health
care settings, clinicians continue to have difficulty incorporating
routine inquiry about domestic violence into their practices and
responding appropriately to women who have been battered by their
partners. Even institutions with established protocols and training
often fail to provide the support necessary for a sustained provider
response. There are several reasons for this.
Unlike traditional "medical problems",
domestic violence often raises complex issues and challenges both
for individual providers and for the institutions that shape the
practice of medicine. Some of these issues involve individual
experiences and responses to abuse, as well as biases and cultural
assumptions about gender and partner abuse. Addressing these
issues requires more than simply adding new diagnostic categories
to differential diagnoses or new technical skills to clinical
repertoires. (emphasis added) Instead, it entails asking
clinicians to behave in ways that may conflict with their personal
needs and cultural values. The development of effective responses
to domestic violence then requires changes in knowledge, attitudes,
and skills that push the limits of a traditional medical framework.
Other structural obstacles can also interfere
with a clinician’s ability to provide an appropriate standard
of care for battered women. For example, when medical training
programs foster an atmosphere in which students and residents
learn to survive at the expense of their own feelings, it can
be difficult for them to respond appropriately to the feelings
of others. If addressing complex psychosocial issues is neither
valued nor supported an institutional level, clinicians’ survival
within the health care system may be placed in conflict with the
needs of their patients. To improve an institution’s response
to domestic violence, these barriers must be addressed systematically."
58 (p. 110)
The National Health Initiative targets these
barriers to improved practice by
- 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:
- Who is required to report?
- Who receives the report?
- Who is required to the report?
- What are penalties for failure to report?
- Is there provider immunity from liability?
- How is provider-patient privilege protected?
- What is the purpose of the reporting?
- 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.
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- 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.
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- 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. 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. 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:
The American Medical Association (AMA)
515 North State Street
Chicago, IL 60610
Phone (312) 464-5000
Fax (312 464-4184
http://www.americanmedicalassociation.org/
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.
Family Violence Prevention Fund
383 Rhode Island St. Suite #304
San Francisco, CA 94103-5133
Phone (800) 313-1310 & (415) 252-8900
Fax (415) 252-8991
http://www.fvpf.org/
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.
Health Resource Center on Domestic Violence
San Francisco, CA
Phone (888) Rx-Abuse (888-792-2833)
Hours: Monday-Friday
9:00 AM-5:00 PM PST
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.
Migrant Clinician’s Network
Family Violence Services
PO Box 164285
Austin, TX 78716
Telephone: 512-327-2017
Fax: 512-327-0719
Email: webmaster@migrantclinician.org
http://www.migrantclinician.org/
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.
National Center on Elder Abuse
1225 I Street, NW, Suite 725
Washington, DC 20005
Phone (202) 898-2586
Fax (202) 898-2583
http://www.elderabusecenter.org/
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.
National Coalition Against Domestic
Violence (NCADV)
P.O. Box 18749
Denver, CO 80218
Phone (303) 839-1852
Fax (303) 831-9251
http://www.ncadv.org/
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.
National Domestic Violence Hotline
3616 Far West Blvd, suite 101-297
Austin, TX 78731-3074
Phone: 1-800-799-SAFE or for hearing impaired (1-800-787-3224
(TDD)
Administration: 512-453-8117
http://www.ndvh.org/help/index.html
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.
National Resource Center on Domestic Violence
6400 Flank Drive Suite 1300
Harrisburg, PA 17112-2778
Phone (800) 537-2238
Fax (717) 545-9456
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
American Academy of Family Practice http://www.aafp.org
American Academy of Pediatrics http://www.aap.org
American College of Emergency Medicine http://www.acep.org
American College of Obstetricians/Gynecologists http://www.acog.org
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. 5th 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. 34th 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. 9th 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 12th 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. 25th, 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
1. Urbancic, J., Campbell,
J., and Humphreys, J. (1993). Student clinical experiences in shelters
for battered women. Journal of Nursing Education, 32(80): 341-346.
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
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