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8
Papers on Preventive
Interventions
Interventions to prevent violence against women and children are as
varied as the settings and populations in which they operate. No matter
what the setting, however, successful interventions demonstrate measur-
able reduction in violence as well as secondary effects such as increases
in gender equality, economic empowerment, life skills development, com-
munity mobilization, resilience, and quality of life. Speakers presented
a number of case studies of such interventions and provided thoughtful
analysis of the possibility of transportation of such programs to alternate
settings.
The first paper is an overview of the Intervention with Microfinance
for AIDS and Gender Equity (IMAGE) program in South Africa. Although
economic empowerment of women is a common method of addressing
structural inequities, IMAGE also incorporated gender-based violence and
HIV prevention programming. The result was a successful multisectoral
response that resulted in reduction of a number of adverse outcomes, in-
cluding violence and HIV transmission.
The second paper describes the success of two programs to address
intimate partner violence and child maltreatment in Hong Kong. Both pro-
grams use obstetricians and nurses who regularly come into contact with
expectant parents to provide additional information and support on com-
munication and parenting skills. Special attention was paid to addressing
cultural norms.
The third paper is an analysis of The Fourth R, a school-based pro-
gram originating in Canada and now offered in a number of settings in
North America. The Fourth R integrates skills building and risk factor
144
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PAPERS ON PREVENTIVE INTERVENTIONS
management into current school programming, reaching adolescents at a
crucial time of development.
The fourth paper summarizes the Community Advocacy Model aimed
at women experiencing intimate partner violence. It is centered around a
“family model” that assesses the strengths and needs of victims and pro-
vides them with social support to protect themselves and their children. The
approach of this intervention is based on the relationship of women with
their communities and the necessity in engaging the community to reduce
norms condoning violence.
The final paper looks at the “systems change model” of Kaiser Per-
manente, an integrated health care system that incorporates all levels and
aspects of health care delivery. Using this pre-existing structure, Kaiser
Permanente has implemented a family violence prevention program meant
to identify potential violence as victims and perpetrators access the health
care system. It also provides training to its physicians and other health care
staff, on-site resources, and linkages to community resources for violence
prevention.
THE IMAGE PROGRAM: SUMMARY
Julia Kim, M.D., M.Sc.
United Nations Development Program
The Intervention with Microfinance for AIDS and Gender Equity
(IMAGE) program1 began in 2001 in rural Limpopo, South Africa, and
is a community-based program that combines microfinance with a gen-
der and HIV curriculum. It began as a partnership between the Rural
AIDS and Development Research Program (RADAR) at the University of
Witwatersrand; the London School of Hygiene and Tropical Medicine;
and the Small Enterprise Foundation (SEF), a microfinance group based in
Limpopo. The IMAGE program has shown that it is possible to address
poverty, gender-based violence (GBV), and HIV together, underscoring
the need for future investments to support multisectoral programming to
address women’s social and economic empowerment in order to reduce
vulnerability to GBV and HIV.
The IMAGE intervention uses microfinance loans as a vehicle for em-
powering the poorest women in rural villages. The microfinance partner,
1 IMAGE has received funding from Anglo American Chairman’s Fund, Anglo Platinum,
the Ford Foundation, the UK Department for International Development, the Henry J. Kaiser
Foundation, the International Humanist Institute for Cooperation with Developing Countries,
the MAC AIDS Fund, the South African Department of Health, and the Swedish International
Development Cooperation Agency.
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146 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
SEF, is based on the Grameen Bank model, whereby groups of five women
aged 18 and older served as guarantors for each other’s loans, with all five
required to repay before the group is eligible for more credit. Loans are
used to support a range of small businesses. Loan centers of approximately
40 women meet fortnightly to repay loans, apply for additional credit, and
discuss business plans.
In addition to the microfinance component, the IMAGE intervention
includes a participatory learning program called Sisters for Life (SFL), which
is integrated into routine loan center meetings. It focuses on issues such as
gender roles, cultural beliefs, domestic violence, power relations, self-esteem,
sexuality, and HIV/AIDS. The SFL sessions are aimed at strengthening com-
munication skills, critical thinking, and leadership. In the second phase,
program participants are encouraged to facilitate wider community mobili-
zation to engage both youths and men in addressing gender norms.
Evaluated as a cluster randomized trial in eight villages in rural Limpopo,
the program assessed the impacts on poverty, women’s empowerment, and
risk of intimate partner violence (IPV), and HIV/AIDS. After two years the
IMAGE study found that the risk of physical and sexual intimate partner
violence among participants was reduced by 55 percent (Kim et al., 2007).
Among young women participating in the program, several factors related to
HIV risk were also positively affected, including an increase in communica-
tion about HIV, a 64 percent increase in voluntary counseling and testing,
and a 24 percent reduction in unprotected sex (Pronyk et al., 2008). The
study also found positive impacts on household economic well-being, in-
cluding increased food security, expenditures, and household assets. In terms
of impact on women’s empowerment, the participants reported increased
self-confidence, autonomy, social capital, collective action, and an ability to
challenge gender norms (Kim et al., 2007). The program was also interested
in exploring whether additional positive changes might diffuse to young
people not directly participating in the intervention, but it did not find any
changes in sexual behavior or HIV incidence among a random sample of
young people living in the intervention villages (Pronyk et al., 2006).
In order to determine whether microfinance without the SFL training
would have been as effective, researchers conducted a cross-sectional analy -
sis comparing microfinance alone against the combined IMAGE interven-
tion. Microfinance alone and IMAGE produced similar economic impacts,
but only the IMAGE program showed benefits in terms of IPV, women’s
empowerment, and HIV risk behaviors (Kim et al., 2009). The study sug-
gests that the combination of microfinance with gender training and com-
munity mobilization is important for generating synergy and broadening
the social and health impacts of microfinance.
IMAGE has successfully been scaled up from a research pilot project to
a sustainable and fully integrated program, which has now reached 12,000
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PAPERS ON PREVENTIVE INTERVENTIONS
women in 160 villages. Supporting the sustainability and expansion of the
approach, the microfinance program is cost-neutral, with its operational
costs being covered by the interest charged in the loan repayment process.
In response to training requests from other microfinance and GBV orga-
nizations, the IMAGE program is currently exploring opportunities to de-
velop as a best-practice learning site to support South-South learning and
replication across different settings. Further research to inform the adapta-
tion and replication of such models will yield important lessons.
There are a number of lessons that have been learned from the IMAGE
program. The program presents encouraging evidence that it is possible to
reduce IPV and to challenge gender norms and violence even when they
appear to be “culturally entrenched” and resistant to change. Second, the
IMAGE program shows the importance of meeting women’s basic eco-
nomic needs as part of a GBV/HIV intervention. Building on a pre-existing
poverty alleviation program made it possible to maintain regular contact
with a particularly vulnerable and difficult-to-reach group (impoverished
rural women) for more than a year—an opportunity rarely afforded most
stand-alone health /HIV interventions. Although this program focused on
microfinance, other strategic entry points for women’s economic empower-
ment could be explored, such as literacy programs and job skills training.
Third, it is important to choose strong sectoral partners and to allow each
to focus on what it does well. There are risks involved in HIV programs
attempting to deliver microfinance, and in this case SEF focused on deliv-
ering the microfinance program while partnering with RADAR to develop
the gender and health aspects. Finally, IMAGE showed that programs can
work indirectly to affect the most vulnerable groups. Recognizing that
young women are particularly vulnerable to HIV and IPV, the program
worked with older women (who are often cultural gatekeepers) as well as
their younger peers to challenge existing gender norms and increase com-
munication across generations. Similarly, given the economic vulnerability
of young women, the program aimed to improve household economic
well-being through loans given to more mature women rather than putting
loans directly into the hand of adolescent girls—an approach that can raise
financial and programmatic challenges. Finally, recognizing the importance
of engaging men, the program worked directly with microfinance clients, in
order to empower them to reach out and engage men during the community
mobilization phase (Kim et al., 2007).
In order for structural-level interventions to be most effective, pro-
grams should focus simultaneously on quick wins and long-term change.
Ultimately, programmatic approaches such as IMAGE need to be supported
and complemented by policy-level interventions that create an enabling en-
vironment for sustained change (Kim et al., 2008). Mainstreaming gender
and HIV within national AIDS and development plans is one way to embed
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148 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
structural interventions within this more long-term, policy-level approach.
It is encouraging that studies such as IMAGE can contribute to policy-level
change, such as the inclusion of microfinance and the empowerment of
women in the South African government’s Strategic Plan for HIV/AIDS.
Further implementation and research focusing on multisectoral approaches
to addressing intimate partner violence and HIV are needed.
INNOVATIVE PREVENTION INTERVENTIONS:
ADDRESSING IPV AND POTENTIAL CHILD
ABUSE AT PRENATAL CARE
Agnes Tiwari, Ph.D., R.N., FAAN
University of Hong Kong
Intimate partner violence (IPV) during pregnancy adversely affects the
health and well-being of pregnant women and their unborn infants. Yet,
pregnancy also offers a unique opportunity for primary prevention of IPV
as well as for interrupting the cycle of violence. In this paper two interven-
tions are presented: the Positive Fathering Program, which was designed as
a primary prevention strategy; and the Empowerment Intervention, which
aims to interrupt the cycle of violence against pregnant women and their
unborn infants.
The Positive Fathering Program
The Positive Fathering Program aims to engage expectant fathers in
prenatal education in order to prepare them for transition to fatherhood
while working in tandem with their intimate partners. Despite the name of
the program, both men and their pregnant partners are actively involved
in the program as couples. Couple involvement is essential in building a
caring, committed, and collaborative intimate relationship within which the
transition to parenthood is nurtured.
The need for engaging men in the transition to parenthood arises from
the fact that such a transition can be a challenging time for men (Cowan
and Cowan, 1995; Goodman, 2005). Specifically, men may have unreal-
istic expectations about involved fatherhood and develop role ambiguity
as fathers (Doherty et al., 1998; Goodman, 2005). Such uncertainties may
be further aggravated by the lack of role models or inadequate guidance
to ease the transition to fatherhood (Goodman, 2005). Thus, adjustment
to fatherhood may turn out to be distressing and frustrating for men and
may strain couple relationships. Furthermore, with the development of a
strong mother-infant relationship, some men may feel excluded and see
the unborn infant as an intruder in their intimate relationships (Anderson,
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PAPERS ON PREVENTIVE INTERVENTIONS
1996). Jealousy and the perceived need to exert control over their partners
may result in IPV during pregnancy (Campbell et al., 1993). Providing
support and guidance to expectant fathers is, therefore, essential in order
to help them develop realistic expectations of fatherhood and to improve
their confidence as new fathers. Furthermore, engaging men in prenatal
education is important so that they may jointly learn and prepare for new
parenthood with their partners, instead of feeling excluded.
Although there is an array of prenatal education programs for child-
birth, parenthood, or both, these programs focus primarily on the needs of
expectant mothers. Indeed a recent Cochrane Review suggests that there are
relatively few prenatal education programs that specifically address expect-
ant fathers’ needs (Gagnon and Sandall, 2008).
The Positive Fathering Program has been developed to address the gap
in the engagement of men in prenatal education. The program is based on
the theoretical framework of self-efficacy, which is the belief in one’s ability
to successfully perform a particular behavior (Bandura, 1982). Providing
expectant couples with knowledge and skills related to caring for the baby
and the mother as well as with opportunities to work together toward the
transition to parenthood helps them acquire confidence in their abilities to
carry out such tasks and also develops trust among the partners that each
will be supportive of the other’s efforts.
The program’s focus on developing a couple’s self-efficacy regarding
care of the baby and mother in the postnatal period is deliberate because
it provides something concrete and meaningful for engaging expectant fa-
thers, a common goal that has practical applications for the couple, and a
forum for listening and responding to one’s partner.
As the program primarily targets Chinese expectant couples, cultural
adaptation is also used to ensure that the program is culturally appropriate
for the intended participants. The key features of the cultural adaptation
are:
• discussing couple relationship issues in the context of raising chil-
dren, which is generally more emphasized than marital issues in
Asian cultures;
• adopting an experiential learning approach (which is honored in
Asian cultures) to promote motivation and understanding;
• helping participants to understand their feelings instead of sup-
pressing them and recognizing the need to understand their part-
ner’s inner world in order to make meaningful connections;
• appropriately using empirical research and theories, which are highly
valued in Asian cultures, when delivering the teaching materials;
• using metaphors when explaining abstract or complicated con-
cepts; and
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150 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
• acknowledging a need to assess the extent to which participants
have been influenced by Western culture and ensuring that the
teaching is sensitive to Chinese cultural norms (Huang, 2005).
The Positive Fathering Program has four components: (1) engaging
men as expectant fathers; (2) promoting parenting self-efficacy, including
as a couple; (3) enhancing couple relationships through partnership and
experiential learning; and (4) managing traditional cultural beliefs in a
contemporary world.
To engage men in their roles as expectant fathers, the program uses
“reality boosters” to bring them closer to their unborn infant, such as
interacting with life-size dolls with the weight and texture of a newborn,
feeling fetal movement, and listening to fetal heartbeats. The program also
encourages the men to express their aspirations to be a supportive partner
and responsible father, while inviting the women to validate their partners’
expressed aspirations. Program administrators assist the expectant fathers
in exploring their needs and how such needs can be met, both by themselves
and with their partner.
In order to be more effective parents, couples learn to identify their
infant’s needs and understand appropriate infant care responses; learn and
practice the behaviors that will best meet those needs, under supervision
and with reinforcement; and explore how social support networks (includ-
ing their families, neighbors, and friends) may enhance their capacity as
new parents. The couple relationships are enhanced through partnership
and experiential learning involving active listening and responding, learning
to express their feelings, and understanding the inner world of the other
person.
In addition, the program helps expectant couples manage traditional
cultural beliefs in a contemporary world by identifying Chinese beliefs
and practices relating to postpartum care and locating them in the context
of research, theory, and reality. This allows participants to anticipate the
impact of cultural practices on the new mother and infant and to respond
constructively. Finally, couples are encouraged to talk through various
strategies they can use to accommodate the involvement of in-laws in infant
care and traditional postpartum practices.
The Positive Fathering Program was implemented, in combination
with standard prenatal education, in a large public hospital in Hong Kong
from August 2009 to February 2011. The differences between the two ap-
proaches are summarized in Table 8-1.
In practice, the Positive Fathering Program was delivered in three con-
secutive, evenly spaced sessions over a 14-week period starting at about
20 weeks of gestation. Each session took about three hours to complete,
depending on the size of the group. In order to be included in the program,
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PAPERS ON PREVENTIVE INTERVENTIONS
TABLE 8-1 Differences Between Standard Prenatal Education and the
Positive Fathering Program
Standard Prenatal Education Positive Fathering Program
5 sessions totaling 10 hours 3 sessions totaling 9 hours
Focus on child birth, breastfeeding, infant Focus on engaging expectant fathers, couple
care, pre- and postnatal emotions, and relationships and communication, parenting
postnatal care efficacy, in-law involvement, and cultural
postnatal practices
Conducted as large classes Conducted as small groups
(> 100/class) (6-8 couples/group)
≤ 50% of the participants are couples 100% couple attendance
Content is based on well-established Content is based on identified needs
prenatal education
Teacher-centered, didactic teaching, Couple-centered, two-way, interactive
one-way transmission of content discussion and hands-on practice
Passive learning Active learning
Minimal couple partnership in learning Couple partnership in learning is the main
theme of the program
the woman needed to be less than 20 weeks into her pregnancy at the time
of recruitment, and the couple had to agree to attend all three sessions
together. Participation was voluntary, and recruitment took place in pre-
natal clinics. The nature of the program and the process was explained to
the potential participants. Those who agreed to participate were asked to
provide a written consent because questionnaires would be administered at
different points of the program for evaluation purposes.
A small group format was adopted in order to maximize active partici-
pation and to ensure adequate hands-on practice. Each group was facili-
tated by a designated nurse or midwife, assisted by at least two members of
the research staff. The same facilitator would work with the group through
all three sessions in order to ensure continuity and to build rapport with
the participants. Meticulous training of the facilitators and research staff
was vital in order to ensure that the program was delivered as planned and
that the same standards were maintained across the groups. To this end,
a two-day training session was provided prior to the start of the program
that focused on the theoretical underpinning and intended outcomes of
the program as well as on the knowledge and skills required for delivering
the content. The facilitator’s performance in delivering the sessions was
assessed by the program leader, and re-training was provided until satisfac-
tory performance was demonstrated.
The obstetrics department of the host hospital provided the venue (a
large seminar room) and the facilities for the group sessions, including
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152 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
hands-on practice in infant care and couple communication skills. Close col-
laboration between the program team and the clinicians ensured smooth re-
cruitment of participants, implementation of the group sessions as planned,
and referrals as necessary (e.g., midwives or obstetricians).
Over an 18-month period, 171 Chinese couples were recruited to the
program. Program evaluation, which was conducted using chart reviews
and self-reports elicited using instruments and telephone interviews, re-
vealed the following:
• A total of 166 couples completed the program, for a completion
rate of 97 percent.
• Five couples did not complete because they unexpectedly had to
work on the days when the intervention was held.
• No adverse events in connection with the program were reported.
• A significant improvement in couple relationship adjustment,
as measured by the Chinese version of the Dyadic Adjustment
Scale comparing the baseline scores with those taken at six weeks
post-delivery, was reported by the couples (p < 0.001) (Shek and
Cheung, 2008).
• A significant reduction in depressive symptoms, as measured by
the Chinese version of the Edinburgh Postnatal Depression Scale
comparing the baseline and six weeks post-delivery scores, was also
reported by the couples (p < 0.001) (Lee et al., 1998).
• A consumer satisfaction survey conducted at six weeks post-
delivery found that a large majority of the couples rated the pro-
gram as “extremely useful to useful.” Specifically, 86 percent of
couples reported that it was helpful in improving their intimate
relationships, 77 percent reported that it enhanced their commu-
nication skills with the partner, and 94 percent reported that the
program increased their confidence in caring for their new infant.
• Telephone interviews conducted with 10 percent of the couples also
provided anecdotal accounts of the positive outcomes of the pro-
gram in terms of couple relationships and care of the new infant.
• The cost of the program was about US$60 per couple.
To summarize, the Positive Fathering Program demonstrated acceptabil-
ity and efficacy for 166 Chinese expectant couples using public prenatal care
in Hong Kong. In the next stage of development, the program will be modi-
fied based on a hospital–community partnership model, which will combine
the use of professional and non-professional caregivers over the pre- and
postnatal period. The program’s efficacy in improving couple relationships,
enhancing parental sense of competence, and reducing postnatal depressive
symptoms will be tested using a cluster randomized controlled trial.
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The Empowerment Intervention
Background
The Empowerment Intervention, a secondary prevention program for
early detection and reduction or elimination of violence against pregnant
women by their intimate partners, is based on the premise that violence
against women by an intimate partner is part of a pattern of coercive control
(Dobash et al., 1992; Parker et al., 1999). Therefore, the intervention aims
to increase abused women’s independence and control (Parker et al., 1999).
Dutton’s (1992) empowerment model, which provides the theoretical basis
for the intervention, includes: protection (with a focus on increasing abused
women’s safety) and enhanced choice making and problem solving (relating
to making decisions about relationship, relocation, and other transitional
issues). In addition, Parker and colleagues (1999) also adopt the approach
that, because relationships are complex and multi-dimensional, the woman
in the abusive relationship understands the situation best. Furthermore,
the woman knows what is best for her and her children. What she needs
is an opportunity to express her feelings to a nonjudgmental and empathic
person and to be allowed to make her own decisions.
Methods
The modified Empowerment Intervention was tested on 110 abused
Chinese pregnant women in a prenatal setting in Hong Kong in 2002 and
2003 using a randomized controlled trial (Tiwari et al., 2005). The par-
ticipants were randomly assigned to the intervention group (n = 55) or the
control group (n = 55). The intervention group received the Empowerment
Intervention as described earlier, and the control group received standard
care for abused women. Data were collected at study entry and six weeks
postnatal.
Intervention
The modified Empowerment Intervention for abused Chinese women is
based on the empowerment protocol of Parker and colleagues (1999) and
on Walker’s cycle of violence (1979), which explain how women become
victimized and why it is so difficult for them to extricate themselves from
abusive relationships (Tiwari et al., 2005). The intervention was carried
out in a private 30-minute session as part of a larger 12-week advocacy
intervention that consisted of 12 social-support telephone sessions based
on Cohen’s Social Support Theory as well as access to a 24-hour support
hotline (Cohen, 1988; Tiwari et al., 2010). The 30-minute empowerment
intervention was carried out in a one-on-one setting with an assurance of
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154 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
confidentiality by a professional who had undergone training for this pur-
pose and who was fully conversant with empowerment theory and with the
modifications that had been made to ensure culture congruence.
The Empowerment Intervention includes the following three compo-
nents: information on the cycle of violence, logistical information related
to safety and legal recourse, and information for assessing the behaviors
of the abuser for danger. The original intervention was modified for use
among abused Chinese pregnant women in Hong Kong in order to en-
sure that it was consistent with the subscribed norms of Chinese women
living in a “shame-oriented” culture (Tiwari et al., 2005). In particular,
because of the fear of rejection or ridicule that many Chinese women
perceive to be associated with revealing their abusive experiences, an ad-
ditional component known as “empathic understanding” and based on
Rogers’ client-centered therapy (1951), was incorporated. Empathic un-
derstanding emphasizes the need for the helping professional to elicit the
woman’s perceptions and feelings in a nonjudgmental way. This approach
is intended to help women who are participating in the intervention to
positively value themselves and their feelings, which is an important con-
sideration, especially if previous attempts to disclose IPV were ignored
or ridiculed. The next three sections offer brief descriptions of the main
components of the modified intervention.
Cycle of Violence
Women in the intervention were taught about the cycle of violence in
order to facilitate their ability to describe their relationship and thus gain
a sense of control over the abusive situation. The cycle of violence was de-
scribed to the participants as consisting of three phases: tension building;
violence; and reconciliation, or the “honeymoon phase” (Walker, 1979).
During phase one, a woman typically works, consciously or unconsciously,
to decrease the building tension in the relationship. By the end of phase
one, she is exhausted and begins to withdraw from the relationship, fearing
that she may inadvertently set off an outburst of violence. In response to
her withdrawal, the abuser becomes violent, thus phase two begins. Dur-
ing phase two, the violent phase, the acute battering incident takes place
and may last for minutes, hours, or days. During phase three, often called
the “honeymoon stage,” the abuser attempts to reconcile the relationship,
showing love, tenderness, and remorse. The abuser’s gestures of buying
gifts, begging for forgiveness, or both may make it more difficult for the
woman to take action against her abuser. She may even believe that if she
is able to keep her abuser happy, they will live happily. Family members
may also get involved. In the case of Chinese families, which emphasize the
need to keep the family intact, the woman may be put under a great deal of
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174 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
Tracking Progress Using Quality-Improvement Measures
In the initial 1998 pilot project, success was measured by tracking the
number of patients identified and referred by clinicians. Later, during the
dissemination of the systems-model approach to other Northern California
medical facilities, an opportunity arose to track progress by using already
existing quality and outcome measurement systems that are based on auto-
mated diagnosis databases. In 2002 Kaiser Permanente Northern California
selected Improving IPV Prevention to demonstrate implementation of a
behavioral health prevention guideline that shows coordination between
primary care and mental health to meet an NCQA standard.5
The quality measures used to track progress toward Improving IPV
Prevention are similar to those used for other health conditions, such as
asthma, diabetes, hypertension, and depression. These measures provide
data to monitor performance over time, between medical centers and de-
partments, and to help teams focus their training and other improvement
efforts.
The quality-improvement measures include both qualitative (process
measures) and quantitative (measures based on clinical identification). The
three process measures for each medical center are: (1) a physician or nurse
practitioner champion, (2) a multi-disciplinary implementation team, and
(3) an inter-departmental referral protocol for members experiencing IPV.
The quantitative measures are designed to answer the following three
questions:
1. How many members received the IPV diagnosis?
2. How does this compare to the estimated number of Kaiser Perma-
nente members who are likely to be experiencing IPV?
3. Of the patients diagnosed, how many received appropriate referral
and follow-up?
Data collection for the quantitative measures utilizes diagnosis codes
from outpatient and emergency department medical visits, which are en-
tered into an automated database. The number of members likely to be
experiencing IPV is based on a prevalence estimate of IPV (in the previous
12 months) among women health-plan members aged 18–64 years. This es-
timate is drawn from a survey of health-plan members and from published
prevalence estimates (McCaw and Kotz, 2005).
5 For information about the NCQA standards, see http://www.innovations.ahrq.gov/content.
aspx?id=2343.
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What the Data Show
The data gathered through the quality-improvement measures show
that from the program’s inception in 2000 through 2010 there was a six-
fold increase in women and men newly identified with IPV (see Figure
8-2). These results far exceed what might have been expected based on the
promising 1998 pilot test.
Figure 8-3 shows the number of women and men newly diagnosed
with IPV each year, by department. A notable trend is that identification
has steadily shifted to less acute settings, such as primary care and mental
health, suggesting that patients are being identified earlier, before more
potentially serious injury occurs.
Although not shown in Figures 8-2 and 8-3, two additional findings
from the data are notable: Of members newly diagnosed, more than 50 per-
cent received follow-up mental-health services, and the IPV identification
rate increased every year—that is, of the total number of Kaiser Permanente
women members estimated to be experiencing IPV, an increasingly greater
proportion were being identified.
Additional Lessons from Implementation
The Role of Technology
Over the 10-year implementation, “technology enablers” have proven
invaluable. For example, clinicians can draw on tools embedded in the
FIGURE 8-2 Members diagnosed with intimate partner violence, 2000-2010.
SOURCE: McCaw, 2011.
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176 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
FIGURE 8-3 Number of women and men newly diagnosed with IPV.
SOURCE: McCaw, 2011.
Kaiser Permanente electronic health record to facilitate documentation of
IPV, make referrals, and learn about best practices. Clinicians can also ac-
cess point-of-care patient handouts about IPV and direct patients to Inter-
net resources in both text and video formats. On-line video training allows
clinicians to view demonstrations of how to provide caring, effective, and
efficient interventions.
IPV services have also been incorporated into Kaiser Permanente’s
appointment-and-advice call center. Use of this service has increased dra-
matically over the past 10 years. Advice nurses, trained in how to inquire
about IPV and equipped with IPV-related scripts and protocols, can respond
immediately to members who contact the health care system by phone,
directing them to the appropriate Kaiser Permanente venue of care as well
as to community resource information.
Engaging the Kaiser Permanente Workforce
The demographics of most health care workforces (made up in large
part by women of childbearing age) means that IPV is, unfortunately,
a common issue for many employees and their families. Although ini-
tial implementation of the systems-model approach focused on provid-
ing resources and information to health-plan members, it quickly became
clear that the Kaiser Permanente workforce was another key audience that
needed information about resources available in the workplace. Over time
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an additional benefit of this workplace outreach emerged: Employees who
had learned about IPV became an essential aspect of the supportive environ-
ment provided for members.
One example of an innovative approach to reaching employees is the
“Silent Witness Display”—a large exhibit that presents the real-life stories
of Kaiser Permanente physicians, medical staff, and employees who have
dealt with IPV. These stories of courage, hope, and survival reflect the di-
versity of the Kaiser Permanente workforce in age, career type, and ethnic
background. The exhibit travels to every Kaiser Permanente medical facil-
ity and is regarded as a powerful tool for increasing awareness of IPV, its
impact on employees and their families, and the resources available to both
employees and members. The stories and the display are available at http://
www.kp.org/domesticviolence/silentwitness/index.html.
Research Collaborations
From the very beginning clinician–researcher partnerships have been in-
valuable. The well-designed evaluation of the pilot program yielded findings
that were both clinically meaningful and operationally useful. These findings
helped to make the case for dissemination to other medical centers, justify
the allocation of regional resources, and secure “buy-in” from front-line clini-
cians. The evaluation also generated additional information on women who
experience IPV, including demographics, perceived health status, and reasons
for accepting referral for follow-up (McCaw et al., 2002, 2007).
Over the past decade, engagement with other Kaiser Permanente re-
searchers has led to inclusion of IPV as a risk factor in studies of diabetes
and self-care, breast-cancer survivorship, incontinence, contraceptive use, and
chronic pain. IPV has also been included in studies that have implications
for improving health care delivery—such as the impact of electronic referral
on mental-health services utilization and predictive modeling using regional
call-center data (Ahmed and McCaw, 2010). A study is now under way to
compare health care utilization by IPV women who receive an intervention
in the health care setting to those who do not receive an intervention.
Challenges of Community Linkages
In contrast to other potentially life-threatening health conditions (for
example, heart attack), victims of IPV may need life-saving interventions
(such as emergency shelter and a restraining order) that are more appropri-
ately provided outside the health care setting and that require the expertise
of community advocates, law enforcement, and criminal justice. Thus, the
development of strong partnerships between health care and community
resources is a key element of the systems-model approach.
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178 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
However, the development of community partnerships is often chal-
lenging because of the differing perspectives of health care providers and
the staff of community agencies. Health care providers tend to view the
medical center as a self-contained entity and may not know how—or why—
to engage community partners in their work. For them, reaching out be-
yond the walls of the facility often requires a fundamental shift in thinking.
On the other hand, staff at community agencies may not be familiar
with the “language” of health care—its quality-improvement metrics, or-
ganizational hierarchy, and clinic workflow. These contrasting perspectives
grow out of differences in training, background, expectations, pressures,
funding sources, and staff turnover. The result is that health care facilities
vary widely in how well community partners are included in the planning
and implementation of the systems-model approach.
Dissemination to Other Kaiser Permanente
Regions: Scaling-Up and Sustainability
Over the past five years, the remaining eight Kaiser Permanente re-
gions have embarked on implementing the systems-model approach. This
scaling-up of the program was inspired by its successful adoption in the
Kaiser Permanente medical facilities in Northern California and also by the
compelling data showing improvement in IPV identification and referral.
Each of the eight regions has designated a physician champion and formed
a multidisciplinary team.
Although each region exercises some degree of autonomy in its imple-
mentation, an effort has been made to maintain consistency across regions.
All regions have adopted the implementation tools developed for Northern
California—for example, the phased “work plan”—and are using them
successfully. All have adopted a single set of member-education materials
that can be customized to each region. All are offering resources to their
Kaiser Permanente workforces, including on-line manager training and the
“Silent Witness Display” described above. In addition, a set of IPV “Smart-
Tools” has been added to the program-wide electronic health information
system to facilitate identification, evaluation, documentation, referral, and
the provision of resource information and safety planning for members.
Quarterly conference calls among the regions’ leadership also help
to maintain consistency by providing an opportunity for regions to share
best practices, learn about new research, leverage resources, explore inter-
regional initiatives, and set common goals.
In the course of the dissemination throughout Kaiser Permanente, it
has become clear that to be sustainable the IPV prevention services must
be closely aligned with other Kaiser Permanente priorities: ensuring mem-
ber safety, improving coordination of care, increasing efficiency, enhancing
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service, and reducing health care disparities. Most importantly, IPV pre-
vention services must be incorporated into the everyday care of members.
To the extent that IPV prevention can be aligned with these larger
goals, executive decision makers will come to see the program as an im-
perative and a positive investment. This top-level support is evident in com-
ments made at a 2007 CEO Roundtable by Robert Pearl, M.D., executive
director and chief executive officer of the Permanente Medical Group: “IPV
prevention is part of a strategic approach to quality, service, and afford-
ability. By doing the right thing, we can improve quality outcomes, member
satisfaction, and the personal lives of our patients, while also decreasing
costs to employers and individuals.”
Beyond Kaiser Permanente: Opportunities for Adoption
of the Systems-Model Approach in Other Settings
In response to inquiries from other health care delivery organizations
in the United States and abroad about how to implement the systems-
model approach, information and tools have been made available at the
Innovations Exchange operated by the Agency for Healthcare Research
and Quality and on the United Nations website, the Virtual Knowledge
Centre to End Violence Against Women and Girls (www.endvawnow.org).
To facilitate implementation at facilities outside of Kaiser Permanente, it
has been important to develop tools that are general enough to be easily
adapted to new sites.
As the systems-model approach has been adopted by other sites, the im-
plementation has been tailored to address a range of cultural issues including:
• age (messaging focused on teens),
• ethnicity (attention to differences in values and communication
style),
• language (translations of the member education materials),
• sexual preference (gender neutral), and
• religion (inclusion of faith communities in community partnerships).
It is particularly exciting to see how the systems-model approach is be-
ing adapted in other countries. In the community clinics in Bangalore, India,
where the approach is being used to improve the response to gender-based
violence, the intervention also reaches out to the mothers-in-law of women
identified as victims of violence. And, in lieu of the “on-site” services used
in the Kaiser Permanente facilities, the clinics’ community outreach workers
are trained to offer IPV information and counseling as part of their routine
home visits. Such cross-cultural adaptations of the systems-model approach
open exciting opportunities for a bilateral exchange of learning.
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180 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
The Way Forward
The list below highlights key “lessons learned” that have emerged from
the 12-year evolution of the Kaiser Permanente systems-model approach to
improving services to members experiencing intimate partner violence. It is
hoped that these lessons will be of use to other health care delivery systems
as they set out to implement, disseminate, and sustain programs to improve
their response to intimate partner violence.
• Use a consistent approach based on systems-model thinking.
• Select a clear conceptual model that is comprehensive and read-
ily customized to available resources (for example, Figure 8-1).
• Implement the approach with local physician or nurse practi-
tioner champions and multi-disciplinary teams.
• Provide organizational leadership to ensure consistency of ser-
vices, alignment with other health initiatives, and dissemina-
tion of innovative practices.
• Identify qualitative and quantitative measures to ensure continuous
quality improvement.
• Take advantage of “technology enablers” to improve services.
• Engage the health care workforce as a partner.
• Establish clinician-researcher partnerships to ensure a robust design
for both the program and its evaluation, and to ensure that evalua-
tion will yield credible findings that are clinically and operationally
meaningful.
Summary
Over the next decade, health care organizations will be called upon
to assume an increasingly important role in society’s response to intimate
partner violence and other forms of family violence—through primary pre-
vention, early identification, and effective interventions. Over its 12-year
evolution, the Kaiser Permanente systems-model approach has achieved a
six-fold increase in the identification and referral of members experiencing
intimate partner violence and has been successfully replicated throughout
this large health care organization. Examples such as the Kaiser Perman-
ente approach that demonstrate measurable results and that can be easily
adapted for other settings are essential to propel the field forward.
Acknowledgments
Program implementation and dissemination: Krista Kotz, Ph.D., M.P.H.,
program director, Family Violence Prevention Program, Kaiser Permanente,
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PAPERS ON PREVENTIVE INTERVENTIONS
Northern California; Violeta Rabrenovich, M.H.A., CHIE, director, Medical
Group Performance Improvement, The Permanente Federation, LLC
Executive sponsorship: Donald Dyson, M.D., associate executive direc-
tor, Permanente Medical Group; Amy Compton-Phillips, M.D., associate
executive director, quality, The Permanente Federation, LLC; Jed Weissberg,
M.D., senior vice president, Kaiser Foundation Health Plan and Hospitals,
Kaiser Permanente
Research partnerships: Division of Research, Kaiser Permanente North-
ern California: Enid Hunkeler, M.A.; Ameena Ahmed, M.D., M.P.H.;
Nancy Gordon, Ph.D.; Leonard Syme, Ph.D., professor emeritus, School
of Public Health, UC Berkeley
Writing assistance: Meg Holmberg, M.S.W.
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