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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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145 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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147 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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149 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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151 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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153 PAPERS ON PREVENTIVE INTERVENTIONS 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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175 PAPERS ON PREVENTIVE INTERVENTIONS 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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177 PAPERS ON PREVENTIVE INTERVENTIONS 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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179 PAPERS ON PREVENTIVE INTERVENTIONS 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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181 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. REFERENCES Ahmed, A., and B. McCaw. 2010. Mental health service referral and utilization among women experiencing intimate partner violence. American Journal of Managed Care 16(10). Allen, N. E., D. I. Bybee, and C. M. Sullivan. 2004. Battered women’s multitude of needs— evidence supporting the need for comprehensive advocacy. Violence Against Women 10(9):1015-1035. Anderson, A. M. 1996. The father-infant relationship: Becoming connected. Journal for Spe- cialists in Pediatric Nursing 1(2):83-92. Bandura, A. 1982. Self-efficacy mechanism in human agency. American Psychologist 37(2):122-147. Beeble, M. L., D. I. Bybee, C. M. Sullivan, and A. E. Adams. 2009. Main, mediating, and moderating effects of social support on the well-being of survivors of intimate partner violence across 2 years. Journal of Consulting and Clinical Psychology 77(4):718-729. Bybee, D. I., and C. M. Sullivan. 2002. The process through which an advocacy intervention resulted in positive change for battered women over time. American Journal of Com- munity Psychology 30(1):103-132. Bybee, D. I., and C. M. Sullivan. 2005. Predicting re-victimization of battered women 3 years after exiting a shelter program. American Journal of Community Psychology 36(1-2):85-96. Campbell, J., P. Sharps, and N. Glass. 2000. Risk assessment for intimate partner violence. In Clinical assessment of dangerousness: Empirical contributions, edited by G. F. Pinard and L. Pagani. New York: Cambridge University Press. Campbell, J. C., C. Oliver, and L. Bullock. 1993. Why battering during pregnancy? AWHONNS Clinical Issues in Perinatal and Women's Health Nursing 4(3):343-349. Chiodo, D., D. A. Wolfe, C. V. Crooks, R. Hughes, and P. Jaffe. 2009. Impact of sexual ha- rassment victimization by peers on subsequent adolescent victimization and adjustment: A longitudinal study. Journal of Adolescent Health 45(3):246-252. Cohen, S. 1988. Psychosocial models of social support in the etiology of physical disease. Health Psychology 7:269-297. Connolly, J., D. Pepler, W. Craig, and A. Taradash. 2000. Dating experiences of bullies in early adolescence. Child Maltreatment 5(4):299-310. Cowan, C. P., and P. A. Cowan. 1995. Interventions to ease the transition to parenthood—why they are needed and what they can do. Family Relations 44(4):412-423.
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