Understanding Barriers to Obtaining Assistance for Victims of Intimate Partner Violence

1. Understanding Barriers to Obtaining Assistance for Victims of Intimate Partner Violence Myra Berry, Dawn Fadden, Starr Ferrari, Heidi Grondahl, Kimberly Miller & Resty Namata December 3, 2008 Research in Nursing

2. Fairview WomanKind Program, Minneapolis, MN • Research by Short, L.M., Hadley, S.M., & Bates, B. (2002) • Three intervention hospitals • Professionals staff were evaluated and provided education to enhance their ability to recognize, relate to, and refer IPV victims • Difference in IPV victims identified • Intervention Hospitals 1719 : Comparison Hospitals 27

3. Healthcare Provider Education FocusKABB • Knowledge • Recognition of Signs • Understanding of complexity of IPV • Attitudes • Build confidence in ability identify and support IPV victims • Develop sense of responsibility to identify IPV • Beliefs • Challenged acceptance of IPV myths • Behaviors • Improved ability to develop rapport/trust

4. Evidence Based Project • Barriers to health care for IPV victims. • Provider attitudes • Fear/Mistrust • Research points to new topic: • How is IPV experienced uniquely in different populations of women? • Adolescents, Pregnant women, Immigrant, Lesbians

5. Presentation Overview Background & Purpose Method Results Conclusion.

6. Intimate Partner Violence IPV is physical, sexual or emotional abuse directed from one intimate partner towards another – including threats of the above mentioned types of abuse. An intimate partner is any individual who is currently, or was in an intimate relationship with the victim. Center for Disease Control, 2006

7. An Astounding Statistic • Worldwide, up to 50% of women have been victims of IPV at some point in their lives • Reports of IPV are universally under-reported by victims, and thus, the problem remains hidden and the abuse continues. (Wong, Jonge, Wester, Mol, Romkens & Lagro-Janssen, 2006)

8. Why is this important? • Screening is not accurate, nor does it capture all victims. • Health care professionals should comprehend how IPV effects its victims. • Health care professionals must also acknowledge the financial burden IPV victims bring to the health care system. Center for Disease Control, 2006

9. Financial Burden of IPV • IPV cost the health care system an estimated 5.8 billion dollars in 1995. • 95% confidence interval: ($3.9 to $7.7 billion) (Max, Rice, Finkelstein, Bardwell & Leadbetter, 2004)

10. Health Care Utilization • Mental Health Services • Emergency Department • Ob-GYN or Women’s Health Clinics • Primary Care Clinics • Pharmacy

11. Method • Databases • Medline • Cinahl • Google Scholar • Ovid • ERIC • PubMed • PsycINFO • Science Direct • InfoTrac • Academic

12. Search Terms • Included a variation of the following: Abuse, battered, violence, women, partner, provider, physician, care provider, clinician, disclosure, reporting, attitude, characteristics, attributes, traits, domestic, assault, barriers, violence, practitioner, health care, health services, pregnancy, domestic violence, physical, sexual, costs, economy, expenditures, trust

13. Barriers - Attitudes Studies of attitude of providers showed: Disclosure of IPV was influenced by the perceived behavior of the care provider. Women were more likely to disclose IPV if: They perceived the provider to appear to be sympathetic, caring, respectful, a good listener, non-judgmental, comfortable with the topic of abuse, and interested in the patient and their welfare.

14. Important Information About IPV Victims Failure to recognize Readiness Motivation The lives of IPV victims are very complex Care and support by healthcare providers

15. An Interesting Correlation In 3 of the 5 studies abstracted : • Only 12-29% of the IPV victims used in these studies had ever been directly asked about abuse by their provider. • In 2 of these 3 studies, of the women who were asked about IPV, greater than 75% of them disclosed the abuse when directly asked.

16. IPV Victims Fear Law enforcement will become involved without their consent Losing the children Losing an intact family/good part of relationship Retribution by the perpetrator Requiring disclosure of the IPV Involvement from healthcare provider will cause the violence to increase Feeling rejected or devalued by healthcare providers

17. Factors that Cause IPV Victims to Mistrust Providers Healthcare provider appears uninterested or callous Healthcare system requires reporting to law enforcement Feeling entrapment or disempowerment Feeling forced to enter a shelter

18. IPV & Immigrant /Epidemiology • 15% of US Population is foreign born • Intimate partners abuse immigrant women by 40-80% & immigrants are disproportionately involved in domestic violence homicides. Gupta, J. et al, 2008 Caetano, 2003

19. Pre-migration violence - men Gupta et al (2008)

20. IPV & immigrant … Haitians/Latina Haitian Women Experience: • View IPV in Culture Context. • Do not report abuse to avoid. • Mainstream IPV services are inaccessible Latina women: • Responded to indirect questions about feelings than to direct ones. Latta et al (2005) Wrangle et al(2008)

21. IPV & Immigrants …Somali Somali women acculturation • Predictors of partner aggression • English proficiency, longer time in US & fewer American friend. (p < .00). • Predictors of intimate partner physical assault • English proficiency, longer time spent in US & more American friends. (p < .00). Nilsson (2008) quantitative study of Acculturation

22. IPV & Immigrant … South Asian • Emotional abuse by in-laws reported by 55% of depth interviewees. Raj, A., et al. (2006) • Train providers to: • Tailor abuse services for immigrant women • Screen for • In-law abuse in South Asians. • Acculturation in Somali refuges • pre-migration violence exposure - PTSD in men.

23. Lesbian Victims of IPV Rate is roughly equal to the rate of IPV in heterosexual relationships Language and attitudes Unique safety needs Re-victimization from healthcare providers and other IPV victims

24. IPV During Pregnancy • The American College of Obstetricians and Gynecologists estimates the prevalance of IPV at 23% during pregnancy of the women seeking prenatal care (Chambliss, 2008)

25. Pregnancy • Assessment for IPV should be assessed at multiple encounters. • Poor neonatal/maternal outcomes can result in the year preceding pregnancy and during pregnancy.

26. Pregnancy • Women at highest risk: • Age less than 24 • Native American • High school education or less • Those who did not seek prenatal care in first trimester • Those who smoke and use alcohol.

27. IPV and Adolescents • Studies showed: • Significant barriers to disclosure and identification, similar to adult findings • Reasons for disclosure of IPV are complex • Reasons for seeking care in general are often structural

28. Summary and Implications Healthcare providers need to: • Become experts on the subject of IPV • Know risk factors for all ages, demographics • Cultural differences in IPV • Promote victim autonomy • Learn to recognize the deficiencies of screening as well as their attitudes and feelings toward IPV • Identify and eliminate barriers for screening of IPV

29. Summary and Implications • Providers need to consider engaging in education and efforts designed to help increase disclosure. • Early detection and screening of IPV can have an effect on maternal/neonatal outcomes. • Understanding abused adolescents’ concerns for interacting with health care providers is essential to form a working relationship for health promotion and disease/trauma prevention.

30. Missing or Inadequate Topics • Due to insufficient assessment, it is difficult to determine all the true barriers • Lack of services to rural populations and special populations • Cultures of silence and isolation • Fear and intimidation by perpetrators • Better understanding of the complex nature of IPV victims lives

31. Missing or Inadequate Topics • Enhanced flexibility in IPV victim resources • Language barriers • Culturally sensitive resources • Lack of adequate funding for services • Fear of law enforcement or failure to act

32. APN Leadership Opportunities Provide education about IPV Capitalize on “readiness” for intervention Empower IPV victims to make own decisions Don’t require disclosure to obtain assistance Provide multiple options for assistance Provide counseling regarding safety strategies, legal resources, and understanding relationships Consistency in care – “always ask”

33. APN Leadership Opportunities Become experts in establishing IPV victim-friendly healthcare environments Identify and eliminate barriers to resources Establish valued services and referral sources Educate colleagues regarding identification of IPV victims Promote IPV victim autonomy in decision-making Identify and address the needs of special IPV victim populations

34. Fairview WomanKind Program, Minneapolis, MN612-672-2700

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