Innovative Strategies for Dealing With Interpersonal Violence During the Perinatal Period

1. Innovative Strategies for Dealing With Interpersonal Violence During the Perinatal Period Phyllis W. Sharps, PhD, RN, FAAN Professor and Associate Dean for Community and Global Programs

2. Session Overview • Describe patterns of IPV and impact on maternal and child health. • Discuss experiences of HVs and women related to IPV screening and intervention. • Describe strategies from Domestic Violence Enhanced Home Visiting Intervention.

3. Patterns of IPV • Intimate partner violence (IPV) is a major public health problem • Two recent large and population based studies of women estimate prevalence IPV rates of 8% in the past year and 9.8% in the past 2 years • Perinatal IPV - IPV that occurs during the childbearing year - has significant consequences for: • Women • Pregnant and Parent Women • Infants and very young children

4. Patterns of IPV Statistical Overview • 1 in 4 women are raped and/or physically assaulted by a current or former spouse, cohabitating partner or date at sometime in their life (Tjaden & Thoennes, 2000). • Two recent studies, each more than 3,500 women reported the prevalence of IPV just under 8%for the past year and 9.8%for the past 2 years (Thompson et al, 2006; Walton-Moss, Manganello, Frye & Campbell, 2005) Health Consequences • Traumatic injuries • Long term physical health consequences (headaches, STDs, chronic backaches) • Long term mental health consequences (depression, low self-esteem, PTSD) (Campbell, 2002; Campbell& Humphreys, 2004; Walton-Moss et al, 2005).

5. Perinatal IPV Statistical Overview • Recent studies estimate that 3% to 19% of pregnant women report being abused during the childbearing year – before, during or after the pregnancy (Campbell, Garcia-Moreno & Sharps, 2000). Health Consequences • Poor Maternal Outcomes • Physical health consequences -late entry into/no prenatal care, poor weight gain, preterm delivery , pregnancy loss • Mental health consequences - depression, low self esteem, PTSD, substance use • Poor Fetal and Neonatal Outcomes • Pre-term delivery; Pre-term birth, low birth weight, fetal injuries (Bullock et all, 2001; Marin et al, 1998; Murphy et al, 2001;). Women are at risk for intimate partner homicide, before, during and after of the pregnancy (McFarlane , Campbell, Sharps & Watson, 2002) & IPH is the major cause of maternal mortality

6. PATTERNS OF IPV DURING PREGNANCY (Ballard et. al., ’98) Protective period • Women beaten before and after – (30%) Risk period • May start during pregnancy (24%) – especially first pregnancy - “Business as usual” • IPV neither increases or decreases (75%) (Martin ’01; Saltzman ‘03)

7. Patterns of IPV During Pregnancy Type of Abuse Changes Physical abuse may lessen or stop but emotional abuse, controlling behaviors stay same or increase (Castro ’03) Teens at Greater Risk Higher prevalence of abuse during pregnancy among adolescents than adult women (Parker, McFarlane ’93)

8. IPV and Children • Each year 3-10 million children are affected by IPV (Campbell & Lewandoski, 1997) • More than 20 years of research have reported the following consequences of IPV for children's physical and socio-emotional health such as: • Depression, poor self-esteem, anxiety, aggression, poor peer relations, poor academic performance, • Physical health symptoms, under immunization • Adolescent risky behavior (Bair-Merritt, et all, 2006; Baldry, 2003; Holden, 2003; Fantuzzo, et al, 1991; Fredland et al, 2008; Kernic et al, 2002; Polillo, 2003).

9. Domestic Violence Enhanced Home Visitation Program (DOVE) Phyllis W. Sharps, PhD, RN, FAAN, PI Johns Hopkins University School of Nursing R01NR009093/NINR

10. Purpose of DOVE • Rigorous test of structured IPV intervention • DOmesticViolence Enhanced (DOVE) Home Visitation Program • 2 Sites • Urban–Baltimore City HD • Urban–Missouri HD • Rural–Missouri HD

11. Design • RCT • Mixed methods – quantitative & qualitative • Urban HD (women and infants) • Eligible women = R→DOVEvs. UC • Rural HDs (women and infants) • 12 HDs = R→ 6 HD DOVEvs. 6 UC • NFP(Olds HV model; mothers and infants) DOVEvs. Olds database • DOVE is a HV intervention for abused pregnant women • DOVE protocol is screening + brochure based brief counseling intervention

12. Research Team • Linda Bullock, PhD, RN, FAAN, Co-PI University of Virginia School of Nursing • Jacquelyn Campbell, PhD, RN, FAAN Johns Hopkins University School of Nursing • Shreya Bhandari, PhD Wright State University • Jeanne Alhusen, PhD, RN Johns Hopkins University School of Nursing • Ifeyinwa Udo, DrPH Baltimore City Health Department • Camille Burnett, PhD, RN University of Virginia School of Nursing

13. Project Team Baltimore/Urban • Project Coordinator • Kim Hill, MPH • DOVE Intervention Nurse • BCHD – Keauna Williams • DOVE Research Nurse • K. Marcantonio • K. Wells • Iye Kanu • Doctoral/Post-Doc Students • Jeanne Alhusen, PhD, RN • Marguerite Baty, PhD, RN • Rachel Klemick, PhD, RN (started as UG Honors Research student) Missouri/Rural • Project Coordinator • Richard Tayloe, MS • Dove Research Nurses • Karen Rupright • Kelly Moore • Kathleen Ellis • Doctoral/Post-Doc Students • Shreya Bhandari, PhD • Chiunghsin Chang, PhD

14. Baseline Demographics

15. IPV Mean Scores

16. Violence Scores Trajectory of IPV Scores: DOVE vs. Usual Care

17. Other Findings • IPV screening in HV program for pregnant women is safe and feasible • DOVE can be integrated into HD HV programs • Good retention (80%) in HV programs –even when asking about IPV • DOVE reduced self reported IPV • DOVE group still less IPV at 24 M PP • UC reduced IPV too • asking frequently/screening – without specific counseling may be important

18. Home Visitors Expressed Concerns • Fears • Making a fool of myself – not knowing how or what to say • Fear of “stirring the pot” • Fear of how to handle the abuser if he walks in • Concerns – if she is IPV+ • Lack of resources • Not knowing what to do next • Fear of increasing her harm

19. Home Visitors Strengths Successful strategies used by HV • Building relationship, rapport and trust • Bringing up IPV casually in the conversation • Using non-judgmental body language • Educating her on “normal” relationships • Showing respect How did the training workshops change practice: • Re-thinking “stirring the pot” – decreasing my own fear • Safety measures that can be used if the abuser walks in • Increased self-realization that I may be hurting my client and outcomes trying to achieve if I do not address the violence

20. Lessons Learned • HV have both personal and professional issues that need to be considered when addressing IPV • IPV training for HV is essential, needs to be on-going, and needs to address the HV own history of violence • HV working with the DOVE study were frustrated at times with the lack of resources in rural and urban areas but realized that just letting the women in their caseload discuss the violence is a powerful intervention in itself

21. Perinatal Nurse Home Visitation Home Visitation Enhanced with mHealth (DOVE 2) NIH/NICHD – R01 HD071771

22. Next Steps: New Study Perinatal Nurse Home Visiting Enhanced with mHealth technology • R01 funded by NICHD • Computer tablets for HV • IPV screening – Nurse w/tablet vs. client completes • Deliver DOVE – nurse-assisted vs. client • Spanish translation Study Aim = to increase identification & intervening of IPV during pregnancy

23. DOVE 2 Intervention • Nurse HV • Same evidence-based DOVE intervention • Design • RCT – 2 arms 1. Nurse Assisted - Paper& Pencil screening + DOVE intervention 2. Tablet Assisted - Tablets for screening + DOVE intervention • Spanish translation

24. Random Assignment

26. Screen Shots

29. DOVE WEBSITE http://www.son.jhmi.edu/research/dove psharps1@jhu.edu 410-614-5312 Thank You !!!