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Preventing Violence Against Women and Children: Workshop Summary (2011)

Chapter: 8 Papers on Preventive Interventions

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Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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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 measurable reduction in violence as well as secondary effects such as increases in gender equality, economic empowerment, life skills development, community 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, including 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 programs use obstetricians and nurses who regularly come into contact with expectant parents to provide additional information and support on communication and parenting skills. Special attention was paid to addressing cultural norms.

The third paper is an analysis of The Fourth R, a school-based program originating in Canada and now offered in a number of settings in North America. The Fourth R integrates skills building and risk factor

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 provides 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 Permanente, 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 gender 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 empowering the poorest women in rural villages. The microfinance partner,

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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.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 communication skills, critical thinking, and leadership. In the second phase, program participants are encouraged to facilitate wider community mobilization 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 communication 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, including 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 analysis comparing microfinance alone against the combined IMAGE intervention. 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 suggests that the combination of microfinance with gender training and community 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

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 organizations, the IMAGE program is currently exploring opportunities to develop as a best-practice learning site to support South-South learning and replication across different settings. Further research to inform the adaptation 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 economic 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 empowerment 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 delivering 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 communication 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, programs 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 environment for sustained change (Kim et al., 2008). Mainstreaming gender and HIV within national AIDS and development plans is one way to embed

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 interventions 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 unrealistic 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,

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 childbirth, 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 expectant 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 fathers, 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 children, 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 suppressing them and recognizing the need to understand their partner’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 concepts; and
Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×
  • 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 (including 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 approaches are summarized in Table 8-1.

In practice, the Positive Fathering Program was delivered in three consecutive, 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,

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 care, pre- and postnatal emotions, andpostnatal care Focus on engaging expectant fathers, couple relationships and communication, parenting efficacy, in-law involvement, and cultural postnatal practices
Conducted as large classes (> 100/class) 50% of the participants are couples Conducted as small groups (6-8 couples/group) 100% couple attendance
Content is based on well-established prenatal education Content is based on identified needs
Teacher-centered, didactic teaching, one-way transmission of content Couple-centered, two-way, interactive 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 prenatal 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 participation and to ensure adequate hands-on practice. Each group was facilitated 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 satisfactory 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

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

hands-on practice in infant care and couple communication skills. Close collaboration between the program team and the clinicians ensured smooth recruitment 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, revealed 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 program 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 communication 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 program 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 acceptability and efficacy for 166 Chinese expectant couples using public prenatal care in Hong Kong. In the next stage of development, the program will be modified 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.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 participants 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

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

confidentiality by a professional who had undergone training for this purpose 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 components: 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 ensure 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 additional component known as “empathic understanding” and based on Rogers’ client-centered therapy (1951), was incorporated. Empathic understanding 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 consideration, 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 described 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. During 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

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

pressure to forgive or sacrifice herself for the good of the family. However, eventually this phase ends, and once again tension begins to build up.

Level of Safety

Another component of the modified intervention is determining the level of safety based on the indicators from the Danger Assessment instrument. This component is designed to assist participants in objectively evaluating the safety of their current relationship (Campbell et al., 2000). The women go through a process of recalling all the violent incidents (including a ranking of severity) associated with the relationship that had happened in the previous year by using a calendar. During this process, information about safety issues is also discussed, including signs of increased danger. In particular, participants are informed that the most dangerous time occurs when a woman leaves the relationship or makes it clear to the abuser that she is leaving for good. As social disharmony is often a taboo subject in Chinese society, and partner violence is frequently treated as a family affair not to be shared with outsiders, many abused Chinese women may not recognize the signs of increased danger; hence, time should be spent to ensure that she understands the warning signs. Based on the participant’s assessment of the situation, a discussion of immediate safety and formulation of an escape plan can be initiated. As Chinese women may view the safety plan as a step closer to leaving their partners, reassurance should be provided that having a safety plan puts them in a better position to make decisions about their options, including the option to stay with the abuser. In keeping with the model of empowerment, it is not necessary for every woman to employ all of the safety behaviors. Rather, each woman should decide what is appropriate for her and how many of the behaviors she wishes to take at any one time. As a part of efforts to ensure cultural relevance of the intervention, helping professionals must not only keep in mind the Chinese cultural context when educating a participant about her options, but also remember that each abused woman has her own unique characteristics and, therefore, requires an individual safety plan, taking into account what works for her at different stages of the relationship.

Selecting an Option

Another component of the Empowerment Intervention is selecting an option, in which the helping professional assists the participant in objectively evaluating her relationship with her partner, including its inherent strengths and limitations. The woman may be in a state of intense confusion or feel conflicting loyalties. As a result, this component of the intervention

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

includes teaching each participant problem-solving and decision-making skills, while avoiding telling her what to do or criticizing the abuser. When working with Chinese women it should be recognized that traditional Chinese culture expects a woman to sacrifice herself for the greater good of the family and also that leaving her partner may mean that she is ostracized within the very community where she needs support. Thus, the woman may be very reluctant to leave her abuser. The options that are available to a Chinese woman who experiences IPV may include remaining in the home and seeking help for herself or her partner, or both; remaining in the home and attempting to anticipate the violence and protect herself and her children; or leaving the relationship either temporarily or permanently.

There are a number of cultural considerations to be made in educating women about their options. The following is a summary of some specific issues that have been considered during the modification of this intervention for Chinese women:

  • Chinese women may be reluctant to disclose IPV to outsiders, so it is beneficial for them to think about whom they can trust and with whom they would share their abusive situation and their safety plan.
  • Some Chinese women may have a fear of authority figures, given their past experience, so they may require close support of a trusted advocate.
  • For many Chinese women, protective orders may be totally alien to them, so every care should be taken to ensure that they are properly informed regarding protective orders before making their decisions.

Results

Following the intervention, women in the intervention group reported significantly higher physical functioning and improved role limitation due to physical and emotional problems compared with women in the control group, as measured by the Chinese version of the Short Form Health Survey (SF-36) (Lam et al., 1998). The participants also reported less psychological abuse and less minor physical violence, as measured by the Chinese version of the Conflict Tactics Scale (Tang, 1994). Significantly fewer women in the intervention group reported postnatal depressive scores of 10 or more, as measured by the Chinese version of the Edinburgh Postnatal Depression Scale, compared with those in the control group (Lee et al., 1998).

In a recent Cochrane Review, this trial passed high evidentiary standards. The Empowerment Intervention has now been further modified for use in a community setting and tested in a randomized controlled trial (Ramsay et al., 2009; Tiwari et al., 2010). At present, a proposal is under

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

way to test the efficacy of the intervention in Hong Kong among immigrant women from China.

THE FOURTH R: A SCHOOL-BASED STRATEGY TO
PREVENT ADOLESCENT DATING VIOLENCE

David A. Wolfe, Ph.D.
Centre for Addiction and Mental Health,
Centre for Prevention Science and University of Toronto

Best Practices in School-Based Violence Prevention

This paper focuses on the prevention of adolescent dating violence, a significant and commonly occurring form of violence and aggression among this age group. The more common behaviors include insults, threats, and intimidation (i.e., mostly abusive but not violent), which are reported among a sizable minority of youths (25 to 35 percent). The significant rates of and consequences associated with adolescent dating violence warrant a public health approach focusing on promotion of healthy relationships and prevention of dating violence, rather than relying solely on identification and intervention with youths already perpetrating or experiencing dating violence. Accordingly, this paper discusses the rationale and evidence for school-based strategies to prevent adolescent dating violence and describes findings from the Fourth R program that has been evaluated and expanded in Canadian schools over the past five years (Wolfe et al., 2009).

Programs aimed at universal school-based violence prevention with children and youths have been expanding in numbers and sophistication since the early 1980s. Such programs have been delivered at all grade levels, from pre-kindergarten through high school, and generally offer knowledge and skills to all children in their own classroom settings (rather than special pull-out classes). A recent systematic review and meta-analysis concluded that there is strong evidence that universal school-based programs decrease rates of violence among all ages of children and youths. However, none of the 249 experimental and quasi-experimental studies of school-based programs aimed at aggressive or disruptive behavior examined by these reviews (all conducted prior to 2005) were aimed at reducing dating violence (Hahn et al., 2007; Wilson and Lipsey, 2007). Currently there are only two published controlled studies of universal school-based programs aimed at dating violence (Safe Dates and the Fourth R), both of which are described briefly below.

An advantage of school-based prevention is that programming can be geared to match developmental stages and demands. Because children who are aggressive in their relationships often progress from bullying to

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

harassment to dating violence as they age, school-based programming provides the opportunity to match this developmental trajectory and address the most salient forms of interpersonal violence at the appropriate developmental stage (Connolly et al., 2000; Chiodo et al., 2009). A further advantage is that programs can be delivered to all students by their teachers, which avoids the stigma of being selected to attend a special program and the cost of providing other resources.

Best-practice principles based on bullying and peer violence prevention have considerable significance for dating violence initiatives. Reports suggest that successful programs are comprehensive in nature, focus on skills, pick appropriate targets for change, use peers, include parents, and attempt to change the larger environment (Blueprints Violence Prevention Initiative, www.colorado.edu/cspv/blueprints; Office of the Surgeon General, 2001).2 In general, effective school-based programs take a more holistic approach that recognizes the complexity and interrelatedness of different settings for youths and offer knowledge and assistance that is appropriately matched.

The most common feature of effective prevention programs is the provision of opportunities to develop interpersonal skills. Skills training usually involves modeling and practice in conflict management and problem-solving skills, often incorporating a role-play component to give students opportunities to increase their ability and comfort level with their newly developed skills. For example, students may role-play strategies to deal with or confront instances of bullying. In some programs, students meet in small groups to discuss and role-play positive alternatives to problem behaviors. Skills training is most effective if it is combined with accurate information about risks and consequences and it is action-oriented, not merely a passive discussion of behavioral options. Some promising prevention programs aimed at relationship-based violence also provide training in help-seeking behavior, such as learning about and navigating social service agencies in the community (Wolfe et al., 2003).

In addition to interpersonal and problem-solving skills, effective violence prevention programs target antisocial attitudes and beliefs associated with aggression and violence. Activities to change attitudes can include awareness-raising activities, such as information about violence against peers or dating partners, and empathy-building exercises. For example, students in the Bullying Prevention Program participate in such classroom activities as role-playing, writing, and small-group discussions geared toward helping them gain a better appreciation of the harm caused by bullying (Olweus and Limber, 2010).

________________

2 See Crooks et al. (2011) for further information.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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Empirically Validated Dating Violence Prevention Programs

Given the relatively short history of dating violence prevention programs and the challenges of implementation and evaluation, it is not surprising that very few have been carefully evaluated with an appropriate randomized controlled design and sufficient measurement and follow-up. Short-term changes in attitudes and beliefs have been documented following classroom discussions or assemblies, but few have had sufficient follow-up with the participants or evaluated actual behavioral change. A critical review conducted in 2006 found only two effective programs that had been rigorously evaluated in a cluster randomized trial (Whitaker et al., 2006). One of these, the Youth Relationships Project, is a selected prevention program for youths considered to be at risk of dating violence because of histories of child maltreatment or exposure to domestic violence (Wolfe et al., 2003). The other, Safe Dates, is a program that was developed for universal implementation in schools (Foshee et al., 2005). Since that 2006 review, a cluster randomized trial conducted with the Fourth R was published, as described below (Wolfe et al., 2009).

Safe Dates is a school-based program based on the premise that changes in norms regarding partner violence and gender roles coupled with improvement in pro-social skills lead to primary prevention of dating violence. The stated goals of the program are to raise awareness of what constitutes healthy and abusive dating relationship, raise awareness of dating abuse and its causes and consequences, equip students with the skills and resources to help themselves or friends in abusive dating relationships, and equip students with the skills to develop healthy dating relationships. The skills component focuses on positive communication, anger management, and conflict resolution. Safe Schools is structured around nine 45-minute sessions in school, with additional community components. School strategies include curriculum, theater production, and a poster contest. Community components include services for adolescents in violent dating relationships and training for service providers. Teachers who implement the curriculum component receive 20 hours of training, and community service providers receive 3 hours. In a cluster randomized trial, Safe Dates reduced psychological, moderate physical, and sexual dating violence perpetration and moderate physical dating violence victimization at follow-up. The program seemed most effective with adolescents who were already involved in dating violence. Program effects were mediated by changes in dating violence norms, gender-role norms, and awareness of community services (Foshee et al., 2005).

The Fourth R: Skills for Youth Relationships is a curriculum-based program for youths aimed at preventing dating violence by promoting skills for healthy, non-violent relationships. The Fourth R is based on social learning and positive youth development theories that emphasize skills, accurate

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

information, and youth involvement to reduce risk behaviors and increase positive decision making in early adolescence. Unlike single-focused programs, the Fourth R integrates topics of dating violence, bullying, sexuality, and substance use by focusing on their underlying relationship connections rather than problem behaviors. The program is integrated into existing curriculum requirements for all students attending health and personal safety courses (typically in grades 8 or 9) and is taught by regular classroom teachers to reduce costs and increase sustainability and availability.

The Fourth R curriculum targets common elements of dating and peer violence (7 lessons), unsafe sexual behavior (7 lessons), and substance use (7 lessons) from a developmental and educational perspective. An underlying theme of healthy, non-violent relationship skills is woven throughout the units to increase generalization across risk situations and behaviors. There is extensive skill development using graduated practice with peers aimed at the development of positive strategies for dealing with pressures and the resolution of conflict without abuse or violence. Peer and dating examples are used interchangeably to increase relevance for youths who are not dating. Classroom activities enhance relationship skills through active learning and role modeling of appropriate behaviors and are accompanied by a Youth Safe Schools Committee and newsletters for engaging parents. The program is adaptable to meet the needs of different communities geographically and culturally.

Results from a recent cluster randomized trial of the Fourth R school-based program (1,722 students from 20 schools) indicated that teaching youths about healthy relationships as part of their required health curriculum reduced physical dating violence and increased condom use 2.5 years later, especially for boys, at a low $16 per-student cost. Specifically, from grade 9 to grade 11, physical dating violence (PDV) was significantly higher for students in the control schools than for those in the intervention schools (9.8 percent versus 7.4 percent, respectively; adjusted OR 2.42, p = .05). Further analyses showed that the effect of intervention differed significantly between boys and girls (p = .002). Boys in the intervention schools were less likely than boys in control schools to engage in PDV (2.7 percent versus 7.1 percent; adjusted OR 2.77). However, girls had similar rates of PDV in both groups (11.9 percent versus 12.0 percent). In addition, condom use among sexually active boys was greater in intervention schools (114 of 168, or 68 percent) than in control schools (65 of 111, or 59 percent).

How Universal Programs Prevent Violence
Against Women and Children

Effective violence prevention programs empower young people to be involved in the work, which then becomes rewarding through the promotion of

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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cooperation and mutual support. To foster healthy adolescent development, simultaneous efforts to reduce or prevent risk behaviors are needed. These efforts need to be matched with an equal commitment to helping young people understand life’s challenges and responsibilities and develop the necessary skills to succeed as adults. Youths need developmentally appropriate knowledge and education, delivered in a nonjudgmental and highly salient format, which emphasizes their choices, responsibilities, and consequences. Youths, especially at-risk youths, need education and skills to promote healthy relationships, to develop peer support, and to establish social action aimed at ending violence in relationships. They need to feel connected not only to their peers, but also to their schools, families, and communities. Such connections require a commitment to building capacity in each community to be inclusive of all youths and to perceiving each adolescent as a person rather than a potential problem. The ultimate act of inclusion is to empower youths to identify the critical issues they face and the solutions that are most meaningful to the reality of their lives and circumstances.3

In addition to providing improved skills and reducing dating violence, universal programs such as the Fourth R may serve to buffer the effects of poor relationship models that adolescents experienced while growing up (an important factor in reducing the cycle of violence). At post-test, youths who had reported a history of child maltreatment at pre-test engaged in fewer acts of violent delinquency, such as fighting or carrying a weapon, than youths with similar maltreatment histories but no school-based intervention (Crooks et al., 2007). Notably, this finding of reduced violent delinquency among youths with maltreatment histories was replicated two years later at follow-up (Crooks et al., in press). The differential impact of this program on youths with child maltreatment histories may be due to the emphasis on healthy relationships and positive relationship skills, and on the resulting focus on safe and respectful behavior in the school. That is, youths who have experienced maltreatment and been exposed to violent, coercive models of relationships in their families typically have not had opportunities to learn healthy alternatives, and they are the youths for whom opportunities to learn healthy, non-violent relationship skills and to attend school in an environment where these skills are emphasized are essential.

How These Efforts Can Be Applied in Different
Settings and with Different Resources

Programs need to be designed with attention to details that increase their likelihood of implementation and sustainability from the outset. There

________________

3 See Wolfe et al. (2006) for discussion of theoretical and empirical support for youth involvement in violence prevention.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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are a number of areas to consider in designing a program or approaching a school district to consider implementing a program. There are areas of potential alignment that increase the acceptability and potential sustainability of a program (e.g., aligning with curriculum expectations or state policies). There are also potential barriers that need to be identified and addressed prior to presenting a case for adoption of a program in a school setting (e.g., the costs of specialized training and school policies about not allowing non-teachers to present programs during school time). In some cases it is possible to deal with these barriers, and an awareness of them and the opportunity to identify possible solutions prior to meeting with educational partners can go a long way. Finally, identifying possible champions within the school system may facilitate the adoption of a program.

One significant challenge lies in examining cultural differences in the nature of dating violence and identifying how programs may need to be significantly revamped in addressing different populations. Beyond looking at a deficit-based model that identifies certain racial or ethnic groups as being at higher risk for dating violence, we need to look at ways that cultural strengths can be accessed as protective factors in interventions.

An implementation study of Canadian schools that have adopted the Fourth R revealed that a critical factor in administrators choosing this violence-prevention curriculum was the research base of the Fourth R and the perception of the program’s potential to have a positive impact on students (Crooks et al., 2008). The curriculum-based nature of the program was also considered important. The greatest potential barrier was the time required to implement the program. We think that this response reflects the bias that violence prevention and health education is still seen as an add-on to the broader health and physical education domain rather than being viewed as an integral component worth 25 or 30 hours of instruction. The length of the program was based on the recommended guidelines of the Ontario Ministry of Education, and other provinces have similar guidelines. Thus, it is not that the program itself is lengthy compared to the mandated requirement; rather, people are still shifting their perceptions about the appropriate amount of health instruction in the classroom.

Since its evaluation was completed in 2007, the Fourth R has been implemented in more than 1,200 schools in Canada and more than 100 schools in the United States. Approximately 350 communities have implemented the program, with an estimated 100,000 students each year learning its lessons. In the 2009-2010 school year, approximately 450 new teachers were trained in 225 different schools, and, as a result, an estimated 20,000 new students have received the Fourth R curriculum in those teachers’ classrooms. All 10 provinces and 3 territories in Canada have communities implementing the Fourth R. In the United States it has been distributed to various schools and agencies in Alaska, Idaho, Massachusetts, New York,

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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Illinois, Ohio, Texas, Missouri, Michigan, Alabama, California, Rhode Island, Washington, and Kansas. Four U.S. evaluation sites are currently using the program as part of the Robert Wood Johnson Start Strong teen dating violence prevention initiative: Bronx, New York; Providence, Rhode Island; Wichita, Kansas; and Boise, Idaho. The program also has been adapted for Canadian Aboriginal populations (First Nations, Metis, and Inuit), Catholic schools, and students in Alternative Education settings. The website www.youthrelationships.org has additional information on the program and research.

THE COMMUNITY ADVOCACY PROJECT:
AN EVIDENCE-BASED PSYCHOSOCIAL INTERVENTION
FOR WOMEN WITH ABUSIVE PARTNERS

Cris M. Sullivan, Ph.D.
Michigan State University

The Community Advocacy Project (CAP) is a 10-week psycho-social intervention for women with abusive partners, which has been shown to decrease women’s risk of re-abuse and to increase their psychological and social well-being. The intervention involves providing trained advocates to work one-on-one with women, helping them generate and access the community resources they needed to reduce their risk of future violence from their abusive partners. Such resources include, but are not limited to, legal assistance, employment, education, housing, social support, and medical care. Like other interventions, CAP is grounded in a number of assumptions. An exhaustive review of the scholarly literature, coupled with numerous conversations with survivors of intimate male violence, led the author to the following conclusions that guide the intervention:

  • Intimate male violence against women is too widespread to be attributed to intrapsychic dysfunction or “relationship problems.”
  • Women with abusive partners are by and large active help seekers who go to great lengths to protect themselves and their children.
  • Positive social support and access to community resources protect women from risk of re-abuse.
  • Intimate male violence against women is often tolerated, if not condoned, by many segments of the community, including the criminal legal system.
  • The community response to domestic violence is a critical factor in whether a woman will be victimized (and re-victimized) by an intimate partner or ex-partner.
Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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Development of the Program

CAP was designed as a family-centered model, focusing on the strengths and unmet needs of clients, as opposed to client “deficits” (Dunst et al., 1991; Sullivan and Bybee, 1999). The family-centered model requires that families guide the services they receive and that clients’ natural support networks are involved in the advocacy process. The efficacy of the family-centered model and the positive implications for consumers served by a family-centered paradigm have been established across a number of different service domains (Marcenko and Smith, 1992; Scannapieco, 1994; Markle-Reid et al., 2006). Although some family-centered interventions employ professionals to work with families, paraprofessional volunteers have been found to be highly successful change agents for numerous populations. The use of paraprofessionals increases the generalizability of the intervention, as it is often easier and less costly for communities to locate, train, and supervise them. Therefore, the decision was made to train undergraduate female college students to serve as the paraprofessional advocates within this intervention.

Components of the Program

Advocates work one-on-one with women in the women’s homes and community for 4 to 6 hours per week over 10 weeks. The two primary components of the advocacy intervention are to (1) help survivors of domestic violence protect themselves and their children from further violence and (2) actively advocate for women by generating and mobilizing community resources they report needing. Safety plans are discussed and individualized based on each woman’s unique circumstances. Regardless of whether women are living with their assailants, advocates discuss what to do in case of emergencies, and they establish plans in case they are ever surprised by the assailants while working together.

The second component of CAP involves actively advocating for and supporting survivors to help them address their self-identified needs and concerns. A critical emphasis of this 10-week intervention is that the survivor decides what is worked on, and she guides all aspects of the intervention. The type of advocacy provided through this intervention consists of five distinct phases: assessment, implementation, monitoring, secondary implementation, and closure.

Assessment consists of two components: gathering important information regarding the woman’s needs and goals and determining which community resources might appropriately meet those needs. After the unmet need has been determined and various community resources have been brainstormed, the advocate and woman move into the implementation phase of generating or mobilizing the community resources.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

The implementation stage involves actively working in the community to obtain resources and to make the community more responsive to women’s needs. If, for example, the woman is looking for new housing, the advocate’s role is not simply to hand her information or make suggestions about next steps. Rather, the advocate would accompany the client through the entire process. This active participation has a number of beneficial outcomes: the client feels emotionally supported through difficult processes, the woman is sometimes treated more respectfully or expeditiously because she is accompanied by an advocate, and the advocate becomes a witness to events in case there is a later dispute between the woman and systems. Another benefit of this type of teamwork is that the advocate gains firsthand knowledge about the hassles and difficulties involved in obtaining many community resources, which often increases her respect for her client’s diligence and determination.

Monitoring the effectiveness of the implemented intervention is accomplished by assessing whether the resource has been successfully obtained, and whether it is satisfactory to meeting the unmet need.

If it is not, then the advocate initiates a secondary implementation to meet the client’s needs more effectively. For example, the advocate and client might obtain convenient and affordable child care for her preschool children. The advocate’s role would be to continue to ask how the child care is working out: Do the children enjoy it? Is the mother satisfied? Is there a backup plan in case of emergency? If the resource is not as adequate as originally hoped, then a secondary implementation—generating or mobilizing a different community resource—is necessary.

Closure begins approximately 7 to 8 weeks into the 10-week intervention. During this phase, advocates work more intensively on transferring all of the skills they learned throughout training and supervision. Through role playing, coaching, and discussions, the advocate ensures the woman can effectively advocate on her own behalf with resistant or hostile community providers after the intervention ends.

Although the five phases of advocacy intervention have been described here as distinct stages for clarification purposes, in reality advocates engage in various phases simultaneously. Multiple interventions may occur throughout the 10 weeks, such that, for example, the advocate may be monitoring one intervention while initiating another.

Combining Systems Advocacy and Individual-Level Advocacy

Advocacy efforts are generally classified as either individual based—working specifically with or on behalf of individuals to ensure access to resources and opportunities—or systems based, which entails advocating to change and improve institutional responses. In reality, many advocacy efforts involve working to change systems and assisting individuals simultaneously.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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CAP is designed to do exactly this by providing numerous individualized advocacy interventions and working with other community-based groups, with the intention of ultimately creating community-level change.

Evidence for the Effectiveness of the Intervention

A number of studies have been conducted to evaluate experimentally the effectiveness of this intervention over time. The initial feasibility study, funded by the George Gund Foundation (1986-1988), included 41 women (24 randomly assigned to work with advocates). Women were interviewed pre-intervention, post-intervention, and at a 10-week follow-up. Findings were positive, with women in the experimental condition being more successful in obtaining desired resources than were women in the control group. The feasibility study is described in more detail elsewhere and was promising enough that the author received funding from the National Institute of Mental Health (NIMH, 1989-1997) to continue the research on a larger scale (Sullivan and Davidson, 1991).

The larger-scale NIMH study included a true experimental, longitudinal design. Effectiveness of the advocacy intervention was examined by randomly assigning 278 women exiting a shelter to the advocacy (experimental) or services-as-usual (National Center for Injury Prevention and Control) condition. Participants were interviewed six times over two years, with interviews occurring pre-intervention, post-intervention, and at 6, 12, 18, and 24 months after intervention. An elaborate protocol was implemented to maximize retention of the sample over time, and this protocol resulted in retention rates at any given time of 94 percent or higher. Rates were not significantly different between the advocacy and control conditions. The specific components of the retention plan can be found in Sullivan et al. (1996).

The immediate impact of the advocacy intervention in helping women access resources was assessed post-intervention by a simple between-conditions comparison of women’s ratings of their effectiveness. Women in the advocacy condition reported being more effective in reaching their goals than women in the control condition. The short-term impact of the advocacy intervention on the major outcome variables—experience of further physical violence, psychological abuse, depression, social support, and quality of life—was tested through multivariate analysis of covariance (MANCOVA). Physical violence and depression were lower in the advocacy condition, while quality of life and social support were higher.

Doubly multivariate repeated-measures MANOVA was then used to test for the persistence of experimental–control group differences on the major outcomes across the next two years. Women who worked with advocates reported higher quality of life and social support over time as

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

well as decreased difficulty obtaining community resources. Perhaps most importantly, women who worked with advocates also experienced less violence over time than did the women who did not work with advocates. Articles containing more detailed descriptions of the multivariate analyses and findings include Sullivan et al. (1992); Sullivan (2000, 2003); Bybee and Sullivan (2002, 2005); Goodkind et al. (2004); Beeble et al. (2009).

Adapting CAP to Other Communities

CAP can be adapted to meet a variety of a community’s needs and to assist a wide range of domestic violence survivors. Although the project originated in a mid-sized city close to a university campus, it can be modified for larger cities as well as for more rural communities. Similarly, although the original studies focused on women who had used domestic violence shelter programs, CAP is equally applicable for women using non-residential support services or who are not receiving any community services at all (e.g., women exiting jails or prisons).

As more and more individuals consider replicating or modifying this program, questions arise regarding implementation issues. The most common concerns are discussed in the following sections.

How Do You Keep Women from Becoming Too Dependent on the Advocate?

For those individuals who are prone to becoming overly dependent on others, such dependency is minimized by the short time frame (10 weeks) of the intervention and the clearly delineated end date. It is important to note, however, that this question typically arises from individuals who view women with abusive partners as “not like me.” We all depend on informal or formal advocacy-type assistance at various times in our lives (whether in the form of family helping us gain employment, friends accompanying us to the doctor, colleagues sharing information about opportunities or commodities, or something else). The more disenfranchised that individuals are from society, the fewer networks they have to rely on for such assistance. This advocacy model is predicated on the beliefs that we could all use more information about resources and how to obtain them and that we can all use a supportive person in our lives through difficult times.

We Don’t Have a University in Our Area. Would This Type of Advocacy Project Work Using Volunteers Instead of Students?

An important next step in exploring the usefulness and generalizability of this intervention will be to investigate whether volunteers would

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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advocate for women as effectively as university students. One reason college students are preferable to volunteers is that they are paying for the experience (through tuition) and earning a grade and potential letter of recommendation for their efforts. This maximizes the likelihood they will work the required hours each week and make this intervention a priority in their lives. It is only natural that when busy individuals have to prioritize their time, it is their volunteer work that usually gets short shrift. A major concern in using volunteers as advocates is that they may be more likely to quit mid-way through the intervention or to put in fewer hours or less effort than is necessary to be effective.

On the other hand, volunteers are quite capable of becoming excellent advocates and, with appropriate training and supervision (ideally from a paid staff member), could do as well if not better than university students. Another advantage of using volunteers is that they may come from more diverse backgrounds than typical university students. Domestic violence service programs might consider aligning with church groups, community organizations, or other volunteer programs to obtain a paraprofessional advocacy workforce conducive to their individual needs.

Shouldn’t an Intended Goal of the Project Be to Help Women Leave the Relationship?

It cannot be overemphasized that an integral component of this model is to follow the woman’s lead in determining goals. Encouraging a client to make certain choices over others is not only disrespectful but is also likely to fail in creating lasting change. Individuals have multiple and complex reasons for making life choices, including relationship decisions. Ending the relationship not only does not necessarily end the violence, but also it sometimes escalates the violence (Sev’er, 1997; Fleury et al., 2000). The advocate’s role must be to help women do what they can to protect themselves and their children, regardless of whether women are in or out of the relationship. Advocates can offer information to help women make decisions, but they should never push a woman toward one path over another. Working from a strengths perspective involves viewing individuals as naturally competent and capable, possessing valuable skills and abilities to make decisions and create positive change in their own lives.

Had we assumed in our research that leaving the relationship should be a desired outcome for all women, we would have analyzed whether women who worked with advocates were

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

more effective in leaving the relationship than were women in the control group. This analysis would have indicated no differences between the two groups. However, when we looked at group differences only for women reporting they wanted to end the relationship, a significant difference emerged. Women who worked with advocates were more effective in ending the relationship when they wanted to than were women in the control condition (96 percent versus 87 percent).

If a Major Goal of the Advocacy Intervention Is to Help Women Become Safe, Why Not Just Focus on Legal Advocacy?

Interestingly, only 72 percent of the women worked on legal advocacy issues during the NIMH-funded study, and not all of those issues pertained to the assailant. Some women, for example, were fighting their landlords in court or had been charged with other crimes themselves. Legal advocacy programs are important and necessary resources for women choosing to use the court system. However, many women choose alternatives to the criminal justice system to keep themselves and their children safe. Furthermore, women reported having a variety of interrelated concerns needing to be addressed, and this intervention was found to be equally effective regardless of the types or extent of such needs (Allen et al., 2004). The more generalized our advocacy efforts can be, the more lives we can effectively touch.

Importance of the Program’s Underlying Philosophy

Although each advocacy intervention must be individualized to meet the unique needs of each participant, all interventions should be guided by three theoretical tenets that contribute to project effectiveness. First, the participant, not the advocate, should guide the direction and activities of the intervention. This relates to the second supposition, which is the belief that survivors are competent adults capable of making sound decisions for themselves. Third, the role of the advocate is to make the community more responsive to women’s needs, and this involves active and pro-active work in the community.

USING A SYSTEMS-MODEL APPROACH TO IMPROVING IPV
SERVICES IN A LARGE HEALTH-CARE ORGANIZATION

Brigid McCaw, M.D., M.S., M.P.H., FACP
Family Violence Prevention Program, Kaiser Permanente

Intimate partner violence (IPV) is a common and costly health problem associated with substantial medical and mental-health issues for victims and their children. Women, the most common victims of IPV, access the health care system frequently over the course of their lives for preventive and routine care as well as for trauma and abuse-related conditions. Thus, health care offers many valuable opportunities for early identification, tailored interventions, and primary prevention.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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Despite these opportunities, identification and intervention for IPV is not a common or consistent practice in most health care settings. This is unfortunate, but not surprising. For many years clinical practice guidelines and recommendations from professional organizations focused primarily on the training of clinicians. Over time, however, it became clear that clinician-focused efforts had only limited success, producing little or no increase in the rates of identification and referral.

In 2001 the Institute of Medicine (IOM) urged health care delivery systems to develop and evaluate innovative programs that would go beyond traditional clinician training methods for addressing IPV. In a report titled Confronting Chronic Neglect: The Education and Training of Health Care Professionals on Family Violence, the IOM called attention to a 1998 pilot program, implemented by Kaiser Permanente Northern California, which had been associated with a significant increase in rates of screening, identification, and referral to mental-health clinicians and had been well accepted by clinicians. The IOM report noted that Kaiser Permanente had achieved these results by implementing a “systems-change model” in which clinician training was just one component of a larger intervention designed to make use of the entire health care environment—not just the doctor office visit—to address intimate partner violence.

Since its 1998 pilot Kaiser Permanente has disseminated the systems-model approach to medical centers throughout the Northern California region (serving 3.2 million members), and currently implementation is under way in eight additional regions across the country. Outside of Kaiser Permanente, the approach is being adapted for use in other clinical settings, both in the United States and abroad.

This summary will describe Kaiser Permanente’s systems-model approach to delivering services for IPV, including how this approach has been implemented and evaluated. We will provide an update on Kaiser Permanente’s progress over the past 10 years on the program’s development and dissemination, giving special attention to what has been learned that may be of value to those who set out to implement this approach in other health care settings.

Organizational Setting: What Kaiser Permanente
Brings to the Issue of IPV

Kaiser Permanente is one of the largest not-for-profit, integrated health care delivery systems in the United States, serving 8.7 million members in eight regions. The Kaiser Permanente workforce comprises more than 15,000 physicians and 164,000 employees.

Kaiser Permanente presents a unique opportunity for implementing IPV services and prevention because it provides the entire scope of care:

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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outpatient, inpatient, emergency, and behavioral health services. Kaiser Permanente has a fully implemented electronic health record system, extensive experience in management of chronic conditions, a team-based approach to care, recognized research expertise, and a strong commitment to prevention and health education—all grounded in a social mission. These elements make it an ideal “laboratory” for developing and implementing new models of care and addressing complex health issues.

The Kaiser Permanente Systems-Model Approach

The systems-model approach has five components: (1) a supportive environment (Sullivan et al.), (2) clinician inquiry and referral, (3) on-site IPV services, (4) linkages to community resources, and (5) leadership and oversight.

Figure 8-1 below depicts how each component is a necessary and interconnected piece of a coordinated health care response. It also lists the interventions used for each component.

images

FIGURE 8-1 Systems model for intimate partner violence prevention.
SOURCE: McCaw, 2011.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
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Testing the Systems-Model Approach: The 1998-1999 Pilot

In 1998 funds were allocated to develop, implement, and test an innovative systems-model approach to improving IPV services in one small medical center (serving 70,000 members) in the Kaiser Permanente Northern California region. The idea was to go beyond the traditional approach of focusing primarily on didactic training of clinicians.

The systems-model approach makes use of the entire health care environment to address IPV prevention. This approach was chosen based on prior research showing the effectiveness of systems change for other clinical and safety issues (Thompson et al., 1995). The effectiveness of the pilot was evaluated based on evidence of actual change in clinician practice (increased IPV identification and referral) rather than on the traditional knowledge-and-attitude survey of clinicians.

The pre- and post-implementation evaluation of the pilot demonstrated a dramatic and statistically significant increase in screening rates, identification, and referral to a mental-health clinician, and the approach was well accepted by clinicians. In addition, after the implementation, more members recalled being asked about IPV, noticed IPV information available at the facility, and reported increased satisfaction with the health plan (McCaw et al., 2001; Kimberg, 2007).

In recognition of its success in boosting rates of IPV identification and referral, the Kaiser Permanente program was chosen by the American Association of Health Plans/Wyeth as the 2003 Gold Winner of its HERA award, presented each year to an exemplary program that advances quality in women’s and children’s health care.

Disseminating the Approach to Other Kaiser Permanente Medical Centers in Northern California

Over the next two years, the model was transferred to six more Kaiser Permanente medical facilities in Northern California through the guidance of a physician champion and a multidisciplinary team in each facility. This success led to identification of an “executive sponsor” and funding for a part-time medical director and project manager to facilitate rapid and efficient implementation across all 49 medical facilities in the Northern California region.

The job of the physician director and project manager was to provide consultation to medical facilities, identify and spread best practices, and ensure that IPV was integrated into region-wide operations—including scripts and protocols for use by nurses in the appointment-and-advice call center, data systems for quality improvement, the electronic health record, and on-line and printed resources for clinicians and members.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

Tools developed to facilitate local implementation included a description of the roles and responsibilities of the physician champion and members of the multi-disciplinary team and a phased work plan for implementing the systems-model approach. Patient education materials, reviewed for readability and cultural appropriateness, were designed to be easily customized with local resource information.

Currently each Kaiser Permanente medical center in Northern California has a multi-disciplinary team led by a physician champion. These teams meet regularly, implement the systems-model approach at their medical facility, provide training to clinicians and front-line staff, respond to quality-improvement data, and ensure that IPV identification and referral is part of everyday patient care. Twice a year members of teams from every medical center come together for leadership development, sharing of innovative practices, updates on research, review of quality metrics, and development of annual goals and strategy.

Although medical facility–based teams ensure the local implementation of the systems-model approach, the role of regional leadership and oversight is also important to make certain that activities are coordinated among medical centers, that new research data is incorporated, and that “lessons learned” and best practices are widely disseminated. The regional medical director and program director meet regularly with other leadership groups and the executive sponsor to evaluate the progress of implementation, review quality-improvement metrics, and identify opportunities to integrate with other initiatives. Sponsorship from the top is critical in sustaining the momentum of the work. An executive sponsor can increase the program’s visibility, assist with goal setting, identify and procure resources, and, when necessary, participate in problem solving (McCaw and Kotz, 2009).

Clinician training, although it is not the primary focus of the systems-model approach, is essential. To maximize its effectiveness, training is offered in multiple ways and venues including: lectures as part of continuing medical education, brief departmental updates, case presentations, on-line training tools, and reports on quality-improvement data. Clinicians are offered multiple options for incorporating IPV screening into their practices in a way that is comfortable and natural for them. Cultural considerations are incorporated into all training.4

________________

4 For further information, see McCaw, B. 2009. Intimate partner violence. In A provider’s handbook on culturally competent care: Women’s health. Kaiser Permanente National Diversity Council.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 automated 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 departments, 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 Permanente 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 entered 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 estimate 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.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 sixfold 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 percent 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

images

FIGURE 8-2 Members diagnosed with intimate partner violence, 2000-2010.
SOURCE: McCaw, 2011.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

images

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 access point-of-care patient handouts about IPV and direct patients to Internet 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 dramatically 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 initial implementation of the systems-model approach focused on providing 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

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

an additional benefit of this workplace outreach emerged: Employees who had learned about IPV became an essential aspect of the supportive environment 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 diversity of the Kaiser Permanente workforce in age, career type, and ethnic background. The exhibit travels to every Kaiser Permanente medical facility 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 invaluable. 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 clinicians. 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 researchers 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 appropriately 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.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

However, the development of community partnerships is often challenging 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 beyond 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, organizational 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 regions 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 implementation, 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 member safety, improving coordination of care, increasing efficiency, enhancing

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

service, and reducing health care disparities. Most importantly, IPV prevention 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 imperative and a positive investment. This top-level support is evident in comments 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 affordability. 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 implementation 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 being 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.

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 readily customized to available resources (for example, Figure 8-1).

•    Implement the approach with local physician or nurse practitioner champions and multi-disciplinary teams.

•    Provide organizational leadership to ensure consistency of services, alignment with other health initiatives, and dissemination 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 evaluation 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 prevention, 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 Permanente 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,

Suggested Citation:"8 Papers on Preventive Interventions." Institute of Medicine. 2011. Preventing Violence Against Women and Children: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/13139.
×

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 director, 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 Northern 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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Next: Appendix A: Workshop Agenda »
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Violence against women and children is a serious public health concern, with costs at multiple levels of society. Although violence is a threat to everyone, women and children are particularly susceptible to victimization because they often have fewer rights or lack appropriate means of protection. In some societies certain types of violence are deemed socially or legally acceptable, thereby contributing further to the risk to women and children. In the past decade research has documented the growing magnitude of such violence, but gaps in the data still remain. Victims of violence of any type fear stigmatization or societal condemnation and thus often hesitate to report crimes. The issue is compounded by the fact that for women and children the perpetrators are often people they know and because some countries lack laws or regulations protecting victims. Some of the data that have been collected suggest that rates of violence against women range from 15 to 71 percent in some countries and that rates of violence against children top 80 percent. These data demonstrate that violence poses a high burden on global health and that violence against women and children is common and universal.

Preventing Violence Against Women and Children focuses on these elements of the cycle as they relate to interrupting this transmission of violence. Intervention strategies include preventing violence before it starts as well as preventing recurrence, preventing adverse effects (such as trauma or the consequences of trauma), and preventing the spread of violence to the next generation or social level. Successful strategies consider the context of the violence, such as family, school, community, national, or regional settings, in order to determine the best programs.

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