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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Board on Children, Youth, and Families is a joint effort of the Institute of Medicine and the Division of Behavioral and Social Sciences and Education.
Support for this project was provided by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. The views presented in this report are those of the Institute of Medicine’s Committee on the Training Needs of Health Professionals to Respond to Family Violence and are not necessarily those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
Board on Children, Youth, and Families (U.S.). Committee on the Training Needs of Health Professionals to Respond to Family Violence.
Confronting chronic neglect : the education and training of health professionals on family violence / Committee on the Training Needs of Health Professionals to Respond to Family Violence, Board on Children, Youth, and Families, Institute of Medicine ; Felicia Cohn, Marla E. Salmon, and John D. Stobo, editors.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-07431-2 (hardcover)
1. Family violence. 2. Medical personnel—Training of—United States.
[DNLM: 1. Domestic Violence—prevention & control—United States. 2. Health Personnel—education—United States. HV 6626.2 B662 2002] I. Cohn, Felicia. II. Salmon, Marla E. III. Stobo, John D. IV. Title.
RC569.5.F3 B63 2002
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COMMITTEE ON THE TRAINING NEEDS OF HEALTH PROFESSIONALS TO RESPOND TO FAMILY VIOLENCE
JOHN D. STOBO (Chair),
University of Texas Medical Branch at Galveston
MARLA E. SALMON (Vice Chair),
The Nell Hodgson Woodruff School of Nursing, Emory University
ELAINE J. ALPERT,
Boston University School of Public Health
JACQUELYN C. CAMPBELL,
Johns Hopkins University School of Nursing
MICHAEL I. COHEN,
Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine
Georgetown University Law Center
Department of Emergency Medicine, Emory School of Medicine
SUSAN R. JOHNSON,
University of Iowa College of Medicine
RICHARD D. KRUGMAN,
University of Colorado School of Medicine
MARK S. LACHS,
Division of Geriatrics and Gerontology, Weill Medical College of Cornell University
GARY B. MELTON,
Institute on Family and Neighborhood Life, Clemson University
GREGORY J. PAVEZA,
School of Social Work, University of South Florida
GEORGINE M. PION,
Vanderbilt Institute for Public Policy Studies, Vanderbilt University
MICHAEL A. RODRIGUEZ,
Department of Family and Community Medicine, University of California, San Francisco
ROBERT S. THOMPSON,
Department of Preventive Care, Group Health of Puget Sound
FELICIA COHN, Study Director
MAURA SHEA, Senior Project Assistant
BOARD ON CHILDREN, YOUTH, AND FAMILIES
EVAN CHARNEY (Chair),
Department of Pediatrics, University of Massachusetts Medical Center
JAMES A. BANKS,
Center for Multicultural Education, University of Washington
Child Study Center, Yale University
Children’s Hospital Medical Center of Cincinnati
MARY JANE ENGLAND, President,
School of Public Health and Department of Psychiatry, Columbia University
Department of Psychology, University of California, Los Angeles
RUTH T. GROSS, Professor of Pediatrics (emerita),
Department of Family and Community Medicine, University of California, San Francisco/San Francisco General Hospital
School of Public Health, University of California, Los Angeles
Washington State Department of Health, Olympia
Department of Pediatrics, Harlem Hospital Center, Columbia University
Department of Pediatrics and Child Health, Howard University
School of Nursing, University of Rochester
School of Public Affairs, Baruch College
Juvenile Justice Center, Dade County, Florida
Center for Human Growth and Development, University of Michigan
University of Wisconsin-Madison
Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology
Department of Pediatrics, Montefiore Medical Center, New York
ELEANOR E. MACCOBY (Liaison, Division of Behavioral and Social Sciences and Education),
Department of Psychology (emerita), Stanford University
WILLIAM ROPER (Liaison, Institute of Medicine),
School of Public Health, University of North Carolina, Chapel Hill
MICHELE D. KIPKE, Director
SONJA WOLFE, Administrative Associate
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Robert A. Burt, Yale University
Linda Chamberlain, Alaska Family Violence Prevention Project
Lynn Mouden, Arkansas Department of Health
Barbara Parker, University of Virginia
Desmond K. Runyan, University of North Carolina, Chapel Hill
Pat Salber, Kaiser Permanente
LuAnn Wilkerson, UCLA School of Medicine
Rosalie Wolf, The Medical Center of Central Massachusetts
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow, Tulane University, appointed by the Institute of Medicine and Luella Klein, Emory University School of Medicine, appointed by the National Research Council’s Report Review Committee, both of whom were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
This report is not the first recent National Academies’ report to focus on the issue of family violence. It is the third and, regrettably, it may not be the last. Family violence continues to plague society and we have not yet developed either the practical interventions or evidence base to address this important social issue.
When Congress passed the Health Professions and Education Partnerships Act of 1998, it issued an important challenge to government and the health professions. The bill’s language suggested that education of health professionals is an important first step in mitigating the problem of family violence. The Board on Children, Youth, and Families of the Institute of Medicine and the Division of Behavioral and Social Sciences and Education of the National Research Council responded to this challenge by establishing the Committee on the Training Needs of Health Professionals to Respond to Family Violence.
The committee’s point of departure for its work was to adopt three fundamental principles: (1) family violence is a health issue; (2) education of health professionals about the issue is therefore important; and (3) while education of health professionals about family violence is necessary to address the problem, it is not by itself sufficient. Other individuals and entities outside the health professions are involved in addressing issues related to family violence, and this larger societal context must not be forgotten.
As the committee began its deliberations, we quickly became aware that education of health professionals in family violence is not a consistent priority across or within health professions education curricula. The challenge of even identifying curricular content or strategies was compounded by the almost complete absence of either educational research or evaluation relating to family vio-
lence education and training for health professionals. In short, while family violence exacts a tremendous cost from its victims and society, it is not viewed as sufficiently important for society to invest the resources and expertise critical for developing the research and demonstrations necessary to improve the response of health professionals and others to this serious social and health problem. That must change.
The charge to our committee reflected a desire by Congress to encourage health professionals in education and practice to assume more responsibility for addressing this difficult, devastating issue. While the committee is sympathetic with this view, we also recognize that the complexity and breadth of this issue call for the involvement of professionals whose work lies outside the health arena. Responding to victims of family violence, and ultimately preventing its occurrence, is a societal responsibility. As such it must be shared.
The committee has chosen to limit the number of our recommendations in the hope that offering a few specific priorities will increase the likelihood of implementation. In our view, family violence should be treated like other public scourges such as heart disease, cancer, diabetes, and AIDS. Resources equivalent to those used to address these problems should be applied to address the problem of family violence. We recommend the creation of education and research centers that will not only generate significant new information with a beneficial impact on family violence but will also be useful in coordinating, integrating, and evaluating educational and intervention activities related to family violence. The work of such centers will benefit the development of sound, evidence-based curricula, contributing to the development of research and scholars around this issue. Such centers will provide focus to activities related to this very serious health problem.
Our recommendations reflect our consideration of the evidence and input that we worked diligently to uncover throughout the study process. It is important to note, however, that the committee members were both troubled and frustrated by the lack of scholarship in this area. We note here a finding that is not explicitly discussed elsewhere: the failure to make progress on education and practice in the area of family violence is in itself clear evidence that society has paid too little attention to what will remain a national shame and tragedy. For too long family violence has indeed been a case of chronic neglect.
John D. Stobo, Chair
Marla E. Salmon, Vice Chair
Committee on the Training Needs of Health Professionals to Respond to Family Violence
No report is possible without the assistance of many people. The Committee on the Training Needs of Health Professionals to Respond to Family Violence would like to acknowledge the efforts of many who contributed to this report.
The study conducted by this committee was funded by the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention (CDC). CDC staff members Rodney Hammond, director for the Division of Violence Prevention, and Lynn Short, previously with the CDC and now executive director for Analytic Systems Associates, Inc., among others, provided useful background material and ongoing support. Joyce McCurdy, public health advisor in the Division of Violence Prevention, served as the project officer for this study and continuously provided invaluable assistance. This study, the result of federal legislation, also benefited from the support of Anne Marie Murphy, legislative assistant in the Office of the Honorable Richard J. Durbin, sponsor of the authorizing legislation.
Several consultants provided important background information, assisted in data collection, and contributed text for use in the report. Jane Koziol-Mclain of Johns Hopkins University prepared materials on issues related to funding and core competencies. Gina Espinosa Salcedo of Boston University assisted in the collection and organization of existing curricula for health professionals on family violence. Paul Mazmanian of the Medical College of Virginia provided background materials on clinician behavior change research. In addition to these formally appointed consultants, a number of other individuals offered background information and contributed text for this report. Kim Bullock of the Georgetown University Medical Center Department of Family Medicine prepared a compre-
hensive description and bibliography on cultural competencies for health professionals. William Rudman of the University of Mississippi provided extensive background materials on health care utilization data related to intimate partner violence. Deborah Horan of the American College of Obstetricians and Gynecologists (ACOG) developed the flowchart describing ACOG’s work on family violence, and Donna Vivio of the American College of Nurse-Midwives (ACNM) developed the timeline of ACNM’s family violence activities for inclusion in this report. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children, provided helpful data and references. Bernice Parlak and Joan Weiss of the Health Resources and Services Administration and Diane Hanner of the Substance Abuse and Mental Health Services Administration provided essential information on the Geriatric Education Centers evaluation. Richard Hodis and Tony Phelps of the National Institute on Aging assisted with information on the Alzheimer’s disease program. David Hemenway of the Harvard Injury Control Research Center provided useful information on the impact of that center. The committee is indebted to each of these individuals for their hard work and cooperation.
The committee’s progress was possible, in part, due to the regular assistance of a number of speakers at committee meetings and other experts on family violence, health professional education, and related topics. Wanda Jones, deputy assistant secretary for health (women’s health) of the U.S. Department of Health and Human Services; Denice Cora-Bramble, special advisor to the director of primary health care of the Health Resources and Services Administration; Lisa James, senior program specialist for the Family Violence Prevention Fund; Lori Stiegel, American Bar Association, Commission on the Problems of the Elderly; and David Cordray, professor of public policy and psychology and co-director, Center for Evaluation Research and Methodology, Institute for Public Policy Studies, Vanderbilt University, provided thoughtful presentations regarding current efforts to educate health professionals as well as frequent insights relevant to the committee’s work. A number of others also served as resources for the committee, including Marcy Gross, Kate Rickard, and Carolina Reyes of the Agency for Healthcare Research and Quality; Angela Gonzalez-Willis of the Bureau of Health Professions; Debbie Lee of the Family Violence Prevention Fund; Hal Arkes and Ann Bostran of the National Science Foundation; Anita Rosen and Joan Zlotnick of the Council on Social Work Education; Rosalie Wolf of the Institute on Aging at the University of Massachusetts; Lynn Moudin of Prevent Abuse and Neglect Through Dental Awareness and the Arkansas Department of Health; Catherine Judd of the University of Texas Southwestern Medical Center at Dallas; Brian Rafferty of Talaria; and Calvin Hewitt of the University of Mississippi.
A number of other individuals provided helpful presentations and background materials on topics related to the committee’s work. The committee appreciates the time and resources offered by the following individuals: Sidney
Stahl, chief, Health Care Organization and Older People in Society, National Institute on Aging; Mark Rosenberg, executive director, Task Force for Child Survival and Development; Brigid McCaw, director of the Family Violence Prevention Project, Kaiser Permanente Richmond and clinical lead for domestic violence prevention, Northern California Kaiser Permanente; Connie Mitchell, medical director for domestic violence, California Medical Training Center; Marilyn Peterson, director, California Medical Training Center, and director, University of California-Davis Child Protection Center; Ellen Taliaferro, medical director, Violence Intervention Prevention Center, Parkland Health and Hospital System, and co-founder, Physicians for a Violence Free Society; Bonnie Brandl, project coordinator, National Clearinghouse on Abuse in Later Life and Wisconsin Coalition Against Domestic Violence; Robert Spagnoletti, chief, Sex Offense and Domestic Violence Section, U.S. Attorney’s Office; Billie Weiss, Injury and Violence Prevention Program, Los Angeles County Public Health and Program Service; Joanne Marlott Otto, program administrator, Adult Protection/ Elder Rights Services, Colorado State Department of Human Services; John Umhau, Laboratory of Clinical Studies, National Institutes for Alcohol Abuse and Alcoholism; Christopher Murphy, Department of Psychology, University of Maryland, Baltimore County; Larry Cohen, executive director, Prevention Institute; Suzanne Donovan, senior program officer, National Research Council; Deborah Danoff, assistant vice president for medical education, Association of American Medical Colleges; and Jeffrey Rachlinski, professor, Cornell Law School.
The committee conducted a public forum in Washington, DC, to inform its deliberations. The forum was designed to elicit the expertise of health professionals, policy makers, family violence advocates, and educators on the content and design of training programs for health professionals on family violence and information on existing guidelines and organizational positions. Representatives from over 20 organizations presented their policies, positions, educational initiatives, and research. The committee appreciates the insights these presentations provided into existing and potential educational approaches and is thankful to each participant and to all of those who submitted written materials.
Finally, the committee benefited tremendously from the support and assistance of several members of the Division on Behavioral and Social Sciences and Education and Institute of Medicine staff, as well as the administrative and research assistants of several committee members. A special thanks goes to Maura Shea, who provided administrative and research support to the committee, assisted in drafting pieces of the report, and helped prepare the report for publication. Drusilla Barnes, Amy Gawad, Rebekah Pinto, Michael Rosst, Mary Strigari, Kerry Williams, and Sonja Wolfe deserve much appreciation for their assistance with committee and meeting organization. The research needs of this report could not have been met without the able assistance of Adrienne Davis, Georgeann Higgins, James Igoe, and others in the National Research Council
Library. The substantive contributions and ongoing support of Nancy Crowell and Rosemary Chalk were inestimable. Bronwyn Schrecker was invaluable to the report review process. Christine McShane edited the report and Yvonne Wise was especially helpful in preparing the report for publication. The public release and dissemination of this report would not have been possible without the hard work of Mary Graham, Jennifer Otten, and Vanee Vines. Several assistants to specific committee members, including Eve Adams, Jandee Christensen, Sandy Froslan, Pat Knox, Latisha Lord, Drew Smith, JoEllen Stinchcomb, and Dianne Winsett, deserve thanks for facilitating the committee process, as do Samantha Coulombe, Caroline Han, Stacey Vaccaro Milonas, and Carla VandeWeerd. Finally, a heartfelt thanks to our study director, Felicia Cohn, who kept us organized and on time while guiding us through the entire process and who made significant contributions to the substance of the report.