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Screen, Assess, Intervene, Follow-upA curriculum to address

Intimate Partner Violence

Sandolsam Cha, MDSome materials used from Futures Without Violence with Permission

Workshop Guidelines

- Because physical and sexual violence are so prevalent, assume that there are survivors among us.

- Some of the slide content may be triggering. If you have to step out for any reason, please feel free to do so.

- Your reactions are legitimate, take care of yourself first.- Respect confidentiality.

- Please turn off your phones, laptops, etc.

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Mental Health Resources for Residents

Working Definition

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Magnitude of the Problem: Globally

Lifetime prevalence of physical and/or sexual IPV among women from 10 different countries ranged from

15% to 71%

Magnitude of the Problem: U.S.

Lifetime prevalence of having been raped and/or physically assaulted by a current or former partner

24.8% of women7.6% of men

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Magnitude of the Problem - Bronx•Women living in the Bronx had higher rates of IPV related hospitalization and emergency department visits than women in other boroughs.

•Black and Hispanic women had higher rates of intimate partner homicide, hospitalizations and emergency department visits compared to women in other racial/ethnic groups.

2015 NYC Domestic Violence Statistics

•74,684 Domestic Incident Reports (DIRs) were made. That’s 205 DIRs a day•85,172 calls were made to the DV hotline. That’s 230 calls a day•62.8% of DV felony assaults in NYC were IPV related – 4,886 reported IPV felony assaults•67% of rapes committed in NYC were IPV related – 243 reported IPV (not stranger) rapes•53% of family-related homicides were IPV – 26 IPV homicides

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Healthy Impacts of IPV

INDICATOR CONNCETION WITH IPV

Tobacco Use Increased risk of smoking (Hathaway et al. 2000)

Substance Abuse Increased risk of high risk alcohol use (Lemon et al. 2002)

Injury and Violence Leading cause of injuries and homicide (Frye et al. 2001)

Mental Health Increased risk of mental health problems (Coker et al, 2002)

Healthy Impacts of IPVINDICATOR CONNECTION WITH IPV

Responsible Sexual Behavior Increased sexual risk-taking and STIs (Coker,Sexual Behavior, 2000); Less likely to use condoms consistently (Wingood et al, 2001)

Access to Health Care Increased risk of late entry into prenatal care(McFarlane et al, 1992; Silverman et al, 2006)

Immunizations Children of battered women less likely to get immunizations (Attala et al, 1997; Bair-Merritt et al, 2008; Webb et al, 2001)

Body Weight Overweight & Current body mass >25 (Black & Breiding, Obesity, 2008); weight gain (Sato-DiLorenzo & Sharps, 2007)

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Disease Burden of IPV

•7.9% of the overall disease burdenfor women, ages 18-44•Larger risk than common risk factors for disease including blood pressure, tobacco use,and obesity

Women who experience IPV are

2.6 times more likely to be diagnosed with cervical cancer

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Women who talked to their health care provider about the abuse were

Question

How does an intervention for reproductive coercion differ from an intervention for IPV?

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Answer

When it comes to reproductive coercion, the health care provideris now key to intervention

- This is done through offering harm reduction strategies for reproductive and sexual coercion and providing discreet methods of contraception

Addressing the Barriers

● Simplifying the process of direct assessment and universal education about IPV for providers○ Connect DSV and health risks to visit type○ Safety card intervention○ Harm reduction○ Referral and support

● Your role is important!○ You do not have to be DSV expert to recognize and help

patients experiencing IPV○ You have a unique opportunity for education, early

identification, and intervention○ Partner with agencies to support your work

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What can we do?

SAIF: Screen, Assess, Intervene, Follow-up

Outline•Screen (S)

Framing statementsLimits of confidentialitySafety Cards

•Assess (A)Screen negative responsesSafety assessmentReproductive Coercion assessment

•Intervene (I)Safety PlanningHarm reductionsWarm referral to SW

•Follow-up (F)Follow-up appointmentDocumentation

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Screen

State the limits of confidentiality before screening!

“Before we get started, I want you to know that everything you share with me is confidential, unless you have been injured by a weapon or are suicidal –those things I would have to report, OK?”

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Mandatory reporting requirements - NY

Framing Statements

“We talk to all our patients about safe and healthy relationships because it can have such a large impact on your health.”“We like to give this card to everyone – it’s kind of like a magazine quiz – do you feel like you are in a healthy relationship?”

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Futures without violence: Safety Cards

Futures without violence - Are you in a healthy relationship?

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Practical Application

● Divide into groups of three. One person is the provider, one person is the patient, one person is the observer

● Practice introducing the Did You Know Your Relationship Affects Your Health? Card. Your goal is to review the Healthy Relationships Panel.

● Discuss as a group- what worked, what would you change?

Video: Olivia’s visit

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When should you screen?

•OB•First prenatal visit•At least once per trimester•Postpartum visit

•GYN•Annual visit•STD testing•Repeat pregnancy test requests•Family Planning

Where should you screen?

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Assess

Potential responses to screening

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Framing the Card for Friends and FamilyWhat we have learned about our intervention● Always give two cards● Using a framework about helping others helps

normalize the situation and allows patients to learn about risk and support without disclosure

● Patients do use cards to help their friends and family

● Having the information on the card is empowering for them- and for the others they connect with

Hotline Referral

Offer patients the use of your office phone to make the call

All these national hotlines can connect you to local resources and provide support

For help 24 hours a day call:National Domestic Violence Hotline1-800-799-SAFE (1-800-799-7233)TTY 1-800-787-3224www.thehotline.orgNational Dating Abuse Hotline1-866-331-9474www.loveisrespect.orgNational Sexual Assault Hotline1-800-656-HOPE (1-800-656-4673)www.rainn.org

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What do you do when you get a positive disclosure of IPV?Validate:

● First, believe the patient.

● Thank the patient for sharing● Validate that IPV is a health issue that you can help with● And let them know you will support them unconditionally without judgement

Assessment of immediate safety

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Assessment of the pattern of abuse

Assessment of contraceptive needs

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Intervene

Developing a Personalized Safety Plan

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http://www.joinonelove.org/my_plan_app

Harm reduction Tip #1 - refering to resources

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Harm reduction Tip #2 - STD reporting

Sotheycanknow.org

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InterventionThese methods are less vulnerable to tampering by a sexual partner - but are detectable due to loss of period/irregular bleeding

Hormonal IUD Depo-provera Nexplanon

Harm reduction Tip #3 - IUD considerationsSome controlling

partners may monitor bleeding patterns

and menstrual cycles.

The safest option may be the copper T IUD (Paragard) as it

does not change their cycles

Consider cutting strings short in the

cervical canal so that the device can’t be detected by partner

Difficult IUD removal is preferable to an

IPV situation becoming more

dangerous

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Harm reduction Tip #4 - EC

Providing a “Warm: Referral

When you can connect to a local program it makes all the difference

“If you are comfortable with this idea, I would like to call my colleague at the local program, they are an expert in what to do next and they can talk with you further about a safety plan,”

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Offering follow-up safetly

SW consult at CFCC•PutasocialworkconsultorderinEPIC•PutasocialworkconsultorderinEPI

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Follow-up

At every follow-up visit

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Documenting IPV

Recap- use Safety Cards as a guide!

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References