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HEALTH ALERT
STRENGTHENING THE HEALTH CARE SYSTEM'S RESPONSE TO DOMESTIC
VIOLENCE
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| Volume 7, No. 1 |
Summer 2001 |
Your Words Make A Difference:
Broader Implications for Screening |
By
Linda Chamberlain, Ph.D. MPH
Since last summer's Health Alert interview with Leigh
Kimberg, MD, "Screening for Domestic Violence Changed My Practice,"
the release of Preventing Domestic Violence: Clinical Guidelines
on Routine Screening, and Health Cares About Domestic Violence
Day, 1999, we have had a flurry of requests for more information
on screening for domestic violence. Many questions arose around
screening in rural areas or under difficult circumstances
and on how screening should be handled when domestic violence
services may not be present near the health care facility.
Long time domestic violence and health care advocate, Linda
Chamberlain shares her thoughts with us on these and other
important issues in this edition of Health Alert.
A Rural Perspective
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Lisa James,
Bridgett McClesdey,
and Linda Chamberlain, embarking on their
flight to train providers in
Fort Yukon, Alaska |
Alaska pushes the boundaries in terms of rural communities
with limited services -- the majority of Alaskan villages
have no road access. Our philosophy and experience has been
that it is even more important for health care providers to
routinely screen for domestic violence in communities where
resources for victims are limited or nonexistent. Routine
assessment and intervention can plant the seed to increase
awareness and education in these communities. Health care
professionals are often the only service providers who have
contact with a victim and the opportunity to talk with her
in a safe and confidential environment.
Your Words Make a Difference
Through my volunteer work at a local shelter and opportunities
to work with survivors, I have seen firsthand how women value
the awareness, supportive statements and compassion of health
care providers who are willing to talk about abuse with their
patients. A woman in her early twenties with three young children
taught me that just letting a victim of abuse know that you
care can make a difference. She belonged to a strict religious
sect from a small, isolated village and had been forced to
marry a man who was extremely abusive. Her family, his family
and the village as a whole refused to acknowledge or address
his violence. One day, a visiting public health nurse told
the young woman that she was "special and did not deserve
to be treated this way."
Three years later, the woman arrived at a shelter more than
200 miles from her village. Having made the decision to leave,
her village would never let her return there -- she and her
children were ostracized. As she recounted the violence, entrapment,
threats and isolation in her life, I asked what had helped
her to recognize that she had options. She told me that it
was the words of the public health nurse that had given her
hope. She had carried around that message like a candle in
her heart as she waited, endured and planned for a different
life.
Is Domestic Violence Screening Worthwhile?
Even within the context of a disease-oriented model, a good
argument can be made to justify routine screening for domestic
violence. Three major criteria are often used to assess whether
screening for a disease is worthwhile: effectiveness, human
costs and sustainability (Fowler et al, 1993). In terms of
effectiveness, screening should not be undertaken unless it
is known with reasonable certainty to be effective in reducing
the burden of disease. Screening for domestic violence, in
and of itself, has therapeutic value. Simply identifying the
abuse and being supportive can make a difference in the life
of a victim.
The human cost of domestic violence is great in terms of
injuries, chronic health problems and quality of life while
the human cost of screening is minimal in terms of time, money
and opportunity. Validated screening instruments are available
at no cost and take a few minutes to complete (Hoff and Rosenbaum,
1994; McFarlane J, 1993; Sherin et al, 1998). When we consider
the impact of domestic violence on the physical and mental
health of victims, it seems unlikely that choosing not to
screen for abuse would be more efficient in terms of time
management. A survey of primary care physicians revealed that
time constraint was not a major concern or predictor of physicians'
decision to screen for domestic violence (Chamberlain, 1996).
Sustainability means that the quality of screening must be
sustained as well as continuing resources being available
to support screening. Follow-up domestic violence training
is needed and a variety of training modalities are available
to sustain the quality of screening. The primary resource
needed is the commitment to take the time to ask the questions
and to be prepared to listen and help.
Shifting Priorities
Social problems like domestic violence challenge us to examine
what guidelines we use to justify routine screening. Surely,
the magnitude of the problem and the health consequences are
important considerations in deciding whether to routinely
screen for domestic violence. Domestic violence is a leading
cause of injuries to women (Stark and Flitcraft, 1981; McLeer
et al, 1989; Abbott et al, 1995). Victims of domestic violence
are more likely than non-victimized women to experience numerous
chronic health problems including depression, post-traumatic
stress disorder, chronic pain syndrome, gynecological problems,
irritable bowel syndrome, eating disorders, and complications
during pregnancy (Bostwick and Baldo, 1996; Drossman et al,
1995; Folingstad et al, 1991; Haber & Roos, 1985; Mullen
et al, 1988; Schei et al, 1989; Talley et al, 1994). If our
decision of which health issues to prioritize for screening
is based on targeting health issues that are prevalent in
our patient population and known to have a significant impact
on health status, then screening for domestic violence should
be at the top of the list.
Patients, both those with a history of abuse and those with
no history of victimization, believe that physicians should
screen for domestic violence (Friedman et al, 1992; McNutt
et al, 1999). The fact that the majority of male and female
survey respondents supported routine screening for domestic
violence is an important consideration for tailoring a health
care system that is responsive to patients' needs and concerns.
Screening as a Prevention Strategy
Prevention strategies are often examined within a framework
of three levels of prevention (Last and Wallace, 1992). When
the potential impact of domestic violence screening is assessed
within this framework, the advantages of routine screening
become apparent: the aim of tertiary prevention is to minimize
the consequences of a disease or health event. In terms of
tertiary prevention, screening victims of abuse provides the
opportunity for disclosure in a safe and confidential environment.
Every time a health care provider talks about domestic violence
with a patient who is being victimized, they are ending the
victim's isolation. Identifying the abuse, validating victims'
experiences and being supportive are the cornerstones of an
appropriate medical response to domestic violence. When you
suspect that a patient is being abused but the patient does
not disclose it, you can express your concern about her safety
and let her know that she has options. Survivors have emphasized
that even when they chose not to disclose their victimization,
the fact that their health care provider asked about the abuse
gave them a message that this person cared and would listen
if they ever wanted to talk.
Screening is usually considered to be a secondary prevention
strategy. The aim of secondary prevention is to detect a health
risk as early as possible to reduce the prevalence of disease
and disability. Early identification of an abusive relationship
can help victims to escape before the violence escalates,
the entrapment leads to further isolation and chronic health
problems limit patient's options. At this secondary level
of prevention, helping patients to understand that the abuse
will only get worse and the impact that it has on their health
and their children will allow them to make more informed choices.
Screening for domestic violence with patients who do not have
a history of abuse is an opportunity for primary prevention.
The aim of primary prevention is to preserve health by removing
the precipitating causes of departures from good health. Screening
informs patients that domestic violence is an important health
care issue and lets them know that you are a safe person to
talk to if they ever experience abuse or if someone close
to them is being abused. A health care provider's decision
not to screen compromises the quality of care that a patient
receives while contributing to the conspiracy of silence around
her abuse Focus groups with domestic violence survivors revealed
that many women felt that their abuse was "unimportant or
embarrassing" to health care providers who chose to focus
on the standard medical treatment without trying to understand
the underlying issue of abuse in their lives (Rodriguez et
al., 1996).
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When a community acknowledges the need for domestic
violence services, we often find previously undiscovered
resources for victims of domestic violence. Health care
providers can be the catalysts for a community identifying
resources and developing a coordinated response. Approximately
one hundred miles north of Anchorage, the small town
of Talkeetna (population: 363) is nestled at the foot
of a mountain range. The community health clinic has
a small staff that serves a huge, sparsely populated
area. The clinic is run by a dynamic physician's assistant,
Jessica Stevens, who became concerned about the number
of women coming in with symptoms of depression. She
was aware of the violence in some of these women's relationships
and called us to provide domestic violence training
for her staff. The clinic implemented routine screening
for domestic violence and was shocked by the number
of disclosures, but the closest women's shelter was
nearly 50 miles away. Even if a victim had access to
a vehicle, she would have to leave her community and
often deal with treacherous road conditions in the winter.
Jessica arranged for me to do a one-hour, call-in radio
show about domestic violence. From the volunteer-staffed,
public radio station located in a tiny log cabin with
no running water, we started what became a series of
radio programs about domestic violence. There was only
one caller that first night when I spoke -- Jessica.
She called in to encourage people to break the conspiracy
of silence about domestic violence. People were afraid
or reluctant to speak out at first. But slowly, people
willing to be a resource for victims came forward. A
survivor who did not want women to go through what she
did came forward, then a clergyman who was concerned
about the level of violence in the community. Female
elders at the senior center donated some money to help.
A support group started meeting one evening a week at
the clinic. Volunteers offered transportation for women
who decided that they needed to leave their community
to seek refuge at a women's shelter.
The clinic and the regional women's shelter worked
together to hire a domestic violence advocate. The process
of integrating advocacy into the health care setting
has not been easy -- it has been difficult to recruit
someone who is willing to relocate and live on a modest
income in a remote community and volunteer efforts have
waned since the advocate joined the clinic staff. This
small clinic has weathered each obstacle while demonstrating
that routine screening can provide the foundation for
a community to identify and build upon existing resources
while strategizing to address unmet needs. Now the community
goal is to open a domestic violence shelter.
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A Quality of Care Issue
Choosing not to screen for domestic violence when victim
services are unavailable locally suggests a very narrow interpretation
of the purpose of screening. On numerous occasions, health
care providers who have participated in training and integrated
screening into their practices have provided feedback to us
about the insight they have gained when a patient disclosed
abuse that they never had suspected. Accurate diagnosis relies
on determining if domestic violence is an underlying issue.
The quality of care is compromised when the potential role
of domestic violence is not evaluated.
A patient's history of victimization should be taken into
consideration during case management. Withholding prescriptions
and limiting access to health care services are common tactics
of abusers that must be taken into account when determining
a treatment plan. Health care providers need to know about
the current violence in a patient's life as well as any past
history. Survivors of abuse may continue to have higher medical
utilization for a variety of health problems for years after
the abusive relationship has ended (Bergman and Brismar, 1991).
Redefining Success
Perhaps some of our concern about screening for domestic
violence when there are no local services available is based
on a misperception of what constitutes success when intervening
for domestic violence. When someone is being victimized, it
is natural for us to want to remove a victim from the harm
in other words, tell a victim to leave their abuser. In fact,
domestic violence survivors have expressed concern that health
care providers will take control of the situation without
the women's permission rather than encouraging them to make
their own decisions (Rodriguez et al, 1996; McNutt et al,
1999). Addressing domestic violence in the clinical setting
does not fit neatly into a medical model. We cannot fix the
problem. We need to redefine success in terms of increasing
a patient's understanding of her situation, educating her
about the health implications of abuse for herself and her
children, informing her about resources, and most of all,
enhancing her safety.
Victims of domestic violence may not go to a shelter or advocacy
program even when the services are available in their community.
There is no one solution for victims to end the violence in
their lives, but there is one universally applicable goal-promoting
safety behaviors for victims and their children. A 20-minute
intervention protocol with pregnant women who were abused
led to a significant increase in victims' safety behaviors
during and after pregnancy (McFarlane et al, 1997). Whether
or not there is a shelter or a victim chooses to use local
services, an efficient and effective protocol to promote safety
behaviors is an appropriate strategy to use with all victims
of abuse.
When considering what options are available for victims living
in communities with no shelter or advocacy program, remember
that a domestic violence shelter that is hundreds of miles
away from your clinical setting can still be a resource. A
victim can talk with an advocate on the phone, discuss safety
planning and arrange transportation if she must seek refuge
outside of her community. For victims who cannot access local
or regional resources, providing the toll-free National Domestic
Violence Hotline (1-800-799-SAFE) can be a lifeline.
A Message from the Outhouse
About a year ago, I received a phone call from a health aide
who lived in a village above the arctic circle. She was the
primary health care provider for her community and had participated
in our train-the-trainers workshop. As a trainer, she was
expected to organize two educational activities on domestic
violence in her village. She had called me to withdraw as
a trainer. When I asked her why, she told me that the head
of the village council was a batterer. She was afraid to talk
about domestic violence in her village. We brainstormed about
what might be safe for her to do. She decided that she would
put domestic violence posters in the public outhouses (there
is no running water in the village).
Six months later I got a phone call from a woman in that
village who had seen one of our posters on an outhouse door.
She did not call the day that she saw the poster. She waited
until she felt that it was safe and then made the call to
get more information. Her call is a reminder that often doing
a little can mean a lot for victims of domestic violence.
Phone calls like this are how we define successÑ ending the
isolation, making connections and letting victims know about
options.
Start Today
The purpose of screening for domestic violence is about much
more than making referrals when abuse is disclosed and the
absence of domestic violence services in your community does
not negate the value of screening. Whether you practice in
a resource rich city with an extensive network of victim services
or you are the only clinician in a rural or isolated town,
your words can make a difference in the lives of domestic
violence victims. They need to know that you care and that
it is OK to talk with you about the violence in their lives.
In the words of Dr. Maureen Longworth, a physician in Juneau,
Alaska, "It begins with me and it begins now."
Linda Chamberlain, PhD, MPH, is the founding director
of the Alaska Family Violence Prevention Project. She serves
on the Board of Directors for the National Women's Health
Network and holds affiliate faculty appointments with Johns
Hopkins School of Hygiene and Public Health and the University
of Alaska, specializing in injury epidemiology and family
violence. She conducts workshops on domestic violence, the
relationship between domestic violence and child abuse, and
its effects on children throughout the United States and eastern
Russia. In her spare time, Linda is a dog musher.
Complete references for noted articles available online
at www.fvpf.org/health/.
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