PREVENTIVE STRATEGIES TO IDENTIFY VIOLENCE AGAINST

WOMEN (VAW) BY COMMUNITY HEALTH

WORKERS (CHW’S), NURSES, AND OTHER CAREGIVERS IN

THEIR HOMES Amy Ansehl, DNP, FNP-BC1

Executive Director ,Partnership for a Healthy Population

Associate Professor and Director of Public Health Practice NYMCSHSP

Padmini Murthy MD, MPH,MS,MPhil, CHES, FRSPH2

Associate Professor Dept. of Health Policy and Management

Global Health Director NYMCSHSP

Agustina Lopez Novillo MPH3

Assistant Director Public Health Practicum

NYMCSHSP

LEARNING OBJECTIVES

Identify a minimum of 5 signs of VAW that present in a home care setting.

Describe between 3 and 5 unique factors that contribute to the increased risk of VAW in a homebound population.

Discuss between 4 and 7 public health strategies to address VAW locally and globally.

INTRODUCTION Violence against women (VAW) is a global threat. It is

pervasive across all cultures and economic groups. World-wide women living in economically disadvantaged areas are at an even greater risk.

According to WHO (2013), 35% of the female population is impacted by this grave threat.

While VAW can occur in a range of settings, it most commonly occurs in the home, with 74.9% of all assaults against women as young as 15 years old occurring in this setting. (WHO 2011)

Developing a population–based approach to train care providers such as nurses and CWH’s to recognize the warning signs of violence and identify those women who are at greater risk is of paramount importance.

WHY DO WE NEED TO ADDRESS VAW?

It is estimated that one in every five women faces some form of violence during her lifetime, in some cases leading to serious injury or death. (WHO Report 2005)

Women make up approximately 66% of elder abuse victims in the United States, and 89% of the cases of abuse occur in a domestic setting. (OWL Report 2009)

Health Canada, the Federal department responsible for health care in Canada, estimated that the direct medical costs of all forms of violence against women was 1.1 billion Canadian dollars. (WHO 2011)

Violence against women is a major threat to social and economic development. The social and economic costs VAW are enormous and have ripple effects throughout society.(WHO Report 2005)

TYPES OF VAW Physical Abuse : includes being handled inappropriately by care

givers. Financial Abuse: miss use of property or financial resources without

consent or understanding. Emotional Abuse: threats of harm or abandonment, belittling,

isolation, and intimidation. Sexual Abuse: including demanding or expecting sexual activities in

return for favors. Abuse specifically related to health condition: such as medication

mismanagement, refusing to provide essential care, and disabling of equipment.

Sources: World Health Organization 2010; US HHS Office on Women’s Health, 2011; OWL Report 2009

VAW WITH SPECIAL NEEDS Women with disabilities are more likely to experience

physical and sexual violence, increased severity of violence, multiple forms of violence and longer duration of violence. (Powers et al. 2009)

A survey of 200 women with disabilities found that 67% of the women had lifetime experiences of physical abuse and 53% had experienced lifetime sexual abuse. (Powers et al. 2009)

Institutionalized adult women with disabilities reported a 33% prevalence of having ever experienced interpersonal violence (IPV) versus 21% for institutionalized adult women without disabilities. (Barrett et al. 2009)

STRATEGIES FOR ASSISTING PEOPLE WITH SPECIAL NEEDS

Assistance for Mobility Impaired persons Ask for permission to move. Make eye contact and communicate at eye level. Facilitate communication by offering alternative positions.

Assistance for Visually Impaired persons Repeat your name and introduce others by name and title when

initiating contact. Describe the layout of the room in detail. Assist with completing forms after reading them aloud to the patient.

Source: Westcop Victims Assistance Services, 2014

STRATEGIES FOR ASSISTING PEOPLE WITH SPECIAL NEEDS

Assistance for Hearing Impaired persons Approach from the front. Find out proffered mode of communication (lip reading, sign

language, writing etc.)

Assistance for Non-Verbal or Verbally Impaired persons Always use adult vocabulary. If communication is not clear ask the patient to rephrase

rather than repeat.

Assistance for developmentally disabled persons Set aside extra time for counseling sessions. Avoid condescending, patronizing treatment. Source: Westcop Victims Assistance Services, 2014

FACTORS CONTRIBUTING TO INCREASED RISK OF VAW

Social/Cultural Factors Patriarchal thinking, women are thought of as being lesser than men, and lack of

educational opportunities.

Economic Factors Economic dependence of women on men and lack of equal pay.

Gender Stereotypes Beliefs in family honor and sexual purity.

Political/Legal Factors Lack of access and understanding of the legal system.

Psychological Factors Fixed gender norms reinforcing the notion that women should be submissive, passive,

and subservient.

Source: Issues in Mental Health Nursing, 2012

WARNING SIGNS OF VAW IN HOME CARE SETTINGS

Chronic, vague complaints that have no obvious physical cause.

Injuries that do not match the explanation of how they were sustained.

History of depression or mental illness. A history of attempted suicide or suicidal

thoughts. Delay between injury and the seeking of

treatment.

Source: The Lancet 2011

ROLE OF NURSES, CHWS, AND OTHER CARE GIVERS IN IDENTIFYING ABUSE Listen. Screen the patient privately with the assurance of

confidentiality. Ask questions in a non-judgmental way. Create a supportive non-judgmental environment. Be alert for “red flags” such as injuries that do not

match the explanation of how they were sustained, chronic, vague complaints that have no obvious physical cause etc.

Source: World Health Organization 1997

ROLE OF NURSES, CHWS, AND OTHER CARE GIVERS IN IDENTIFYING ABUSE

Document observations objectively and do not make assumptions.

Immediately report. Do not confront family members. Provide medical care if needed. Refer patients to available community resources.

Source: World Health Organization 1997; Westcop Victims Assistance Services, 2014

BARRIERS TO IDENTIFICATION, ASSESSMENT, AND INTERVENTION. Health care workers lack of time and support resources. Work overload. Health care workers fear of offending the woman. Inadequate training and prejudiced beliefs. Care giver fear of opening “Pandora's box”. Practitioners may feel helpless about their inability to “fix” the

situation or influence a patient’s decision. Frustration at the perceived lack of responsiveness of patients to

care giver advice. Lack of community resources and referral networks for abused

women. Isolation of victims by their abuser. Fear of perpetrator retaliation. Fear of legal implications.

Source: Pan America Health Organization 2003

PREVENTION OF VAW Primary prevention: Involves intervening before

violence has occurred. Prevent perpetration by targeting root causes such as inequality between the sexes, social norms, and substance misuse.

Secondary prevention: involves immediate response to survivors through services such as medical treatment, counselling, protection, and legal assistance.

Tertiary prevention: encompasses long term responses directed at rehabilitation and reintegration of survivors and perpetrators.

Source: British Medical Journal, 2013

PUBLIC HEALTH STRATEGIES TO ADDRESS VAW

Raise awareness and encourage reporting of abuse by displaying posters and leaflets on VAW in health care settings.

Provide space in health care settings for self-help support groups. Development of protocols for all relevant clinical settings. Provide information and referral services by ensuring physical accessibility to

facilities and 24-hour access to transportation, interpreters and communication assistance.

Develop training manuals and implementing training for health providers that challenges them to address issues of power and abuse in their own lives, at work, and in society.

Integrate violence against women or family violence content in medical school curricula of health care providers, and focusing on helping them understand the dynamics by which abused women make decisions.

Development of stronger partnerships with non-governmental organizations that have been working with women.

Source: World Health Organization 2013

TRAINING HEALTH CARE WORKERS TO SUPPORT ABUSED WOMEN

Identify and prioritize the patient’s fears, dangers and needs.

Validate women’s experience and address her abusive environment as such.

Educate women on the importance of communicating and reporting abuse.

Inform women of their rights.

Source: Bulletin of the World Health Organization 2008

TRAINING OF HEALTH CARE WORKERS TO ADDRESS VAW

Regular training of health workers that addresses their own values and attitudes and provides specific skills.

Health providers need to relate to the experiences of women and support them in their decisions, while trying to increase their safety.

Provide HCW’s training on appropriate screening procedures and interview techniques.

Health care workers need to work with other organizations that provide support services to abused women, enlist local leaders, and promote development of social sanctions for men who abuse women.

Source: World Health Organization, 2005; International Journal of Gynecology and Obstetrics,2006

INTERVENTIONS IN HEALTH CARE SETTINGS

The level of intervention that is appropriate will vary between settings depending on the availability of human and financial resources and of services to which health workers can refer women.

Protocols, training, and information should be adapted to the specific needs of each setting.

Interventions can involve screening programs, providing referral to a shelter, and working with other stakeholders to empower women, and give them information on their rights.

Source: USAID 2010

TESTED INTERVENTIONS FOR THE TREATMENT AND CARE OF ABUSED WOMEN

Providing access to a woman’s shelter. Group counseling to discuss options for support. Facilitating economic skills building to promote

economic stability of women.

Source: Issues in Mental Health Nursing, 2012

PROPOSED STRATEGIES FOR THE EMPOWERMENT OF WOMEN

Health Based Microfinance: Microfinance has considerable impacts on women’s self-confidence, decision making, and empowerment, and it prepares women for addressing inequality issues at the family and community level.

Family-Based Models: Involvement of males in programs to curb VAW. Family-based models can build trust and a sense of safety and to increase dialogue between women and their partners and other family members, and between women and their health care providers

Source: Issues in Mental Health Nursing, 2012

OPPORTUNITIES FOR INTERVENTION TO REDUCE VAW

Education: Public education campaigns against violence.

Legal Reforms: gender friendly laws and assurances that women have legal recourse under which they can be protected.

Infrastructure: Existence of supportive infrastructure through non-governmental organizations (NGOs) that have established support systems for women.

Media: Media allows civil society to work to educate and empower women who are victims of VAW.

Source: Issues in Mental Health Nursing, 2012

CONCLUSION Health services are increasingly recognized as being able to play an

important part in addressing violence against women, especially in secondary and tertiary prevention.

Public health complements existing approaches to violence, which are mainly reactive, by focusing on changing the behavioral, social, and environmental factors that give rise to violence.

A health-care provider is likely to be the first professional contact for survivors of domestic violence or sexual assault.

The health sector can contribute to public education efforts to address attitudes, behaviors, and cultural norms that perpetuate violence.

An effective response from the health sector to women living with violence will include regular training of health workers, and development of protocols for all relevant clinical settings. In addition, better recording and sharing of experiences across settings is needed, and every setting will need to assess barriers and opportunities to solve this problem.

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