Innovative Strategies for Dealing With Interpersonal Violence During the Perinatal Period

Phyllis W. Sharps, PhD, RN, FAANProfessor and

Associate Dean for Community and Global Programs

1. Describe patterns of IPV and impact on maternal and child health.

2. Discuss experiences of HVs and women related to IPV screening and intervention.

3. Describe strategies from Domestic Violence Enhanced Home Visiting Intervention.

Session Overview

Intimate partner violence (IPV) is a major public health problem

Two recent large and population based studies of women estimate prevalence IPV rates of 8% in the past year and 9.8% in the past 2 years

Perinatal IPV - IPV that occurs during the childbearing year - has significant consequences for:◦ Women◦ Pregnant and Parent Women◦ Infants and very young children

Patterns of IPV

Statistical Overview 1 in 4 women are raped and/or physically assaulted by

a current or former spouse, cohabitating partner or date at sometime in their life (Tjaden & Thoennes, 2000).

Two recent studies, each more than 3,500 women reported the prevalence of IPV just under 8% for the past year and 9.8% for the past 2 years (Thompson et al, 2006; Walton-Moss, Manganello, Frye & Campbell, 2005)

Health Consequences Traumatic injuries Long term physical health consequences (headaches, STDs,

chronic backaches)

Long term mental health consequences (depression, low self-esteem, PTSD)

(Campbell, 2002; Campbell& Humphreys, 2004; Walton-Moss et al, 2005).

Patterns of IPV

Statistical Overview Recent studies estimate that 3% to 19% of pregnant women

report being abused during the childbearing year – before, during or after the pregnancy (Campbell, Garcia-Moreno & Sharps, 2000).

Health Consequences Poor Maternal Outcomes

◦ Physical health consequences -late entry into/no prenatal care, poor weight gain, preterm delivery , pregnancy loss

◦ Mental health consequences - depression, low self esteem, PTSD, substance use

Poor Fetal and Neonatal Outcomes ◦ Pre-term delivery; Pre-term birth, low birth weight, fetal injuries (Bullock et

all, 2001; Marin et al, 1998; Murphy et al, 2001;).

Women are at risk for intimate partner homicide, before, during and after of

the pregnancy (McFarlane , Campbell, Sharps & Watson, 2002) & IPH is the major cause ofmaternal mortality

Perinatal IPV

PATTERNS OF IPV DURING PREGNANCY (Ballard et. al., ’98)

Protective period Women beaten before and after – (30%)

Risk period May start during pregnancy (24%) – especially

first pregnancy -“Business as usual”

IPV neither increases or decreases (75%) (Martin ’01; Saltzman ‘03)

Patterns of IPV During Pregnancy

Type of Abuse Changes Physical abuse may lessen or stop but

emotional abuse, controlling behaviors stay same or increase (Castro ’03)

Teens at Greater Risk Higher prevalence of abuse during pregnancy

among adolescents than adult women (Parker, McFarlane ’93)

Each year 3-10 million children are affected by IPV (Campbell & Lewandoski, 1997)

More than 20 years of research have reported the following consequences

of IPV for children's physical and socio-emotional health such as:

Depression, poor self-esteem, anxiety, aggression, poor peer relations, poor academic performance,

Physical health symptoms, under immunization Adolescent risky behavior (Bair-Merritt, et all, 2006; Baldry, 2003;

Holden, 2003; Fantuzzo, et al, 1991; Fredland et al, 2008; Kernic et al, 2002; Polillo, 2003).

IPV and Children

Phyllis W. Sharps, PhD, RN, FAAN, PIJohns Hopkins University School of Nursing

R01NR009093/NINR

Domestic Violence Enhanced Home Visitation Program

(DOVE)

Purpose of DOVE

Rigorous test of structured IPV intervention

DOmestic Violence Enhanced (DOVE) Home Visitation Program 2 Sites

Urban – Baltimore City HD Urban – Missouri HD Rural – Missouri HD

Design RCT Mixed methods – quantitative & qualitative Urban HD (women and infants)

Eligible women = R→ DOVE vs. UC Rural HDs (women and infants)

12 HDs = R→ 6 HD DOVE vs. 6 UC NFP (Olds HV model; mothers and infants)

DOVE vs. Olds database DOVE is a HV intervention for abused pregnant

women DOVE protocol is screening + brochure based brief

counseling intervention

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Research Team Linda Bullock, PhD, RN, FAAN, Co-PI

University of Virginia School of Nursing

Jacquelyn Campbell, PhD, RN, FAANJohns Hopkins University School of Nursing

Shreya Bhandari, PhD Wright State University

Jeanne Alhusen, PhD, RN Johns Hopkins University School of Nursing

Ifeyinwa Udo, DrPHBaltimore City Health Department

Camille Burnett, PhD, RN University of Virginia School of Nursing

Project Team

Baltimore/Urban Project Coordinator

Kim Hill, MPH DOVE Intervention Nurse

BCHD – Keauna Williams DOVE Research Nurse

K. Marcantonio K. Wells Iye Kanu

Doctoral/Post-Doc Students Jeanne Alhusen, PhD, RN Marguerite Baty, PhD, RN Rachel Klemick, PhD, RN

(started as UG Honors Research student)

Missouri/Rural • Project Coordinator

• Richard Tayloe, MS• Dove Research Nurses

• Karen Rupright• Kelly Moore• Kathleen Ellis

• Doctoral/Post-Doc Students• Shreya Bhandari,

PhD• Chiunghsin Chang,

PhD

Baseline DemographicsDemographic

CharacteristicsDOVE

SampleN= 124 (52%)

% (n)

Usual Care Sample

N= 115 (48%)% (n) p value

Mean Age 24.3 23.4 0.18

Racial Background: African American White Non-Hispanic Other

43.9 (54)44.7 (55)11.4 (14)

51.3 (59) 40.0 (46)8.7 (10)

0.49

Education: Less Than High School HS graduate/GED Some College/Trade Trade school College/ trade school

grad

40.5 (49)26.4 (32)23.9 (29)

9.1 (11)

41.1 (46)24.1 (27)22.3 (25)

12.5 (14)

0.84

Marital Status: Single Partnered/Not Married Married Other

52.0 (64)24.4 (30)14.6 (18)8.9 (11)

49.1 (56)26.3 (30)7.9 (9)

16.7 (19)

0.14

Employment Status: Employed FT Employed PT Unemployed

12.2 (15)11.4 (14)12.2 (15)

12.2 (14)20.9 (24)12.2 (14)

0.12

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IPV Mean Scores

Violence Indicator

DOVE

Usual Care

Baseline (n=124)

12M(n= 89)

24M(n= 52)

Baseline (n=115)

12M(n= 81)

24M(n= 55)

Conflict Tactics Scale(IPV)

*** p<.001

48.5 10.1 2.6***

44.7 10.3 9.7

Violence Scores

Trajectory of IPV Scores: DOVE vs. Usual Care

Baseline 12 M 18 M 24 M - (p<.01)

DOVE 48.5 10.1 5.2 2.6

Usual Care

44.7 10.3 8.7 9.7

5

15

25

35

45

55

DOVE Usual Care

Pp <.01

Other Findings

IPV screening in HV program for pregnant women is safe and feasible

DOVE can be integrated into HD HV programs

Good retention (80%) in HV programs –even when asking about IPV

DOVE reduced self reported IPV DOVE group still less IPV at 24 M PP

UC reduced IPV too asking frequently/screening – without

specific counseling may be important 17

Home Visitors Expressed Concerns

Fears Making a fool of myself – not knowing how

or what to say Fear of “stirring the pot” Fear of how to handle the abuser if he

walks in

Concerns – if she is IPV+ Lack of resources Not knowing what to do next Fear of increasing her harm

Home Visitors Strengths

Successful strategies used by HV Building relationship, rapport and trust Bringing up IPV casually in the conversation Using non-judgmental body language Educating her on “normal” relationships Showing respect

How did the training workshops change practice:

Re-thinking “stirring the pot” – decreasing my own fear

Safety measures that can be used if the abuser walks in

Increased self-realization that I may be hurting my client and outcomes trying to achieve if I do not address the violence

Lessons Learned

HV have both personal and professional issues that need to be considered when addressing IPV

IPV training for HV is essential, needs to be on-going, and needs to address the HV own history of violence

HV working with the DOVE study were frustrated at times with the lack of resources in rural and urban areas but realized that just letting the women in their caseload discuss the violence is a powerful intervention in itself

NIH/NICHD – R01 HD071771

Perinatal Nurse Home Visitation Home Visitation Enhanced with

mHealth (DOVE 2)

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Next Steps: New Study

Perinatal Nurse Home Visiting Enhanced with mHealth technology R01 funded by NICHD Computer tablets for HV

IPV screening – Nurse w/tablet vs. client completes

Deliver DOVE – nurse-assisted vs. client Spanish translation

Study Aim = to increase identification & intervening of IPV during pregnancy

DOVE 2

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Intervention Nurse HV Same evidence-based DOVE intervention

Design RCT – 2 arms

1. Nurse Assisted - Paper& Pencil screening + DOVE intervention

2. Tablet Assisted - Tablets for screening + DOVE intervention Spanish translation

Random Assignment

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Paper & Pencil IPV

Screen

Computer Tablet IPV

Screen

DOVE Brochure

Intervention

DOVE Computer

Tablet Intervention

Screen Shots

DOVE WEBSITE

http://www.son.jhmi.edu/research/dove

psharps1@jhu.edu410-614-5312

Thank You !!!29