FVPF eJournal
Futures Without Violence eJournal
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Trainings to Integrate Sexual and Domestic Violence Screening into Family Planning Settings: Key Components for Success

by Jill Clark, MPH and Beth Nagy, MPH

Jill Clark, MPH
Massachusetts Department of Public Health, Family Planning Program

Beth Nagy, MPH
Massachusetts Department of Public Health, Division of Violence and Injury Prevention

Background

Massachusetts and national statistics are clear that violence is prevalent in many women’s lives.  In the United States today, one-quarter to one-third of all women report experiencing domestic or sexual violence (Tjaden & Thoennes, 2000), and in Massachusetts, 15% of girls report experiencing dating violence (Massachusetts Departments of Elementary and Secondary Education [MDESE] and Public Health [MDPH], 2008).  Unfortunately, these experiences may be much more widespread than these numbers suggest, since sexual and domestic violence remains heavily underreported.

Sexual and domestic violence are important public health issues that affect many individuals, including those served by all types of public health programs.  In 2002 the Massachusetts Department of Public Health (MDPH) conducted a grant-funded self-assessment of important issues facing a wide variety of maternal and child health programs.  These programs included nutrition programs such as WIC, early intervention, family planning, and home-visiting programs.  Consistent with current knowledge about the prevalence of violence, the survey results showed that 93% of MDPH respondents dealt with issues of domestic violence in their programs, even when violence prevention and response was not the primary goal of the program.

Survey results showed that 93% of MDPH respondents dealt with issues of domestic violence in their programs, even when violence prevention and response was not the primary goal of the program.

The findings from this self-assessment prompted MDPH to promote the integration of violence prevention and screening into a variety of public health programs.  These efforts were bolstered by the Massachusetts Safe Families project, part of a collaboration of the Association of Maternal Child Health Programs (AMCHP) and the Family Violence Prevention Fund (FVPF).  The Safe Families Project brought together a wide variety of partners to work on integrating sexual and domestic violence prevention and response into maternal and child health programs, and provided a natural springboard for launching a training program for family planning providers and others.

Development of the Family Planning Training

MDPH staff, in close collaboration with the FVPF, provided trainings on sexual and domestic violence screening in the family planning setting.  The MDPH Family Planning Program funds clinical family planning and reproductive health services—including medical exams, contraception, testing and treatment for sexually transmitted diseases, and client-centered counseling—throughout Massachusetts.  Twelve agencies are funded to provide these services in more than 80 clinical locations.  Annually, these agencies provide important services to over 98,000 clients (MDPH, 2008), many of whom are low-income and un- or under-insured.

The training was developed with the intention of reaching as many family planning providers as possible—both clinical providers (e.g., nurses and nurse practitioners) as well as non-clinical providers (e.g., family planning counselors).  In order to reach the greatest number of providers and be as relevant as possible to the family planning setting, a number of key elements were critical to the success of the training.

First, to maximize the number of providers who could attend, as many trainings as possible were held locally or onsite at the family planning agency.  The trainings were also scheduled in conjunction with the agencies to ensure convenient timing, to minimize conflicts with clinic scheduling, and to ensure minimal impact for clients.

Prior to the trainings, each agency was asked to complete the Family Violence and Reproductive Health Program Assessment Tool to establish a baseline of violence screening practices at each agency.  The tool, which is available at www.endabuse.org, asks detailed questions about policies and procedures for sexual and domestic violence screening, staff roles, types of sexual and domestic violence for which clients are screened, intervention and referral strategies, training, and data collection.  This tool was helpful to document the starting point of each agency with respect to violence screening, but it also had two important secondary roles.  First, the information provided by completing the assessment tool allowed each training to be tailored to the specific characteristics of the individual agency, making the training more relevant and more effective.  Second, completing the assessment tool was also informative for the family planning agencies, as it suggested leverage points where violence screening could be incorporated into the flow of the family planning visit.  Some sample questions from the assessment tool are shown in Box I.

Box I:  Sample Questions from the Family Violence and Reproductive Health Program Assessment Tool

Assessment Methods

  • Does your family planning program have a written protocol for screening and responding to clients for intimate partner violence?  Sexual assault?  Child abuse?
  • How are clients screened for domestic and sexual violence?
  • Which staff are primarily responsible for screening clients for domestic and sexual violence?
  • How often are clients screened for domestic and sexual violence?

Intervention Strategies

  • Does the family planning program staff have resource lists?  Who is responsible for updating the lists?  How often are they updated?

Networking and Training

  • Do your protocols advise staff on what to do if they do not feel comfortable or adequately skilled to help a client when domestic and sexual violence is disclosed?
  • Is there a buddy system or internal referral to assist staff when they are overwhelmed or uncomfortable addressing violence with a client?
  • What type of training(s) do new family planning staff receive re: domestic and sexual violence?  Do staff receive booster training at least once a year?

Staff Safety and Support

  • Does your family planning program have a protocol for staff experiencing domestic and sexual violence?  A protocol for what to do if a perpetrator is on-site and displaying threatening behaviors?

Data and Evaluation

  • Does your family planning program record the number of clients screened for domestic and sexual violence?  Record the number of clients who disclose domestic and sexual violence?  Annually review all protocols relating to violence?

Environment and Resources

  • Does your family planning program have brochures or information about domestic and sexual violence that clients can take?  Have posters about domestic and sexual violence been displayed?

Each training session also included staff from local sexual and domestic violence resources.  This was a critical component that facilitated networking, collaboration, and the development of referral resources.  Key personnel from domestic violence agencies, rape crisis centers, sexual assault nurse examiner programs, and shelters attended the trainings.  This allowed family planning and sexual and domestic violence staff to make face-to-face connections with one another, improving referral relationships for clients in the future.  Instead of referring clients to an agency, providers could now make a specific referral to an individual whom they knew.  Including staff from sexual and domestic violence programs in the training also allowed for peer education among providers, increasing each others’ competency in their areas of expertise.

Key Training Concepts

Although each of these structural factors was important to the success of the trainings, the key component was the training content.  Providers in a busy clinical setting needed to understand the importance of violence screening to their work, and to develop strategies for including sexual and domestic violence concepts into their existing clinical practice.  The key concepts that helped to make the case for the importance of sexual and domestic violence screening in family planning settings were the linkages between the experience of violence and health, and the concept of reproductive coercion.

The Connection between Sexual and Domestic Violence and Health

Research has demonstrated strong linkages between a lifetime experience of violence/trauma and adverse health outcomes.  The landmark Adverse Childhood Experiences (ACE) study by Felitti and colleagues (1998) demonstrated profound connections between early traumatic experiences and an increased risk of adult chronic disease and death.  This research provided some of the most compelling evidence that violent experiences can have an effect on health outcomes.  Other work has documented connections between violence experiences and health behaviors; that is, people who have experienced violence are more likely to engage in behaviors that put their health at risk.  This connection was explored in depth at the trainings for family planning providers.  For example, providers learned that:

  • Girls who were sexually abused were twice as likely to have their first sexual intercourse before 16 years (Fergusson, Horwood, & Lynskey, 1997)
  • One out of two girls who experienced sexual abuse had more than five sexual partners by age 18 (Fergusson et al., 1997)

These risky behaviors, and others like them, were much more common among clients who had experienced abuse and were also associated with negative sexual and reproductive health outcomes.  Examples of the type of information that was shared with providers included:

  • Women disclosing physical abuse were three times more likely to experience a sexually transmitted infection than women not disclosing abuse (Coker, Smith, Bethea, King, & McKeown, 2000)
  • 40% of pregnant women experiencing abuse reported that the pregnancy was unwanted (vs. 8% of non-abused pregnant women) (Hathaway  et al., 2000)
  • Women presenting for a third or subsequent abortion were more than two and a half times more likely to report a history of violence compared to women seeking their first abortion (Woo, Fine, & Goetzl, 2005)
Providers quickly grasped that understanding the effects of violence on their clients’ lives and discussing the impact of violence with individual patients was not an “extra” task to be added on to an already busy clinical visit.  Instead, effectively screening for sexual and domestic violence would allow them to identify clients at greater risk for engaging in unsafe sexual behavior and to work with these clients to offer resources and strategies for improving their reproductive health as well as address the violence in their lives.

Educating providers about these statistics during the trainings energized and empowered family planning providers.  Providers quickly grasped that understanding the effects of violence on their clients’ lives and discussing the impact of violence with individual patients was not an “extra” task to be added on to an already busy clinical visit.  Instead, effectively screening for sexual and domestic violence would allow them to identify clients at greater risk for engaging in unsafe sexual behavior and to work with these clients to offer resources and strategies for improving their reproductive health as well as to address the violence in their lives.  In order to fully grasp the impact of sexual and domestic violence—especially experiences of violence in a client’s current relationship—providers needed to understand their client’s experiences through a lens of reproductive coercion.

The Concept of Reproductive Coercion

Reproductive coercion is a dimension of inter-personal violence related to reproductive health.  Reproductive coercion is an attempt to control or manipulate another person through their reproductive health.  Examples of reproductive coercion include, but are not limited to:  intentionally exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a woman against her will; intentionally interfering with a partner’s birth control, or threatening or acting violent if she does not comply with the perpetrator’s wishes regarding sexual activity, contraception, or the decision whether to terminate or continue a pregnancy.

Family planning providers were already familiar with the effects of reproductive coercion.  Many had worked with clients who repeatedly reported unprotected sex and unsuccessful use of contraception despite extensive counseling on safer sex methods and contraceptive use.  However, viewing a client’s health behaviors with an understanding of the impact of violence on sexual and reproductive health behaviors, and with a reproductive coercion lens, allows previously invisible experiences of violence to suddenly become visible to reproductive health providers.  Clients that repeatedly request emergency contraception may be unable to effectively use other contraceptive methods because of a controlling or violent partner.  Clients with unintended pregnancies may have become pregnant against their wishes.  Clients who do not practice safer sexual behaviors may have a history of violent experiences and relationships.  Using a lens of reproductive coercion, each of these clients becomes a priority for sexual and domestic violence screening and, if she discloses violence in her past or present relationships, she receives support and collaborative referrals to appropriate services.

Without screening for violence, family planning providers might never elicit the root causes of many sexual and contraceptive behaviors that prevent many clients from staying healthy, successfully preventing pregnancy, and having healthy relationships.

This knowledge constituted a fundamental shift in the way family planning clients’ behaviors are understood, and energized family planning providers to do more for their clients.  Family planning providers began to understand quality, sensitive, and appropriate sexual and domestic violence screening as integral to their success as providers of family planning services.  Without screening for violence, family planning providers might never elicit the root causes of many sexual and contraceptive behaviors that prevent many clients from staying healthy, successfully preventing pregnancy, and having healthy relationships.  This results in missed opportunities for contraceptive counseling, education on reducing risk behaviors, and referrals to supportive services.

Furthermore, the experiences that many clients had disclosed to family planning providers were eye-opening to domestic violence and rape crisis staff.  Although sexual and domestic violence program staff were used to hearing about the direct effects of violence, many had never asked their clients questions about their reproductive health or barriers that they experienced to safe sex and effective contraception.  Hearing about family planning clients’ experiences of reproductive coercion educated the sexual and domestic violence program staff about these issues and suggested new questions they might ask their clients.  These connections also encouraged support and referral of sexual and domestic violence provider clients to family planning programs.  Sexual and domestic violence providers learned about strategies for successful contraception in the context of a relationship characterized by reproductive coercion, such as “invisible” contraception like injectables, implants, or IUDs.

To support enhanced screening in the context of the connections between violence and health and reproductive coercion, family planning providers requested specific tools for use in a clinical setting.  In close partnership with the Family Violence Prevention Fund, tools were developed with provider input and disseminated at a follow-up training.  Providers were offered “scripted questions” that gave concrete examples for asking clients about violence in ways that were normalizing, non-judgmental, and relevant to the client’s present clinical concerns.  These materials were presented in many different formats—as detailed scripts, in list format, and on “flash cards” that could be carried in a pocket—in order to be helpful and relevant to the widest possible array of providers and clinical settings.  Some examples of the scripted questions and scripted responses appear in Box II.

Box II:  Sample Scripted Questions and Responses
Scripted questions for an emergency contraception (EC) visit
I’m glad you know about EC. I ask all my patients who come in for EC:  Do you think your partner was trying to get you pregnant when you didn’t want to be?  Tell me how you felt about the sex that led up to you needing EC.
Scripted questions for a positive STI test
Do you feel comfortable sharing the results of your test with your partner?  What do you think will happen?  Are you worried your partner will blame you for the STI?  Are you worried your partner will hurt you?  Can we help you to tell your partner?
Scripted responses when the client is experiencing reproductive coercion
“This isn’t right and it isn’t your fault.”  Discuss ‘invisible’ birth control.  Follow up by saying things like:  “I’m worried about you.”

  • Offer support and validation
  • Address immediate safety issues
  • Refer to resources

Training Outcomes

Providers were enthusiastic both at the initial training and the follow-up training where the tools were introduced.  Nearly all participants in the first round of training felt that the training was helpful and that their assessment skills were enhanced by the training.  Participants’ feedback described how the training had influenced their screening practices.  Comments included that screening for sexual and domestic violence is “totally relevant to the work that I do,” and that “repeat pregnancy tests and terminations could be red flags for DV, not necessarily teens trying to get pregnant.” Providers also reported that they were “able to think of questions in a new way, with an understanding of the purpose.” After the second trainings focused on the provider toolkits, participants were similarly positive, reporting that exercises and materials were helpful and that the training provided them with new knowledge and skills.  Participants also appreciated the focus on usable tools.  One participant commented that the best thing about the training was the focus on “how to talk to patients and language to use.  I have been to several trainings but none have done so until now!”

The 12 MDPH-funded family planning agencies are periodically reviewed by MDPH staff for compliance with the Family Planning Program Standards.  An expectation for routine sexual and domestic violence screening of all family planning clients is included in the Program Standards.  Since the completion of the trainings, three agencies have been reviewed; at all three agencies, counselors were observed conducting appropriate and relevant sexual and domestic violence screening.  Site reviews will continue and additional sites will be assessed.  Most importantly, implementation of the training has raised awareness about the importance of sexual and domestic violence screening among both MDPH staff as well as providers, ensuring that violence screening is assessed as one of the key aspects of good family planning counseling.

Lessons Learned and Future Directions

Although the trainings appear to have been successful in increasing awareness among providers and increasing screening for sexual and domestic violence in family planning settings, some aspects of the program could be improved in subsequent trainings or in implementation in other states.  First, the trainings described above were a collaborative work-in-progress between MDPH and FVPF.  The toolkit materials and trainings on practical skills emerged over time with input from both organizations as well as the family planning agencies themselves.  With the benefit of hindsight, providing some of the practical skills and toolkit materials earlier would have reinforced the important training messages as well as given providers tangible tools to use immediately following the completion of training.

Second, there are many opportunities to provide additional tools and technical assistance to the family planning providers that could be utilized.  Providers and administrators may need assistance to update documents such as medical record forms, counseling protocols, and referral documentation in order to complete the transition to new approaches to violence screening.  Especially at larger, more complex agencies, support and technical assistance may be needed to overcome administrative barriers that can delay the implementation of sexual and domestic violence screening indefinitely.

Finally, provisions for ongoing sustainability of screening must be addressed.  Staff turnover is a very important issue to address, resulting both in loss of trained staff at family planning agencies as well as loss of personal referral connections between family planning and sexual and domestic violence programs.  Institutionalizing the expectation of both violence screening and relationship building among community-based programs is critical.  One way that relationship building has been institutionalized in Massachusetts is a programmatic standard that family planning programs and rape crisis center programs meet for cross-training at least once a year.  This standard has been incorporated into the standards for both MDPH-funded family planning programs as well as MDPH funded rape crisis center programs.

However, even if expectations for ongoing training and relationship building have been institutionalized, resources are needed for refresher trainings to ensure that new staff are familiar with the connections between sexual and domestic violence and reproductive health and coercion.  One option may be developing a training curriculum that can be delivered to provider agencies and conducted in-house for new hires.  Ensuring that violence screening is expected by funding agencies (in this case, the MDPH Family Planning Program) is also critical to monitoring performance and ensuring sustainability.  Standards about sexual and domestic violence screening should be explicit, informed by the latest scientific evidence, specific, and enforced.

Ultimately, implementation of violence screening in family planning settings can be accomplished with limited resources.  The key is the providers themselves:  offering compelling evidence that violence screening enhances client outcomes, both directly and indirectly related to reproductive health, and encouraging providers to offer screening in an environment where they will be supported both personally and with effective referral resources for their clients.  Offering training and support to providers that achieves these goals can increase violence screening and improve outcomes for family planning clients.

References

Coker, A.L., Smith, P.H., Bethea, L., King, M.R., & McKeown, R.E. (2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9(5), 451-457.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. & Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245-258.

Fergusson, D.M., Horwood, L.J. & Lynskey, M.T. (1997). Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child Abuse and Neglect, 21(8), 789-803.

Hathaway, J.E., Mucci, L.A., Silverman, J.G., Brooks, D.R., Mathews, R., & Pavlos, C.A. (2000). Health status and health care use of Massachusetts women reporting partner abuse. American Journal of Preventive Medicine, 19(4), 302-7.

Massachusetts Department of Public Health Family Planning Program. (2008). Family Planning Program Summary of Service Data from 12 Program Annual Reports, Fiscal Year 2007. Boston, MA.

Massachusetts Departments of Elementary and Secondary Education and Public Health. (2008). Health and Risk Behaviors of Massachusetts Youth, 2007. Boston, MA.

Tjaden, P. and Thoennes, P. (2000). Extent, Nature, and Consequences of Intimate Partner Violence. Findings From the National Violence Against Women Survey.  Washington, DC: National Institute of Justice, Centers for Disease Control and Prevention.

Woo, J., Fine, P., & Goetzl, L. (2005). Abortion disclosure and the association with domestic violence. Obstetrics and Gynecology, 105, 1329-1334.