Apr 7, 2011
Home Visiting Programs’ Response to Intimate Partner Violence: What We Know and Why It Matters for the Health of Our Children
by Megan H. Bair-Merritt, MD, MSCE
Megan H. Bair-Merritt, MD, MSCE
200 North Wolfe Street, Office 2021
Baltimore, MD 21287
Phone: (443) 287-8954
Home visiting programs across the United States vary with regard to specific elements of model implementation such as frequency, duration and timing of visits, and educational background of the home visitors. Despite differences in design, however, most home visiting programs target families deemed to be at-risk for adverse outcomes; depending upon the study, ~15-45% of families enrolled in home visiting programs report intimate partner violence (IPV) (Chamberlain, 2007). Additionally, all home visiting programs are united in their goal to optimize maternal and child health. In order to most successfully achieve this overarching goal, home visiting programs should include standardized protocols to assess for IPV and to provide assistance both to women experiencing abuse and to the children exposed to this violence.
The following article describes why inclusion of IPV-specific content is an important component of ensuring excellent child health, what is known in the scientific literature about the impact of home visiting programs on IPV, and what interventions are currently being studied as options for adding IPV- specific content to home visiting models. Finally, recommendations are made for translating research to practice. Complementary information can be found in the Davis, James, & Stewarts’ (2010) guide for policy makers on IPV and home visiting.
Why is the inclusion of IPV screening and response important in ensuring excellent child health?
Childhood exposure to IPV independently predicts poor child health and development. Thus to maximize children’s well-being, IPV must be recognized and addressed, and mothers’ health, safety and positive parenting skills must be supported.
The National Scientific Council on the Developing Child (2005) defines a toxic stressor as â€œstressful events that are chronic, uncontrollable, and/or experienced without the child having access to support from caring adultsâ€ (p. 1); such stressors activate children’s stress response system, with chronic activation of this system potentially leading to permanent physiological changes which have been associated with adverse health outcomes (National Scientific Council on the Developing Child, 2005). Childhood IPV exposure is a particularly potent â€œtoxic stressâ€ for children because it is often chronic and uncontrollable, and it may impact caregivers’ ability to engage in positive parenting practices (Levendosky, Leahy, Bogat, Davidson, & von Eye, 2006).
Childhood IPV exposure has been associated with poor social-emotional child health outcomes from infancy through adolescence (Kitzmann, Gaylord, Holt, & Kenny, 2003; Holt, Buckley & Whelan, 2008). Infants exposed to IPV may exhibit signs of traumatic stress such as frequent crying and inability to comfort, particularly when their mothers have experienced severe abuse and have resultant symptoms of post-traumatic stress disorder (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006). Toddlers display excessive separation anxiety, increased aggression with peers and lower social competence (Howell, Graham-Bermann, Czyz, & Lilly, 2010). School age children frequently blame themselves for the IPV, and are at increased risk for both internalizing (e.g. anxiety, depression) and externalizing (e.g. aggression) disorders (McFarlane, Groff, O’Brien, & Watson, 2003; Hazen, Connelly, Kelleher, Barth, & Landsverk, 2006). Finally, adolescents exposed to IPV are more likely than their peers to engage in risk-taking behaviors such as substance use and abuse, and risky sexual behavior (Holt, et al., 2008). Teenagers exposed to IPV are also more likely to enter into relationships characterized by dating violence (Holt, et al., 2008).
Emerging evidence also supports that children exposed to IPV are at increased risk of a host of physical health problems (Bair-Merritt, Blackstone, & Feudtner, 2006). Boynton-Jarrett, Fargnoli, Suglia, Zuckerman, & Wright (2010) reported that children exposed to â€œchronicâ€ IPV had an 80% increase in odds of obesity at 5 years of age. Suglia, Enlow, Kullowatz, & Wright (2009) found that IPV-exposed children develop asthma at twice the rate of children not exposed. Interestingly, however, Suglia et al. (2009) found that IPV-exposed children were protected from this increase in asthma incidence if there were high levels of positive maternal-child interaction. This latter finding suggests that interventions that strengthen the relationship between a supportive caregiver and a child, such as home visiting, may help to buffer the adverse impact of IPV on child health.
Finally, children exposed to IPV have altered, and sub-optimal, health care use patterns. These children are less likely to attend regular well-child care with a primary provider, and are more likely than non-exposed peers to be under-immunized (Bair-Merritt, Crowne, Burrell, Caldera, Cheng, & Duggan, 2008). When severe IPV is occurring, they may be more likely to visit the emergency department (Bair-Merritt, Feudtner, Localio, Feinsten, Rubin, & Holmes, 2008). In general, children exposed to IPV incur ~20% higher health care costs than children who are not exposed (Rivara, et al., 2007).
The presence of IPV may limit home visiting programs’ ability to prevent child maltreatment.
The American Academy of Pediatrics states that â€œidentifying IPV may be one of the most effective means to prevent child abuse…â€ (Thackeray, et al., 2010; p. 1094). This statement is based in part on the common co-occurrence of child maltreatment and IPV. Review studies have estimated that the median overlap in at-risk samples is between 30 and 60% (Appel & Holden, 1998; Edleson, 1999).
Some home visiting programs have had documented success in reducing child maltreatment (Bilukha, et al., 2005). However, an analysis of data from Nurse-Family Partnership in Elmira, New York found that while, in general the home visiting program reduced child maltreatment, rates did not decrease significantly when frequent IPV was present (Eckenrode, et al., 2000). Thus, IPV is the proverbial â€œelephant in the room.â€ Without properly addressing violence within the caregivers’ relationship, efforts to prevent child maltreatment may fall short.
What is known in the scientific literature about the impact of home visiting programs on IPV?
The evidence is limited, and existing study findings need to be replicated in other home visiting programs.
A review conducted by Bilukha et al. (2005) examined the relationship between home visiting and the prevention of myriad types of family violence. This review concluded that there was insufficient evidence to determine if home visitation was associated with reduced rates of IPV and called for further research in this area. Several studies, however, have examined the impact of home visiting on IPV. For example, reports from the Nurse-Family Partnership in Denver, Colorado found lower rates of IPV for nurse-visited women when children were four years of age (Olds, et al., 2004), but no program effects on IPV for women in Memphis at 6 or 12 year follow-ups (Olds, et. al., 2004; Olds, et al., 2010).
Bair-Merritt, et al. (2010) recently published a study using data from the Hawaii Healthy Start Program (HSP) to determine whether home visiting was associated with reduced rates of both maternal IPV victimization and perpetration. Results indicated that in the home visiting group, as compared to the control group, rates of IPV victimization decreased and rates of IPV perpetration decreased significantly during the three years of program implementation when children were aged 1 to 3 years. At long-term follow-up when children were 7 to 9 years of age, rates of IPV victimization and perpetration decreased for both intervention and control mothers but there were no longer statistically significant differences between the two groups (Bair-Merritt, et al., 2010).
The recent Hawaii HSP study raises two important issues that warrant further comment. First, measurement and definitions are important if IPV is a primary outcome of interest. It is preferable that IPV not be viewed as â€œpresentâ€ or â€œabsent,â€ but that researchers and program evaluators consider program impact on frequency or rates of IPV; while the ultimate goal is cessation of IPV, reduction in frequency also may be beneficial to maternal and child health. Also, when considering child impact, IPV victimization and perpetration should both be considered.
Second, an association existed between home visiting and reduced IPV even though Hawaii HSP home visitors reported discomfort with their knowledge about IPV, and did not consistently link women experiencing abuse with resources (Duggan, et al., 2004). This reticence to ask women about IPV has been documented in other home visiting studies as well (Tandon, Parillo, Mercer, Keefer, & Duggan, 2008). Reductions in IPV instead may have been related to the home visitors’ encouragement of maternal self-efficacy and to the longitudinal relationship of the mother and home visitor.
Finally, recent evidence suggests that the ability of home visitors to form trusting relationships with mothers, and to potentially reduce IPV, may relate to the mother’s attachment status and depression. Using data from Healthy Families Alaska, Duggan, Berlin, Cassidy, Burrell & Tandon (2009) found that the program had a differential impact on IPV based upon the mother’s baseline depression and attachment status. Specifically, the program attenuated IPV, but only with depressed mothers who scored low to moderate on baseline measures of discomfort with trust/dependence (Duggan, et al., 2009).
What IPV interventions are currently being studied as enhancements to home visiting models?
Recognizing IPV identification and response as a critical part of home visiting, sites across the country are testing the effectiveness of IPV-specific content delivered during home visiting. Two of these projects are detailed here with additional promising programs detailed in the Davis, James, & Stewarts’ Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment. A Guide for Policy Makersâ€ (2010).
With funding from Centers for Disease Control and Prevention through the West Virginia University Injury Control Research Center, investigators from several academic centers are conducting a study to develop and evaluate a model of an in-home IPV intervention for mothers enrolled in the Nurse Family Partnership program (NFP). Â For phase 1 of the studyâ€“ development of the IPV interventionâ€“ qualitative case study methods have been used. Â The intervention is currently being pilot tested for feasibility and acceptability. Â The second phase of the study will involve a cluster randomized controlled trial (RCT) to test the effectiveness of the NFP plus IPV intervention compared with the existing NFP model in improving the client’s quality of life and reducing the recurrence of IPV. Â NFP sites are currently being recruited for the RCT; enrollment of participants is planned to start in the fall of 2010.
The DOmestic Violence Enhanced Home Visitation (DOVE) Project is a National Institutes of Health (NIH/NINR) funded research project conducted over 5 years as a collaborative effort between Johns Hopkins University, the Baltimore City Health Department, the University of Missouri, and Missouri Department of Health and Senior Services. The DOVE intervention is a highly-structured public health nurse-administered IPV home visitation program, designed to educate new mothers who screened positive for IPV and reduce their overall risk of continued IPV. To date 257 women have been recruited. Initial results show that, compared to control mothers who did not receive the intervention, women in the DOVE group reported significantly lower physical and sexual IPV scores at delivery (p<.05). At 18 months post- delivery, DOVE participants reported lower overall total IPV scores and lower scores on negotiation and psychological IPV (p<.05) as measured by the Conflict Tactics Scale. These reductions are a promising trend and provide evidence that integrating IPV-specific content into existing home visiting programs may reduce IPV against pregnant and parenting women.
How can research best translate to policy and practice?
To most effectively promote children’s healthy growth and development, home visiting programs should include IPV-specific content.
Although writing such a recommendation is easy, translating research to practice is challenging, and must be done with significant forethought and care. Some flexibility in IPV-specific program content is important to meet the individual needs of the communities that each program serves. However, several general recommendations can be made:
1. Home visitation programs should include explicit, evidence-based content designed to screen for and address IPV. Emerging results from trials such as the NFP study and DOVE should help to inform the use of evidence-based practices. Until results of these trials are disseminated, existing literature about efficacious IPV interventions tested in non-home visiting settings may be a useful guide. For example, Kiely, et al. (2010) reported results from a randomized controlled trial of a tailored IPV counseling intervention that was delivered to women in prenatal clinics. The authors found that women who received the intervention group experienced lower odds of recurrent IPV (Kiely, et al., 2010).
2. Once the IPV-specific content is integrated into home visiting models, an implementation system must be put into place to ensure that home visitors acquire, maintain and apply the skills necessary to enact this content. For example, the ability to successfully implement IPV-specific content may differ based on qualities of the home visitor or the family, and the implementation system needs to specifically address these issues. This likely will take an investment in time and money to train, supervise and coach home visitors, and must include an honest assessment of barriers to screening and management.
3. Programs should routinely assess fidelity. As discussed in #2, a well-conceived implementation plan with quality improvement initiatives may foster model fidelity (Rubin, 2010).
4. If IPV-specific content is delivered with fidelity, programs should consider if this content is effective; however, program evaluators must decide a priori how they will define and measure effectiveness. This likely should include outcomes related to the home visitor (such as knowledge of IPV and its impact on children and awareness of community-based IPV resources) and the caregiver (such as rates of IPV, steps taken toward safety planning, connection with community-based IPV resources). To assess whether IPV is ongoing, one option is administering a validated IPV measure at regular intervals. Repeated screening may be necessary because it is common for caregivers to transition into and out of violent relationships (Bair-Merritt, Ghazarian, Burrell, & Duggan, submitted). Caregiver reporting of frequency, severity and directionality of IPV also may be helpful in evaluating program effectiveness in reducing IPV.
5. A related consideration is whether there are circumstances in which the content is more or less effective, and how the content should be modified to best meet the needs of families for whom it is less effective.
The focus of this issue of the e-journal on the intersection of home visiting and IPV is timely given the recent federal funding of home visitation programs as part of health reform. Moving ahead, close collaboration between researchers, practitioners, advocates and policy makers is needed to optimize the delivery of IPV-specific content as part of the home visitation model.
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