Essential Health Care Services Addressing Intimate Partner Violence (2024)

8

Recommendations¹

The Committee on Sustaining Essential Health Care Services Related to Intimate Partner Violence During Public Health Emergencies carefully reviewed the available evidence about intimate partner violence (IPV) and public health emergency (PHE) planning and response, leading to the committee’s eleven recommendations for Health Resources and Services Administration (HRSA) consideration. Following its thoughtful review and debate of compelling evidence, the committee recommends the following actions.

Essential Health Care Services

The committee used the Social Ecological Model to guide their understanding of the health care needs of women experiencing IPV and to identify the essential health care services related to IPV. That process was also informed by the Care Coordination Model’s guidance that high-quality referrals and transitions to resources outside of the traditional health care system are a key component of effective health care delivery. This led the committee to conclude that the health consequences of IPV often require care that extends beyond the traditional health care system.

In order to identify the essential health care services related to IPV, the committee’s review of evidence included several literature searches; recommendations from the U.S. Preventive Services Task Force (USPSTF), the Women’s Preventive Services Initiative (WPSI), and the World Health

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¹ This chapter does not include references. Evidence and citations to support the text and recommendations herein are provided in the body of the report.

Organization (WHO); and insight gleaned from presentations to the committee and a commissioned paper by experts in IPV-related care. This analysis identified numerous serious and high prevalence adverse health effects associated with experiencing IPV. Those adverse health outcomes fall in the following categories: acute physical injuries, gynecologic and reproductive health issues, perinatal and obstetric health issues, behavioral health issues (including mental health and substance use), and other chronic health issues that are either exacerbated by acute IPV or related to experiencing long-term IPV. A discussion of these conditions can be found in Chapter 4 as well as in Appendix B. The committee concluded that the essential health care services related to IPV were those that addressed the most common and most serious health conditions associated with experiencing IPV and those that facilitate disclosure and protect the safety of those experiencing IPV and their children, if needed. Recommendation 1 outlines the committee’s recommendation as to what health care services related to IPV are essential. A detailed discussion of these services can be found in Chapter 5. The committee concluded that given the prevalence of IPV, it is likely that all U.S. health care systems provide care for women experiencing IPV. Therefore, the committee designated all U.S. health care systems as the responsible entities in this recommendation.

IPV disclosure is frequently the first step in accessing IPV-related health care services. Universal IPV screening is meant to facilitate that disclosure. However, women who are not aware of available resources or who feel that their clinician does not have time or is disinterested in addressing IPV are less likely to disclose. Universal IPV education that is either active (such as conversations about healthy relationships) or passive (such as prominently displayed posters and brochures) can reduce those perceptions. Additional discussion of the barriers to IPV disclosure can be found in Chapter 2 and additional discussion of universal IPV screening and education can be found in Chapter 5. Notably, both the USPSTF and WPSI recommendations for universal IPV screening include a recommendation to provide or refer a woman who screens positive for IPV to care and support services. Women who experience IPV are at high risk for traumatic brain injuries and mental health disorders, which make it difficult for them to navigate the often complex processes of accessing needed health care services. Warm referrals, in which a clinician directly connects an individual to referred services instead of simply providing a phone number or the address of a web site, are critical to facilitating access to essential health care services related to IPV during steady state conditions and PHEs.

Reducing Health Inequities

Many of the populations that experience health inequities also report a greater prevalence of IPV. This includes minoritized racial and ethnic populations, those living in historically under-resourced communities (both rural and urban), people with low incomes, and sexual and gender minority populations. A more detailed discussion of populations disproportionately affected by IPV can be found in Chapter 2. This interaction exacerbates the negative health consequences of experiencing IPV. Women from these populations face substantial barriers to accessing essential health care services related to IPV. These barriers are discussed in detail in Chapter 5. The committee concluded that just as all U.S. health care systems are likely to care for people experiencing IPV, all U.S. health care systems have a responsibility to ensure that they deliver IPV-related health care services that are consistent with the needs of the populations they serve.

Prevention for Adolescents

Many adults report that they first experienced IPV as an adolescent. Sadly, IPV is a common experience for adolescents. This is discussed further in Chapter 2. Adolescence is a period of complex biologic, cognitive, and social–emotional development, which makes it an important period for prevention strategies that can disrupt the developmental pathways toward IPV. The Centers for Disease Control and Prevention (CDC) developed guidance that includes specific prevention strategies for adolescents. While adolescents experience IPV in forms similar to those experienced by adults, the approach to their IPV care requires unique considerations. Confidentiality is especially important for adolescents. The presence of a trusted adult can support disclosure. School- and youth-based settings offer unique opportunities for disclosure and connection to care. Tailored IPV services for adolescents are critical to ensuring that this vulnerable population has access to appropriate, confidential care.

Essential Health Care Services Related to Intimate Partner Violence in Public Health Emergencies

The committee was tasked with identifying the essential health care services related to IPV during PHEs and strategies to ensure access to those health care services during PHEs. The committee began this process by asking “Does the list of essential health care services related to IPV during steady state conditions change during PHEs?” The committee considered evidence from U.S. policy and WHO guidance regarding essential health care services during the COVID-19 pandemic, and the adverse health effects related to experiencing IPV. This is discussed further in Chapter 6. The committee concluded that a health care service is essential due to its impact on

health, not situational pressure. Therefore, the same health care services related to IPV that are essential during steady state conditions are essential during PHEs. However, health care systems face substantial obstacles to care delivery during PHEs. The committee sought to balance the need to deliver these essential health care services related to IPV with the reality of PHE-induced obstacles to care delivery. The committee drew on the Federal Emergency Management Agency’s (FEMA’s) Community Lifelines approach to develop a phased approach to delivery of essential health care services related to IPV during PHEs. This approach prioritizes those services that are essential for protecting life safety for immediate access, with other services that are essential but less time sensitive restored throughout PHE response as resources become more available. A discussion of the committee’s application of the Community Lifelines approach can be found in Chapter 6. The committee defined three phases of PHE response for the purpose of this report, which organize this phased approach. These phases are defined below:

• The initial or immediate-response phase occurs while the situation is unstable and unknown before supplementary resources can be deployed to the affected area or resources within the community can be redirected. During this phase, the disaster health responders’² efforts are focused on saving and sustaining life using limited resources. This is also the point at which initial requests for additional resources are made.
• The response operations phase occurs once the health care system and associated jurisdictional authorities have assessed the incident and have stood up relevant incident coordination structures. During this phase, disaster health responders have begun to receive additional resources such as supplies and staff to support temporary care delivery sites. At this point, while health care delivery capacity has increased beyond life-saving and -sustaining activities, resources are not adequate to support full delivery of all essential health care services related to IPV for all individuals.
• The stabilization phase occurs when basic lifeline services have been provided to PHE survivors, either by rapid reestablishment of those services or through the employment of a contingency response solution. At this point all essential health care services related to IPV are available for all individuals.

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² For the purposes of this report, disaster health responders are the leaders and staff with expertise in public health and health care who are working and providing care in those settings during response to a PHE.

The committee prioritized delivery of essential health care services related to IPV that are most integral to protecting life safety during the initial phase of PHE response. In some cases, specific components of an essential health care service are essential for protecting life due to the severity and time-sensitive nature of certain IPV-related health conditions or are critical for women from groups that have an elevated risk for life threatening outcomes, such as pregnant women. Then, as health care staff and supplies become more available, the full essential health care service can be delivered more broadly. However, the committee emphasizes that all of these services are essential to IPV care regardless of the phase in which they recommend it be restored. These services are discussed in Chapter 5, and the phased model for restoration of services is discussed in Chapter 6. The phased model outlined in Recommendation 5 and the accompanying table (Table 8-1) are designed to balance the restoration of these essential services with the delivery challenges posed by PHEs.

TABLE 8-1 Essential Health Care Services for IPV During Public Health Emergencies—A Phased Return to Steady State

Planning and Operationalization of Intimate Partner Violence Care During Public Health Emergencies

The professionals who serve as disaster health responders during PHEs are expected to effectively deliver care in high stress and often unpredictable conditions. Given the increased prevalence and severity of IPV associated with PHEs, they are likely to encounter women who have experienced physical and psychological trauma related to IPV that may be compounded by trauma related to the PHE. Disaster health responders must be provided with adequate resources in the form of knowledge and skills, protocols, and supplies to ensure that they can effectively care for women experiencing IPV during PHEs. These resources are crucial for sustaining delivery of essential health care services related to IPV.

The committee took a pragmatic approach to developing recommendations targeted at facilitating delivery of essential health care services related to IPV during PHEs. The committee was intentional in their identification of the entity responsible for carrying out those recommendations. For example, the committee recognized that not all state, local, tribal, and territorial (SLTT) jurisdictions are organized in the same manner, with varying structures and titles for those agencies and offices responsible for emergency planning. Therefore, the committee concluded that naming specific agencies or offices at the SLTT level in recommendations for those entities could lead to confusion and contribute to a delay or failure of a jurisdiction to act on those recommendations. The recommendations in this section were developed to address key gaps that the committee identified in PHE preparedness and associated protocols related to IPV care that negatively affect both access to care for women experiencing IPV during PHEs and disaster health responders’ ability to provide that care. A discussion of these gaps can be found in Chapter 7. These gaps include:

• standard guidance and best practices for the development of IPV care protocols for disaster health responders,
• public-facing PHE response plans that specifically address IPV care and formal coordination with community-based IPV care providers,
• training specifically focused on IPV for disaster health responders that is easy to find and access, and
• protocols to ensure medical supply caches for use in PHE response include all necessary items for delivery of the essential health care services related to IPV.

Disaster health responders come from diverse health care backgrounds, and some professions may not include IPV identification or care as part of their

training. Additionally, they may not regularly care for women experiencing IPV in their steady state roles. Given that PHEs are associated with increases in IPV prevalence and severity, disaster health responders are likely to encounter women who have experienced IPV and need care. Adequate training provides disaster health responders with the knowledge they need to recognize that a woman is experiencing IPV and provide or connect her to the care she needs. Chapter 7 highlights opportunities for drawing on existing training mechanisms and structures to incorporate training about IPV for disaster health responders. The committee concluded that the Administration for Strategic Preparedness and Response (ASPR) and HRSA were well suited to develop and disseminate training and guidance for IPV care during PHEs in light of each entity’s experience and existing structures that could support such efforts.

Well-designed protocols are necessary to guide an effective PHE response. The existing guidance for development of IPV care protocols for disaster health responders is limited in nature and scattered across different documents from different entities. However, the committee identified international guidance, such as that developed by WHO and the United Nations Population Fund (UNFPA) that can inform development of guidance for domestic protocols. Chapter 3 discusses the committee’s findings pertaining to protocols for IPV care during PHEs. It was common for existing U.S. guidance to discuss IPV as part of domestic violence or to only discuss domestic violence, framing IPV in the context of families with children and relationships with both partners living in the same home. This can lead planners and disaster health responders to overlook the possibility of IPV in families who do not have children, couples who do not live together, or former intimate partners. As previously noted, disaster health responders may not regularly provide care for women experiencing IPV in their steady state roles. They also may be reallocated to provide care in settings and geographic locations that differ from where they work during steady state

conditions. This makes protocols for IPV care during PHEs that are based on standardized guidance an important tool for ensuring disaster health responders can effectively deliver essential health care services related to IPV.

Protocols for sustaining essential health care services related to IPV need to be incorporated into PHE planning at the federal and SLTT levels. Emergency Support Function 8 (ESF 8) of the National Response Framework, particularly the Public Health and Medical Service Annex of ESF 8, create a uniform structure with associated responsibilities at the federal level. Additional information about federal structures to guide PHE response planning can be found in Chapter 3 and Appendix A. However, SLTT jurisdictions vary in their organizational structure and allocate emergency planning responsibilities differently. The committee concluded that given the increased prevalence and severity of IPV associated with PHEs and the unique needs of women experiencing IPV during PHEs, emergency planning entities at all jurisdictional levels need to incorporate expertise in IPV care delivery. Additionally, community-based organizations are also frequently involved in responding to PHEs. Their staff are often trusted members of the community who have unique and critical knowledge about and credibility in their community. These groups are also frequently involved in providing IPV-related care. Representatives from these organizations can bring an important perspective to PHE response planning bodies. Their involvement can also increase community trust in those planning bodies.

• At the state, local, tribal, and territorial government level, IPV care planning and coordination should be assigned to a specific office or division that is part of the emergency planning or emergency management team.
• At all levels, jurisdictional emergency planning teams should include representation from social service providers and IPV-related community-based organizations to ensure that strong partnerships exist between disaster health responders and the organizations providing care for IPV survivors.

There are several federal sources of emergency medical supply caches. These are discussed in Chapters 3 and 7. While these caches are typically supplemented by supplies maintained by private and SLTT actors, kits meant for acute deployment are pre-packaged and standardized. Many of the essential health care services related to IPV during PHEs are the same as those for individuals not experiencing IPV. However, there are some unique and critical supply considerations, particularly related to caring for a woman who has experienced IPV-related sexual assault or rape. The committee found that standard protocols to guide the allocation of resources, such as supplies and medications, specific to providing IPV care in austere settings or in disrupted health care environments during PHEs are not currently widely available in the United States. However, international guidance, particularly the guidelines included in the UNFPA Inter-Agency Emergency Reproductive Health Kits for Use in Humanitarian Settings can inform domestic supply plans. This international guidance is discussed in Chapter 7. The committee acknowledges that those located in certain geographic areas in the United States may encounter challenges procuring specific and vital supplies for IPV care, such as emergency contraception or supplies needed for pregnancy termination. However, the committee emphasizes that emergency medical caches should include all of the necessary supplies to support delivery of all essential health care services related to IPV, regardless of geographic location.

Intimate Partner Violence Research

Early in the committee’s deliberations, it was evident that data for the prevalence of IPV in the U.S. population has key limitations that negatively affect evidence-based care and prevention as well as evidence-based policy making related to IPV. Population-based surveys and clinic-based studies use varied terminology and reporting items when collecting IPV data. The variations in terminology and reporting items are discussed further in Chapter 2. This substantially limits the nation’s ability to estimate the prevalence of IPV and restricts comparisons between datasets. It also creates barriers for data sharing. Inconsistent terminology across studies leads to substantial differences in what information is represented in each study’s data and data categories. That precludes aggregation of shared data from across studies into common categories that would inform accurate analysis. These inconsistencies in terminology also limit the ability to compare outcomes across intervention studies. CDC sought to address these inconsistencies when it released its first version of Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements in 1999 and an updated version in 2015. However, the guidance in this document has not been widely adopted.

Accurate and comparable prevalence data are critical for identifying populations that need additional targeted support and for tracking the effects of that additional support. Inconsistent and inadequately designed approaches to collection of demographic information have led to under-representation and erasure of some historically minoritized populations in data analyses, such as American Indian and Alaska Native women and Pacific Islanders. This is discussed further in Chapter 2. Standardized data reporting rules, including requiring the use of standard definitions for types of IPV and the collection of accurate demographic data, would greatly improve the accuracy of prevalence estimates for IPV. Standardized data reporting rules would also allow for the development of a more robust literature on promising models and practices for IPV care.

The committee identified several key gaps and limitations in the IPV-related research literature specific to this study’s statement of task. These include:

• population-based studies of individual IPV intervention outcomes and the effectiveness of those interventions during steady state and PHE conditions;
• comparative effectiveness studies of adequate size to inform development of best practices for IPV identification and care in the health care setting during steady state and PHE conditions;
• population-based studies of the effects of different types of PHEs on IPV severity and prevalence;
• large population-based studies of IPV in populations that experience health disparities; and
• studies that clarify the occurrence and nature of harms associated with IPV screening and, if any harms are identified, best practices for reducing or avoiding those harms.

Numerous programs exist to help women experiencing IPV. However, beyond small-scale studies, there have been few efforts to evaluate the effectiveness of individual interventions. There are unique challenges associated with conducting IPV research that likely contribute to the relatively small study populations of many IPV-related studies. These unique challenges are discussed further in Chapter 1. Unfortunately, small populations limit the representativeness of the data. It is difficult to develop an understanding of IPV among minoritized populations without data that include adequate representation of those populations. While some in the fields of IPV care and advocacy have voiced concern about the potential harms associated with IPV screening, there is limited research available that clarifies the link between IPV screening and these harms or that elucidates the best practices to mitigate them. A more robust body of evidence about the degree to which such harms exist and effective strategies to reduce or prevent those harms can inform IPV screening and education protocols and reduce provider hesitancy around screening. Additionally, studies investigating the interaction between PHEs and IPV are limited and primarily focused on the recent COVID-19 pandemic. PHEs vary greatly. While the all-hazards³ approach is generally the standard for planning and preparation, it is applied with the

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³ An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to prepare for, respond to, and recover from the full spectrum of emergencies or disasters, whether human-made or natural. The committee notes that their application of an all-hazards approach acknowledges that not all disasters and emergencies are identical, nor are their effects on different populations and communities.

understanding that different types of PHEs will require some differences in response activities. For example, response to an infectious disease outbreak may require the affected community to shelter-in-place and limit interactions with people from outside their homes for a period of time. However, response to a wildfire usually requires people to evacuate their homes, often to congregate shelters and unfamiliar locations. The different responses needed to address different types of PHEs affect communities differently. A greater understanding of whether and how different types of PHEs (infectious disease outbreaks, wildfires, oil spills, hurricanes, etc.) interact differently with IPV can provide important insight for all involved in IPV care and PHE planning. Strengthening the data and research infrastructure is core to developing a better understanding of how to reduce the incidence of IPV and how to best care for women who experience IPV. The committee concluded that HRSA is well-positioned to support efforts to address these gaps and build a more robust evidence base.

FINAL THOUGHTS

The committee’s recommendations address gaps in knowledge about the essential health care needs related to IPV as well as its prevalence, effects, and effective interventions. They also build on HRSA’s strategy to address IPV. Further, these recommendations offer specific guidance for incorporating IPV care into PHE planning for emergency planners and health care systems and ways to increase access to quality IPV-related health care services across all populations. If adopted, these recommendations will facilitate improvements in the health and well-being of women experiencing IPV, support disaster health responders to care for those women, and contribute to reducing health disparities in the United States.