Essential Health Care Services Addressing Intimate Partner Violence (2024)

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Sustaining Intimate Partner Violence Services During Public Health Emergencies

ESSENTIAL HEALTH CARE SERVICES DURING PUBLIC HEALTH EMERGENCIES

The World Health Organization (WHO) has described the process of prioritizing essential services during a public health emergency (PHE) as “context relevant.” In its Maintaining Essential Health Services: Operational Guidance for the COVID-19 Context (June 2020), WHO provided the following list of high-priority categories (WHO, 2020, p. 6):

• Essential prevention measures for communicable diseases, including immunizations;
• Services related to reproductive health, including during pregnancy and childbirth;
• Care for vulnerable populations, such as infants and older adults;
• Provision of medications and supplies to support the ongoing management of chronic diseases, including mental health conditions;
• Uninterrupted critical inpatient care;
• Management of emergency health conditions and common acute presentations that require time-sensitive intervention; and
• Auxiliary services, such as basic diagnostic imaging, laboratory, and blood bank services.

While intimate partner violence (IPV) is not specifically called out here, the committee found this guidance to be a helpful resource to identify priorities. A recent study on U.S. policy responses to maintain essential

health services built off WHO’s guidance and defined essential services in this way: “Essential health services—including services for human immunodeficiency virus (HIV) infection and/or acquired immunodeficiency syndrome (AIDS), tuberculosis, malaria, routine immunization, noncommunicable diseases, nutrition and reproductive, maternal, newborn, child and adolescent health—are foundational to primary health care and vital for protecting population health” (Gurley et al., 2022, p. 168). Disruption to these services was found to increase mortality and widen existing inequities in care (Gurley et al., 2022). This study highlights two important aspects of defining some health care services as essential. First, they are essential in relationship to their impact on human health, not based on situational pressure. For example, malaria care is essential regardless of whether there are COVID-19 based pressures on the health care system. Essential health care services related to IPV will similarly be based on the conditions and sequelae that co-occur with IPV. A discussion of the most common health conditions related to IPV, as well as their impact on human health, can be found in Chapter 4. Second, there are documented existing inequities in accessing this care (Wasserman et al., 2019). That is, just because services are designated as essential does not mean that they are currently broadly available in all locations even in steady state conditions, let alone during PHEs. The committee acknowledges these services are unevenly available throughout the United States. The committee also notes that essential health care services are determined by the health care needs of populations and not the ability to provide them. Therefore, essential health care services retain their designation of essential, regardless of a system’s status in the disaster cycle.

The committee sought to address the balance between essential health care services and the service obstacles created within a PHE. This led them to draw on the Federal Emergency Management Agency’s (FEMA’s) Community Lifelines approach and its associated toolkits, detailed in the current National Response Framework (DHS, 2019; FEMA, 2023). This approach designates critical Lifelines that support community function which should be stabilized and recovered during a disaster. One such Lifeline is Health and Medical, with public health as a key component (FEMA, 2023). By providing subsequent objectives leading to final stabilization of a given Lifeline, this framework both delineates which services are essential and outlines an order for the recovery of those services, given the constraints of the PHE.

The Community Lifelines Implementation Toolkit notes that the primary objective of the Lifelines is to ensure delivery of services critical to addressing immediate threats to life and property (FEMA, 2023). Medical services meeting that mark would be the first recovered (FEMA, 2023). However, the framework also states that the “network of assets, services, and capabilities that provide Lifeline services are used day-to-day to support the recurring

needs of the community and enable all other aspects of society to function” (FEMA, 2023). This means that after life safety is established, the other services needed for the full function of the community should be reestablished as well. While these are not less essential for human well-being, they are less time sensitive based on immense resource constraints during PHEs.

RESTORING ESSENTIAL INTIMATE PARTNER VIOLENCE CARE IN PHASES

The committee identified the essential health care services related to IPV during steady state conditions in Chapter 4. The committee then defined three phases of disaster response, described below (also see Figure 6-1), and delineated which essential services to reestablish during each phase (Table 6-1).

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, disaster health responders’ efforts are focused on saving and sustaining life using limited resources.¹ This is also the point at which initial requests for additional resources are made.

The response operation 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 the 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

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¹ 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.

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.

The committee identified these phases of restoration not only to guide prioritization of specific essential health care services, but also to identify those services that, once they have been identified as part of public health preparedness planning, can be included as part of the process of identifying necessary supplies for emergency stockpiles and can, in some cases, be provided by a variety of clinical staff. As Table 6-1 depicts, the committee identified the services that need to be prioritized and what services could be restored once response operations and stabilization are occurring according to response plans. Chapter 4 details the evidence to support the services in Table 6-1. The table prioritizes services that require immediate access even during PHEs and ones that cannot be expected to be delivered when resources are severely restricted.

TABLE 6-1 Essential Health Care Services for Intimate Partner Violence During Public Health Emergencies—A Phased Return to Steady State

The committee integrated the Community Lifelines approach in the development of a phased approach to sustaining and restoring essential health care services related to IPV. It 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 required to protect life. This is due to the severity and time-sensitive nature of certain IPV-related health conditions. In other cases, components are critical for averting serious or life-threatening outcomes in vulnerable patients, such as pregnant women. For example, during the initial phase of PHE response, a woman experiencing IPV with abnormal vaginal bleeding or discharge may have an urgent need for gynecologic care because these symptoms may indicate serious injury or infection that could rapidly progress to life-threatening hemorrhage or sepsis. In contrast, while timely preventive gynecologic care is essential for women’s health, a brief delay during the initial phase of PHE response is unlikely to immediately lead to an acutely life-threatening condition. Additionally, as previously discussed, unintended pregnancy as well as IPV during pregnancy are associated with serious adverse health outcomes, including fetal death and intimate partner homicide. Thus, women who have experienced IPV-related rape or IPV-related unintended pregnancy that need to prevent or terminate a pregnancy have a time-sensitive need to access care. Emergency contraceptive methods generally need to be initiated within 3-5 days of the assault (Mazer-Amirshahi and Ye, 2023). During times of limited availability of providers and medical supplies, it is logical to engage medical interventions that have the least intensive needs for both. Medication-based protocols for pregnancy termination do not require special equipment and do not have the multiple and prolonged staff needs associated with surgical procedures. However, these medications need to be taken during the first 70 days of gestation (Beaman et al., 2020). Therefore, this care cannot be deferred.

The committee also considered PHE-induced constraints related to staff and supply availability during PHE response in the development of this phased approach. During the initial and response operations phases in particular, health care systems may reallocate staff and supplies in the short term to treat life-threatening injuries and conditions. This was exemplified on a large scale during the initial response to the COVID-19 pandemic. Many hospitals assigned clinicians who did not typically staff the intensive care unit (ICU) to their ICUs and cancelled elective surgeries so that both staff and supplies could be directed to caring for the surge of seriously ill patients (Mathews et al., 2022; Kerlin et al., 2021). The committee prioritized components of essential health care services that protect life safety and can be delivered safely and effectively using the least staff and supplies. For example, some forms of contraception, such as intrauterine devices or subdermal

implants, require an office procedure and a specially trained clinician (Teal and Edelman, 2021). Such procedures usually require more than one staff member and additional supplies. Other forms of contraception can be delivered as an injection or pill (Teal and Edelman, 2021). Those forms of contraception require fewer staff members, less staff time, minimal supplies, and do not require a provider to be trained in a special procedure.

Universal education and screening are crucial for connecting women experiencing IPV to needed resources during PHEs, whether they seek care in traditional clinical settings or the various settings in which disaster health responders deliver care. However, the committee recognizes that during PHEs, health care delivery often occurs under substantial time constraints and levels of urgency, particularly during the initial phase of PHE response. As a result, universal IPV education in the form of substantial educational discussions may not be feasible. During this time, prominently displayed posters and easily accessed brochures can be used to make women aware of key IPV-related information and how to access resources. Posters can be displayed in a variety of places, including temporary health care facilities such as alternate care sites, vehicles used for transporting people affected by the PHE, and emergency shelters. Universal IPV screening can also be maintained throughout the PHE response phase but may need to be modified. For example, while most screening instruments involve several questions, screening during the initial phase of a PHE may need to be limited to one or two targeted questions due to the acute time constraints associated with caring for a high volume of people experiencing acutely life-threatening conditions. Disaster health responders will need to keep women’s health, safety, and privacy in mind when asking such questions, just as providers do when screening during steady state conditions. The committee acknowledges that during the initial and response operations phases of PHE response, there are some circumstances and settings in which universal IPV screening and education are not appropriate. For example, the initial encounter with a woman in the moments after she has been extracted from a building that was destroyed by a tornado is not an appropriate time for IPV screening or education because the focus of care must be on ensuring that she is medically stable.

Crisis Standards of Care and Resource-Limited Conditions

Crisis standards of care (CSCs) were conceptualized as a means of guiding health care decision making during a disaster or PHE in times when a substantial change in the ability to deliver usual health care is experienced or expected (IOM, 2009). The goal of a CSC approach rests on a well known tenet of disaster management: do the greatest good for the greatest number of patients. The ethical challenges of implementing CSC guidelines

were evident during the COVID-19 pandemic, when clinicians had to make difficult choices about resource allocation, such as reuse of PPE, identifying what surgeries must be performed and which should be delayed or canceled, and deciding who on the health care team was deemed essential. A lack of planning for women’s health needs during PHEs potentially increases risks for those who have been experiencing IPV.

Thus, a CSC approach can be applied in IPV care to prioritize the allocation of resources for IPV survivors who are at the highest risk of harm, according to such criteria as severity of injuries, likelihood of survival, and potential to prevent further harm. In the context of IPV health care, a modification of the standards of care can mean providing more focused and streamlined services, such as prioritizing emergency medical care and safety planning over longer-term counseling or therapy.

CSCs emphasize the importance of collaboration and coordination among clinicians, emergency responders, and other stakeholders and could involve strengthening partnerships between clinicians and those community-based organizations that can provide additional resources and support (IOM, 2009). Clear communication and transparency about the allocation of resources and the decision-making process are central tenets of CSCs and are relevant to IPV care, as survivors may be hesitant to seek care or disclose their experiences because of fear of retaliation or stigma.

The COVID-19 pandemic served as a reminder that existing societal inequities are exacerbated during PHEs (Evans et al., 2020; Mishra et al., 2021). While CSCs rest on their ability to support unbiased and consistent health care decision making, unconscious biases and existing structural inequalities were clearly present in early pandemic health care (Evans et al., 2020; Hick et al., 2021; Mishra et al., 2021). For example, reports emerged describing how hospitals were not accepting or were delaying transfers based on the insurance status of patients (Evans et al., 2020). In IPV care during a PHE, ensuring equitable access to information, basic health care, testing, vaccinations, and early treatment is even more essential for individuals who may have pre-existing challenges in accessing health care (Evans et al., 2020; Hick et al., 2021). Incorporating CSC protocols with an equity focus is therefore essential in the development of IPV PHE protocols. While CSC protocols used for making urgent allocation decisions in a disaster are not expected to address structural inequity, they ought not worsen existing underlying disparities (Hick et al., 2021).

INTIMATE PARTNER VIOLENCE CARE DURING PUBLIC HEALTH EMERGENCIES IN GLOBAL CRISIS SETTINGS

There is much knowledge to be gained from the decades of advancements to support women and girls affected by gender-based violence (GBV)

in global humanitarian crisis settings, which can inform federal plans. GBV is a broader term used to refer to acts of violence that disproportionately affect a group of people based on their gender. GBV includes IPV and other forms of abuse, such as child marriage, sexual harassment, and human trafficking (UN Women, 2022). Given the limited existing U.S.-based IPV and disaster protocols, this section first covers the available guidance on sheltering, followed by a discussion of standards for providing essential health care services from international guidance sources. These standards represent common agreement on what constitutes adequate quality and are developed to be universally relevant to all emergency settings, with the expectation that the guidance will be modified according to the specific context.

Inter-Agency Minimum Standards for Gender-Based Violence in Emergencies

The United Nations Population Fund’s (UNFPA) Inter-Agency Minimum Standards for Gender-Based Violence in Emergencies² (GBVIMs) provides 16 minimum standards for GBV prevention and response programming in emergencies (UNFPA, 2019). The 16 minimum standards describe the capabilities needed to prevent and respond effectively to GBV across different sectors. Their objective is to establish a common understanding of what constitutes minimum prevention and response programming for GBV in emergencies. This guidance was useful to the committee during the process of identifying priorities for ensuring access to essential health care services related to IPV during PHEs in the United States.

In a U.S.-based IPV context, the GBVIMS can provide transferable guidance through four key mechanisms:

• Developing policies and protocols for screening, assessing, and treating patients who have experienced IPV (with contextualization, the guidelines can be used for mandatory reporting, particularly around supporting safety, confidentiality, and respect for self-determination);
• Providing training and support for training clinicians on identifying, responding to, and referring IPV survivors;
• Strengthening partnerships and referral networks, including collaboration and coordination among service providers, such as health care facilities, social service agencies, and law enforcement; and
• Ensuring survivor-centered care through guidance on responsive care that includes the needs and preferences of the IPV survivors, focusing on principles of dignity and respect.

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² https://www.unfpa.org/minimum-standards (accessed August 25, 2023).

Individuals who experience IPV may be reluctant to disclose or ask for help if they do not encounter survivor-centered attitudes or if clinicians are not equipped to discuss or knowledgeable about IPV. Therefore, the GBVIMS guidance for survivor-centered care emphasizes the following actions for health care facilities:

• Having female staff present;
• Asking appropriate questions in a nonjudgmental manner;
• Having private spaces for consultation;
• Having protocols for provision of health care, essential medicines, and supplies to survivors;

• Offering confidential mechanisms for documentation;
• Communicating clearly about the types of services that are available; and
• Communicating that any disclosure made will be approached with respect, sympathy, and confidentiality (UNFPA, 2019, p. 28).

See Box 6-1 for the GBVIMS standards, adapted slightly to fit the context of this report.

Minimum Initial Services Package for Sexual and Reproductive Health

The Minimum Initial Services Package (MISP)³ for Sexual and Reproductive Health is UNFPA’s set of priority life-saving sexual and reproductive health services and activities designed to be implemented at the onset of all humanitarian emergencies (UNFPA, 2020). The goal of implementation of the MISP is to prevent or decrease sexual and reproductive health-related morbidity and mortality among the populations affected by the crisis (UNFPA, 2020).

The MISP and associated Interagency Field Manual on Reproductive Health in Humanitarian Settings provides guidance for clinical care in emergency settings for survivors of sexual violence, such as management of physical injuries and the provision of emergency contraception and prophylaxis for sexually transmitted infections and HIV as well as guidance on providing psychosocial support in emergencies, including counseling and other mental health services to support survivors (IAWG, 2018). Emergency triage is an important component of this guidance and involves quickly assessing the medical needs of survivors and prioritizing care based on the severity of their condition. Similar to the GBVIMS, key components include ensuring access to accurate and timely information about the patients’ health and well-being and developing strong referral networks for connecting survivors with appropriate services and resources.

Essential Services Package

UNFPA’s Essential Services Package (ESP) is designed to be applicable in any setting, although it was originally intended for stable settings where the response organizations have established communications and implementation processes. The ESP provides guidance for the identification of essential services needed for women and girls who have experienced GBV, with a focus on necessary services to be provided by health care, social services, police, and justice organizations (UNFPA, 2015).

The ESP, GBVIMS, and MISP each provide guidance about implementation, but they do so in different ways. While the GBVIMS and MISP were developed specifically for use in humanitarian emergencies and provide more targeted guidance on specific issues related to GBV and reproductive health services, the ESP provides a comprehensive set of guidelines for providing essential health care services. IPV care challenges that are not well defined in the United States (e.g., the triage of survivors in resource-limited settings, IPV toolkits for field triage, communications in resource-limited environments

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³ https://www.unfpa.org/resources/minimum-initial-service-package-misp-srh-crisis-situations (accessed August 25, 2023).

that allow for health care provider access, referral networks, procedures for just-in-time training, management of chronic and ongoing health conditions without causing further trauma) can be adapted from these international resources. This includes having well-established formal partnership agreements and protocols with health care centers in order to provide needed services, such as emergency contraception and related treatment under the direction of a licensed health professional.

ADDRESSING CHALLENGES IN SUSTAINING HEALTH CARE SERVICES

Training for Disaster Response Personnel

During the immediate response phase of a disaster, emergency health care may be delivered by local, state, or federal response teams or volunteer organizations active in disasters (VOADs), which come from diverse health care backgrounds, so IPV training may not be a requirement of their usual health care role (NVOAD, 2020). Scant evidence exists among federal disaster response entities, as well as among national VOADs, regarding protocols or guidance for IPV care in emergencies.

Ongoing capacity development for disaster health responders is imperative. This can be accomplished by dedicating time for participation in education and training focused on IPV identification and care in the context of PHEs. Incorporating IPV health care services will require the availability of clinicians qualified to perform such care. Licensing concerns may present an issue, as was seen in communities experiencing patient surges during the COVID-19 pandemic. Future planning will need to include consideration for “changes to licensing or certification requirements and suspension or modification of protocols, rules, or even certain laws may be necessary to coordinate the restoration of a health care system” (IOM, 2015, p. 176).

Access to Supplies and Community Resources

Protocols are needed to guide the allocation of resources, such as supplies and medications, when providing IPV care in austere or disrupted health care environments. Additionally, IPV resources outside of health care institutions are needed to ensure the safety, security, and community acceptability of the care setting (UNFPA, 2019). Long-term investments in local women’s organizations can help ensure that IPV services are sustainable and viable both during and after PHEs. Investing resources—material, intellectual, and financial—in these groups can provide communities with effective IPV care during PHEs as well as sustainable services after an emergency. As evidenced in the MISP framework, input from women’s rights activists,

who have expertise on women’s experiences, risks, and perspectives, can help guide decisions about resource allocation (UNFPA, 2020).

Challenges for Community-Based Organizations

During a PHE, community-based groups that help victims of IPV may face several unforeseen difficulties or challenges. These impediments can include a complete disruption in services, reduced and limited resources, an increase in demand for services, increased access for underserved populations, burnout, a lack of coordination, an increased risk of repetitive exposure to violence, and a myriad of mental health challenges. It is critical therefore to have established ongoing partnerships with essential community services providers before the emergency.

Restricted and Reduced Resources: PHEs may have a substantial impact on a region’s economy, resulting in reduced financial resources available to community-based groups. Supply chains may also be disrupted, which limits access to supplies and equipment. This hampers these groups’ ability to deliver care to people experiencing IPV (Garcia et al., 2022; Lauve-Moon and Ferreira, 2016; Sapire et al., 2022).

Disruption of Services: Disasters can result in infrastructure being destroyed, people being uprooted, and communication lines being disrupted, making it challenging for community-based groups to offer basic support services to women experiencing IPV. Virtual support might be limited as well, which could interrupt services such as telehealth (First et al., 2017; Lauve-Moon and Ferreira, 2016; Sapire et al., 2022).

Increased Demand for Services: Generally speaking, disasters cause stress levels to spike, and this increases vulnerability for those at risk for IPV. Community-based groups might be easier to access than traditional health care settings, but they lack sufficient capacity. During the COVID-19 pandemic, several services were deemed nonessential, resulting in a backlog of services for clients in need (First et al., 2017; Lauve-Moon and Ferreira, 2016; Sapire et al., 2022; Toccalino et al., 2022).

Burnout: During the COVID-19 pandemic, IPV and sexual assault workforces based at community-based organizations were on the front lines of the PHE, continuing to meet survivor needs (Garcia et al., 2022). Trauma associated with the PHE can combine with the trauma of caring for people experiencing IPV. As with other frontline workers (e.g., the medical workforce), IPV and sexual assault frontline workers experienced chronic burnout during the COVID-19 outbreak (Hu et al., 2020; Morgantini et al., 2020; Stogner et al., 2020). Community-based organizations that help IPV victims may lessen these difficulties by forming solid alliances with other groups, creating emergency plans, and boosting their capacity to deliver trauma-informed support services.

Protecting Confidentiality

Protecting the confidentiality of individuals experiencing IPV is essential to health and personal safety. During the immediate response period, when usual health care operations are disrupted or care is being provided in austere settings, such as a field hospital, the standard means of communicating and reporting protected health information may be altered. Furthermore, mandatory reporting (which varies among states, tribes, and territories) may be disrupted by limited communications, limited law enforcement availability, or when local law enforcement is being supported by federal resources, such as the National Guard.

The federal law, HIPAA⁴ sets national standards for the privacy of individuals’ protected health information, which includes medical records and other individually identifiable health information. The law’s Privacy Rule requires that clinicians, health plans, and other health care clearinghouses put in place measures to ensure that patients’ health information remains confidential. While the Privacy Rule cannot be suspended during a national or public health emergency, certain provisions may be waived during declared disasters that present specific safety risks to individuals experiencing IPV who are seeking health care.⁵ Additionally, support service providers who receive funding under the Violence Against Women Act⁶ must follow a stricter set of confidentiality laws.

Health care clinicians have an ethical responsibility to protect the safety of their patients, and as such, their focus should remain on the individual who is experiencing IPV, including offering ongoing and supportive access to those health care resources that are available, addressing safety issues, and ensuring that the patient is aware of all available options (Lizdas et al., 2019). At the same time, information sharing on the part of care teams during PHEs is still beneficial to the provision of essential health care services. To best support the delivery of safe and equitable health care, protocols that define standards of patient confidentiality during periods when HIPAA provisions are waived need to be developed, including procedures for communications

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⁴ Health Insurance Portability and Accountability Act of 1996 Privacy Rule. 45 CFR Part 160 and Subparts A and E of Part 164. (December 28, 2003).

⁵ Privacy Act provisions that may be waived during declared disasters include the requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care (45 CFR 164.510[b]), the requirement to honor a request to opt out of the facility directory (45 CFR 164.510[a]), the requirement to distribute a notice of privacy practices (45 CFR 164.520), the patient’s right to request privacy restrictions (45 CFR 164.522[a]), and the patient’s right to request confidential communications (45 CFR 164.522[b]). See https://www.hhs.gov/hipaa/for-professionals/faq/1068/is-hipaa-suspended-during-a-national-or-public-health-emergency/index.htm (accessed June 26, 2023).

⁶ Violence Against Women Reauthorization Act of 2019, H.R 1585, 116th Cong., 1st Session (April 10, 2019) H. Rept. 116-21

and contacts for mandatory reporting and safeguarding protected health information when electronic health record systems are not functional.

CHAPTER SUMMARY

Essential health care services are defined in terms of their impact on human health. The essential health care services related to IPV during steady state conditions remain essential during PHEs. The response to a PHE is marked by conditions such as infrastructure damage and resource restrictions that create barriers to care delivery that improve as resources are directed to the affected geographic area. Therefore, a phased restoration of essential health care services related to IPV is the most practical approach that also ensures care access to those who need it most. Planning for restoration of these services can be informed by current disaster management strategies, such as the equitable application of crisis standards of care, as well as guidance from international humanitarian organizations.

Barriers to restoring and sustaining essential services can be overcome with a variety of strategies. These include cooperation with community-based organizations, incorporating considerations for delivering IPV-related care in PHE planning, and adequate training for disaster responders. Importantly, the confidentiality of people experiencing IPV should be protected in all services.

REFERENCES