Essential Health Care Services Addressing Intimate Partner Violence (2024)

7

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

All-hazards protocols for intimate partner violence (IPV) care can draw from the past effective use of the systems, supplies, staff, space organizational approach to disaster preparedness and response (CDC, 2019; IOM, 2005). This approach describes four variables. Defined in terms of all-hazards IPV protocols, they are:

• Systems: The decision-making channels, logistical networks, and communication necessary for preparedness and response.
  • Decision making for stocking supplies
  • Coordination across disaster response agencies (both federal and state, local, tribal, and territorial) and other actors involved in IPV care
  • Community-based organizations
  • Identifying adaptations for how organizations can deliver care during disasters
• Supplies: The countermeasures, equipment, and basic necessities required to care for people experiencing IPV during an emergency.
  • Tailored supply caches for IPV care
  • Strategic National Stockpile resources
  • Medications
  • Guidance from the Inter-Agency Emergency Reproductive Health Kits for Use in Humanitarian Settings (UNFPA, 2019)
  • Materials for standing up makeshift shelters sufficient for people at risk for experiencing IPV

• Staff: The deployment of disaster health responders as well as the training that responders will need to adequately care for people experiencing IPV.
  • On-call and telehealth IPV resources
  • Just-in-time training modules
  • Federal response specific training (Disaster Medical Assistance Teams, Veterans Health Administration, U.S. Public Health Service Public Health Emergency Response Strike Teams)
• Space: Considerations for the physical and built environment for providing adequate care for people experiencing IPV, as well as such factors that may prevent IPV during sheltering.
  • Sheltering¹
    • Disaster shelters
    • IPV emergency shelters

Many of the examples above have been developed for use in general emergency preparedness. However, they largely have not been adapted for IPV care during an emergency. Developing protocols specific to IPV will help sustain essential health care services related to IPV during public health emergencies (PHEs). This chapter discusses these four factors and how they affect care for people experiencing IPV during emergencies.

SYSTEMS FOR INTIMATE PARTNER VIOLENCE CARE DURING PUBLIC HEALTH EMERGENCIES

Opportunities for Intimate Partner Violence Care within Existing Systems and Settings

Federal Medical Stations

Federal medical stations (FMSs) are deployable supply caches that can be rapidly deployed to convert a pre-identified building into a temporary medical facility to support health care systems anywhere in the United States (ASPR, n.d.-b). Each FMS has enough medical and pharmaceutical resources to serve up to 250 stable primary or critical care patients needing medical and nursing services for 3 days. Essentially a hospital in a box, FMSs are managed by the Strategic National Stockpile and can be deployed during disasters and

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¹ Guidance about organizing emergency shelters to protect from IPV is found in this chapter. Guidance about the materials and processes needed to efficiently stand up emergency shelters in general can be found in the International Federation of the Red Cross and Red Crescent (IFRC) Shelter Kit Guidelines (https://www.ifrc.org/document/shelter-kit-guidelines) (accessed November 27, 2023).

PHEs (ASPR, n.d.-a). An FMS could be designed to have a women’s health module that provides for IPV essential care and supplies.

Health Care Coalitions

Health Care Coalitions (HCCs), described in Chapter 3, coordinate and organize throughout the disaster management cycle. The role of HCCs in disseminating information and preparing health care organizations for PHEs may provide an opportunity to ensure the provision of IPV care. Moreover, HCCs provide a forum for communication and coordination between different actors (ASPR, 2016). By including IPV-related efforts in their preparedness tasks, HCCs can help sustain essential health care services related to IPV. However, HCCs often struggle with a lack of funding and resources, so they may be reluctant to take on additional roles (Barnett et al., 2022).

HCCs are uniquely positioned to locally implement promising practices and other evidence-based interventions. An example of this is training in trauma-informed care, which acknowledges a patient’s life experiences (including IPV and other traumatic stressors) and is crucial for providing effective essential health care services related to IPV. In the context of a PHE, trauma-informed care recognizes the patient’s past traumatic experiences and the immediate disaster incident when planning for and delivering care.

One example of an HCC incorporating trauma-informed care is the Los Angeles County Hospital Preparedness Program, which trains staff in hospitals and community clinics to provide trauma-informed health care during PHEs (Los Angeles County Health Services, 2007). Los Angeles County offers three such training modules, each designed for a specific set of end users: administrative, disaster planning, and disaster response staff; hospital and clinic staff, which includes clinical, non-clinical, and mental health staff; and Los Angeles County mental health staff. These trainings include level-setting with regard to key definitions and procedures as well as examples of how staff can plan for and implement trauma-informed care into disaster operations. Other trainings and planning documents offer more specific programmatic guidance, such as recommendations to include mental health professions in disaster planning, identifying mental health staff for hospital incident command roles, and including mental health in annual exercise programs (Shields, 2011). This program also employs the PsySTART Disaster Mental Health Triage system, which allows emergency medical and primary health care professionals to rapidly determine the risk for trauma-related stress disorders during a PHE, considering a patient’s prior trauma history (Schreiber et. al., 2014). Los Angeles County has several training documents explaining PsySTART to health care professionals. Other HCCs that train staff for trauma-informed care include the North

Central Texas Trauma Regional Advisory Council and My Health My Resources of Tarrant County, Texas.

Alternate Care Sites

Alternate care sites (ACSs) are locations converted, usually temporarily, to provide health care services when existing facilities are either compromised by a hazard impact or when an expected volume of patients exceeds the available capacity and capability of the local health care system (ASPR, 2023). As part of the design process for an ACS, locations that are appropriate for the type of patient care intended to be delivered are selected. ACSs are sometimes situated inside of the health care systems they are intended to support, particularly when a specific type of care is needed. More commonly, ACSs are set up outside of the traditional health care setting. During the COVID-19 pandemic, ACSs existed in convention centers, athletic facilities, and former hospitals and clinics (Bell et al., 2021).

Although ACSs are generally thought of as providing acute or chronic care, they can be designed to meet the needs of the population affected by the PHE. For example, an ACS may be designed to provide women’s health care services when these are lacking in the community. ACSs can support IPV care by intentional design choices or through post hoc changes depending on the community’s specific needs.

ACS design needs to include the necessary amounts of staff and equipment in an appropriate setting so that patients can continue to receive the optimal quality of care and practitioners can provide care that does not compromise their safety (Bell et al., 2021). The development and implementation of ACS in multiple locations may pose challenges regarding staffing and supplies, especially during times of national or global emergency. The large number of ACSs that were rapidly scaled up across the country during the COVID-19 pandemic meant that essential supplies, most notably personal protective equipment but also including cots, linens, and privacy screens, were difficult or impossible to source, as supply chains were overwhelmed or limited because of global disruptions (Bell et al., 2021).

PROMISING MODELS FOR INTIMATE PARTNER VIOLENCE CARE IN PUBLIC HEALTH EMERGENCIES

Rapid Response Teams and Mobile Health Clinics

Some countries have developed models of IPV care delivery for use during humanitarian crises, in some cases through nongovernmental organizations. One such example is the Panzi Foundation, founded by 2018

Nobel Peace Prize winner, Dr. Denis Mukwege in the Democratic Republic of Congo (Panzi Foundation, 2021). While the contexts in which the Panzi Foundation serves may seem far removed from those of the United States, learning from this organization’s approach and structure can help to advance IPV care during PHEs in the United States.

The Panzi Foundation has mobile care clinics and rapid response teams to address gender-based violence (Panzi Foundation, 2021). When reports of mass rape or other severe attacks on women and girls are received, the Panzi Foundation deploys rapid response teams composed of doctors, psychosocial assistants, and legal advocates urgently to provide on-the-ground care. Additionally, the Panzi Foundation’s mobile health clinics include medical staff, psychosocial assistants, and lawyers who travel to remote locations to identify and provide health care to women and girls who have experienced severe gynecological trauma (Panzi Foundation, 2021). These health clinics are interdisciplinary and aim to provide holistic care to women and the affected community. Specifically, mobile health clinics provide communities with medications, supplies, and general medical care for the entire community. The Panzi Foundation partners with local health clinics to ensure they have a reliable stock of post-exposure prophylaxis medications and supplies (Panzi Foundation, 2021).

Mobile health clinics have been used in the United States as well. Some have been used specifically to deliver women’s health care, including perinatal care (Edgerley et al., 2007). An analysis of 2007–2017 data from 811 mobile health clinics found that 55 percent of clients that used those clinics were women (Malone et al., 2020). As seen in overseas humanitarian crises, this model could be used to deliver IPV care during PHEs.

Integrating Intimate Partner Violence Care with Other Health Care

Primary care and other non-IPV health care units are settings in which clinicians may help ensure that their patients receive effective IPV health care and support services. Screening, universal education, and referral are three key tools that health care professionals can use in this context. However, some models have built out broader systems around these concepts. For example, the Pathways Program² at Chicago’s Swedish Hospital³ is a model designed to bridge the gap between health care services, support services, and social services for intimate partner violence, such as those offered

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² See https://swedishcovenant.org/community/pathways-program (accessed September 15, 2023)

³ The information about the Pathways Program in this paragraph and the next is based on a presentation to the committee by Maria Balata, Gender-Based Violence Response in Health Care Settings, Meeting 2, February 23, 2023.

by governmental domestic violence agencies and community organizations (see Box 7-1). Clinicians at Swedish Hospital identify patients who may be experiencing IPV via screening, universal education, or observation. Patients may be referred from the hospital’s emergency department, inpatient units, labor and delivery unit, psychology unit, outpatient medical offices, and community partners. Once a patient is identified, the Pathways Program offers bedside crisis intervention and trauma-informed care.

Like many clinics, the Pathways Program makes connections and referrals to community organizations. However, it also takes an active role in providing care and resources to patients. Services provided include on-site mental health services, safety planning, transportation, and burner cellular phones.⁴ These services are provided on a free and confidential basis in sev-

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⁴ A burner phone is a cellular phone that does not require registration with a cellular service provider and instead operates on prepaid service credits and is usually intended to be disposed of after use. See https://www.merriam-webster.com/dictionary/burner%20phone (accessed August 25, 2023).

eral languages. The Pathways Program serves people of all gender identities, sexual orientations, immigration statuses, and housing statuses. Because the health care setting is more discreet than going to a shelter or seeking counseling services elsewhere, it provides both cover and privacy for people experiencing IPV. Hospitals allow for more ambiguity, as routine treatments are provided there and allow for an easy explanation as to why someone might see a medical professional. However, mandatory reporting and clinician training may negatively affect patients’ comfort with the program.

Clinics can also take a role beyond screening and referral. The PurpLE (Purpose, Listen and Engage) Health Foundation⁵ has created a model designed to do so. PurpLE is a nonprofit organization intended to “advance health equity for women and girls and people across the gender spectrum who have experienced gender-based violence, no matter where they are in their survivorship journey” (see Box 7-2). PurpLE uses a trauma-informed care lens in a three-part care model that includes primary care, mental health services, and a survivor-led care navigation program. PurpLE stresses the importance of recognizing patients’ social history and how lived experiences affect the type of care patients are comfortable with receiving. Integrating social histories as part of the patient intake process allows for strong care coordination and prescribing care that the patient is likely to follow through with. The PurpLE Health Foundation patient population consists of those currently experiencing IPV or trafficking, those who have recently left a relationship due to IPV, and those who are several years removed from an abusive relationship and still struggling to receive care.

PurpLE also emphasizes continuity of care for patients and aims to keep those services consistent regardless of the social service that referred the patient. PurpLE tracks barriers to care and works to mitigate the structures in place that keep patients from seeking care. PurpLE incorporates the following considerations and strategies in their IPV prevention framework:

• Considering ways to provide care for those currently experiencing IPV, e.g., contraception, safety planning, documentation, exit plan;
• Minimizing the risk for reentry into a dangerous situation or re-exposure to trauma by removing financial barriers to accessing health care and assisting with housing, employment, incarceration prevention, child custody; and
• Identifying advocacy opportunities to address the systemic problems that created the need for the above care.

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⁵ See https://purplehealthfoundation.org/ (accessed September 15, 2023) The information about the PurpLE Health Foundation in this paragraph and the following paragraphs is based on a presentation to the committee by Anita Ravi, PurpLE Health Foundation, Meeting 3B, April 4, 2023.

A core component of the PurpLE organization is planning for long-term survivorship, and it is committed to helping IPV victims regardless of insurance coverage. The organization scaled up its model by educating clinicians. PurpLE has successfully trained 10,000 health care professionals across the country in trauma-informed care (Ravi, 2023).

Intimate Partner Violence Care for American Indian/Alaska Native Communities

IPV care is more effective when it is culturally relevant and salient for the people to whom it is delivered. Models of providing IPV care to American Indian/Alaska Native (AI/AN) communities demonstrate this. The Family Spirit Home Visiting Program⁶ is a home visitation program

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⁶ See https://cih.jhu.edu/programs/family-spirit-home-visiting-program/ (accessed September 15, 2023). The information about the Family Spirit Program Foundation in this paragraph and the next is based on a presentation to the committee by Lisa Martin, Family Spirit Home Visiting Program Connections and Impact on IPV during Public Health Emergencies, Meeting 3A, March 29, 2023.

rooted in traditional Indigenous and cultural practices. Family Spirit was co-created by AI/AN communities and is centered on strength-based, culture-based, and evidence-based programming that promotes tribal sovereignty while demonstrating impact (see Box 7-3). The team at Family Spirit has developed 63 lessons across six modules. These curricula include lessons about goal setting, reproductive health, family planning, substance abuse, nutrition, budgeting, conflict resolution, and problem solving. Home visits begin during pregnancy and last through 3 years postpartum. Decision-making and assessment tools are in place to help home visitors navigate IPV in the household. If a family is in crisis, there is a structured process that home visitors are trained in to provide the best support necessary. The program was designed with the hope of having a multi-generational impact, by modeling healthy behaviors and cycles that will last beyond the nuclear family and onto the following generation.

The Family Spirit program serves tribal communities by recognizing the specific strengths and barriers that are present in each community. Home visitor educators are thoroughly trained in the model, so they are well versed in the curriculum. The Family Spirit program has been delivered in 155 communities across 24 states. A key component in the success of the program is the strong relationships fostered with the families and the home visitors. The model works with small and large agencies. Working with different types of agencies allows for adaptation and flexibility for the program to be delivered to a variety of communities while meeting their specific needs.

Another unique challenge for providing IPV care for AI/AN women is the remoteness of many reservations. Amá Dóó Álchíní Bíghan (ADABI) Healing Shelter, Incorporated,⁷ provides services to people experiencing intimate partner violence, domestic violence, sexual assault, and rape in the Chinle Agency of the Navajo Nation. It provides shelter, food, transportation, and support groups in a culturally relevant manner. ADABI refers clients to the Chinle Indian Health Service, which in turn refers clients to ADABI. This relationship has helped both organizations serve clients more effectively, such as by ensuring private spaces and safe exits for people experiencing gender-based violence.

ADABI staff have had to adapt to unique challenges, including the geography of the Navajo Nation (see Box 7-4). For example, the sparse, muddy terrain makes transportation more difficult, cell reception is sparse in many parts of the reservation, and there are not many stores, gas stations, or other support service providers from which survivors can seek help. Some families have many children, necessitating the use of several vehicles to transport them to the shelter. ADABI’s 24-hour on-call line and network of shelters are designed to help overcome these challenges.

Telehealth and Other Technology-Delivered Interventions

Prioritizing access, privacy, and safety is critical for successfully implementing any technology-delivered platform during a PHE. Safety guidelines for addressing domestic violence during PHEs through technology have been released by various entities, including Futures Without Violence, the National Domestic Violence Hotline, the National Network to End Domestic Violence (NNEDV), the National Coalition Against Domestic Violence, the Center for Court Innovation, and the Sexual Violence Research Initiative (Emezue, 2020). IPV care providers, advocates, and clinicians can

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⁷ See https://www.adabihealingshelter.org/ (accessed September 15, 2023). The information on Amá Dóó Álchíní Bíghan in this paragraph and the next is based on a presentation to the committee by Lorena Halwood, Amá Dóó Álchíní Bíghan Healing Shelter, Meeting 3A, March 29, 2023.

use these guidelines to gauge the applicability, usefulness and safety of different digital tools for those experiencing IPV (Emezue, 2020). NNEDV developed a PHE digital services toolkit, as part of the Safety Net Project, which outlines best practices for using various types of tools, including text, chat, and video, to communicate with people with experiences of IPV during a PHE (NNEDV, 2020). The toolkit also offers worksheets and recorded webinars focused on assessing capacity and choosing an appropriate delivery platform (NNEDV, 2020).

Many technology-based solutions were implemented during the COVID-19 pandemic, ranging from online- and phone-delivered support to conversion from in-person to digital services provided by an advocate or IPV care provider and mobile self-help apps (e.g., I-DECIDE) (Su et al., 2022). Expanding web-based services for those experiencing IPV, combined with 24-7 digitalized responses (e.g., domestic violence hotlines, telehealth services including counseling, and guidance on relevant mobile apps) have been highlighted as important resources during the COVID-19 stay-at-home orders (Emezue, 2020).

Digital Services Provided by Advocates and Clinicians

During PHEs, the physical delivery of social and support services may no longer be feasible. As a result, such services may need to be delivered digitally. For example, the Crystal Judson Family Justice Center in Pierce County, Washington, shifted to digital services during the COVID-19 pandemic (Moyer et al., 2022). They offered both traditional (e.g., domestic violence hotlines) and new services in a digital modality. Such new services included advocate follow-up to assess past-year clients’ conditions and consider potential changes as well as mobile follow-up for IPV-related 911 calls to offer short- and long-term support.

Increased time investments may be needed for advocates, clinicians, and staff to provide trauma-informed care, create safety plans, and provide other sources of support (e.g., orders of protection) (Moyer et al., 2022). This time increase is partly due to the nature of the introductory content included in these interactions, which ensures ongoing safety and educates individuals about the risks of digital services. The unique safety issues associated with digital service means that IPV care providers also may need to educate clients on how to erase internet browser histories, use incognito browsers, and identify cookies as part of safety education (Schrag et al., 2022).

Mobile Applications

Novel mobile applications (apps) have been developed or modified and deployed during PHEs. Snapchat, a popular multimedia messaging app,

partnered with NNEDV to include more resources for users affected by IPV and those who wanted to support a friend in such a situation (Fried, 2020). The resources were made available in subtitles for those who did not feel comfortable or safe viewing content with the sound on.

Another mobile app, Promoting Safety in Emergencies, or PROMiSE has been adapted from an individualized safety planning web app known as Pathways (O’Campo et al., 2021). PROMiSE allows women to assess the severity, danger, and potential lethality of violent behaviors in their relationship, identify safety priorities, and develop and maximize safety planning discreetly in the context of PHEs through decision-support tools (O’Campo et al., 2021). PROMiSE was developed with a disguise feature, wherein the app content is overlaid onto an innocuous webpage (e.g., Pinterest board for Home and Garden television channel) to account for women being near their partner during a PHE (O’Campo et al., 2021).

The VictimsVoice app, collaboratively designed with attorneys and law enforcement, guides users in collecting the evidence needed to inform an IPV criminal case while keeping all of the collected information (e.g., photos of injuries, physical exam details, doctor visit documentation) in one safe and secure place (Victims Voice, n.d.). All data are encrypted and stored off-device, and there is a safety exit button to ensure the site does not remain in the browser history. VictimsVoice is currently being used in all U.S. states (Victims Voice, n.d.)

The Digital Divide

Although telehealth and technology-delivered interventions designed to address IPV have advantages, several disadvantages and barriers need to be considered in the implementation process during a PHE. The key disadvantages or risks include compromising personal safety (e.g., video call software automatically storing call history), loss of privacy (e.g., disclosure of abuse via message threads intentionally or unintentionally viewed by someone else), and loss of confidentiality (e.g., personally identifying information on a mobile device used by advocates) (NNEDV, 2020). The digital divide—inequitable access to the internet and technology due to socioeconomic barriers, language barriers, low literacy levels, and limited access to technology-delivered interventions and services—affects the widespread uptake and continued IPV service provision to those in need (Ghidei et al., 2022; Storer and Nyerges, 2023). Some individuals from socially marginalized backgrounds (e.g., unhoused, AI/AN, and immigrant populations) do not have equitable access to technology-delivered IPV services.

Unstable or unavailable internet connectivity can contribute to inequities in delivering IPV services. In part, the residential or neighborhood context contributes to the inequity. One study found that even when an organization

could provide clients with the equipment and technology they needed, their clients could not access a stable internet connection due to their geographical location (Ghidei et al., 2022).

As noted earlier, AI/AN people often reside in isolated and remote areas within tribal lands and reservations, which may lack health and public safety infrastructure to address IPV (Sabri et al., 2019). Within these tribal lands and reservations, individuals may reside in concentrated and dense housing with limited privacy and limited cell phone access. Even with access to cell phones, the service may not work due to connectivity issues. This issue was further complicated during the COVID-19 pandemic when court closures resulted in increased reliance on email for some court documents (see Box 7-5).

Additionally, women who are immigrants or refugees may reside in overcrowded households, limiting their ability to have privacy to engage in technology-delivered IPV interventions (Rai et al., 2020).

Individuals with disabilities also experience unique barriers to accessing digital technologies, further exacerbating IPV-related disparities (Ghidei et al., 2022). For example, it may be difficult for members of the deaf community to access interpreters virtually or to receive services through video-based options because they rely on lip-reading (Ghidei et al., 2022). Currently, few telehealth platforms interface well with assistive technologies used by people with disabilities (Valdez, 2021).

Advocating for youth and young adults in communities with limited access to the internet, computers, and cameras is critical for reducing inequities in health care delivery. The available models include providing telemedicine in schools and other community settings, partnering with community organizations to reach unstably housed youth or those involved in the juvenile justice system, and expanding connections to specialty adolescent care in rural settings (Evans et al., 2020).

Challenges in the virtual delivery of IPV services emerge differently for IPV care providers. Qualitative studies of the transition to virtual delivery during the COVID-19 pandemic revealed that it was difficult for many IPV care providers accustomed to in-person settings to develop authentic emotional connections, thus making it challenging in these virtual environments to build solid therapeutic relationships (Ragavan et al., 2022; Voth Schrag et al., 2023). Other challenges included the inability to contact clients, difficulties with technology once contact had been made with a client, and the inability to engage in important aspects of their job virtually (e.g., safety assessments with children, fear that others in the home or other environment were listening into a session or tracking a client’s movements electronically) (Voth Schrag et al., 2023; Williams et al., 2021).

The digital divide remains a substantial barrier to accessing IPV care. This barrier can be reduced through greater and more equitable access to internet-capable devices and the internet, language equity in digital IPV resource development, accessible digital resources for people with disabilities, and strategies to build computer literacy.

Disaster Case Management

During an emergency, access to basic necessities such as food, water, and shelter is often disrupted. These harms can be exacerbated for people experiencing IPV. Services uniquely for people experiencing IPV can also be disrupted. For example, IPV shelter operations may be interrupted during an emergency, leaving shelter clients unable to secure housing away from the person engaging in IPV. Disaster case management (DCM) is one way to connect people experiencing IPV to the services and resources they may need.

DCM is a time-limited partnership between a trained case manager and a disaster survivor that entails the development of a disaster recovery plan and a shared effort to meet the unmet needs caused by the disaster that are outlined in the recovery plan (FEMA, 2023). This disaster recovery plan aids in assessing and addressing disaster survivors’ unmet needs. The plan includes resources, decision-making priorities, direction, and tools to assist the disaster survivor with an effective recovery (FEMA, 2023). DCM planning could be contextualized to fit the needs of people experiencing IPV.

Additionally, disaster case managers may be some of the first disaster health responders with whom a disaster survivor interacts. Training disaster case managers in recognizing the signs and symptoms of IPV, universal education and screening, and how to connect clients to relevant support services can help connect those experiencing IPV to vital resources.

Community-Based Intimate Partner Violence Programs

State, local, tribal, and territorial (SLTT) governments can help ensure that people experiencing IPV have the resources they need by linking them to key social and support services. For instance, Miami-Dade County’s Violence Prevention and Intervention Division⁸ provides several community-based resources to community members experiencing IPV (see Box 7-6). These programs include emergency shelters, long-term residential housing options, access to legal services and advocates, a one-stop center that houses many community partners, and a program that partners with the state authority on child abuse to provide resources to those experiencing domestic violence. Ensuring confidentiality within all programs is a crucial component to the safety of the survivors and the success of their programs (see Box 7-6). All programs within the Violence Prevention and Intervention Division are certified in using the Danger Assessment tool and use that alongside other needs assessments to help determine the best safety plan for their community members.

Operating community-based programs can present a variety of challenges. Some of the challenges that the Miami programs have encountered include tension with police officers who may not understand the confidentiality requirements of the different programs, families wanting to track their family members, navigating a co-ed emergency shelter space, providing additional protections to undocumented clients and residents, and a need for further education about survivorship for those working in the long-term residential housing units. The COVID-19 pandemic presented several issues for emergency shelters and residences due to room shortages and social distancing. Following the COVID-19 outbreak, programs began to integrate the use of updated technology practices into their programs, leading to further efficiency of intake and support services. Technology is something that will continue to be used throughout these programs as they continue to grow and develop.

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⁸ The information about Miami-Dade County’s Violence Prevention and Intervention Division in this section is based on a presentation to the committee by Ivon Mesa, Miami-Dade County Violence Prevention and Intervention Division, Meeting 2, February 23, 2023.

Multi-Sector Collaboration

Some IPV care providers have engaged in collaborative efforts to address certain adverse health effects of intimate partner violence. One example is the CACTIS Foundation,⁹ a community-based organization that conducts continuing medical education, supports research-focused preclinical and clinical programs, and supports clinical trials. Currently the foundation focuses on traumatic brain injuries (TBIs) in several populations, including people experiencing IPV. Much of their work in this area has focused on improving the epidemiological measurement of concussion incidence among people experiencing IPV (see Box 7-7).

The CACTIS Foundation has developed a number of brief questionnaires and point-of-incident concussion assessments tailored for use by frontline workers and IPV care providers to assess people who have experienced IPV. CACTIS has partnered with and trained police departments, social workers, and domestic violence shelters to screen for concussions. This training also helps these frontline workers to recognize behaviors that are symptoms of concussions that they may have overlooked or attributed to other things, such as drug use (see Box 7-7). The organization is collaborating with the University of Arizona’s rural pharmacy program to pilot an IPV and concussion education program in community pharmacies in rural Arizona.

Role of the Hyperlocal Response

Hyperlocal responses build on the strengths and collective impact of communities. In many cases, communities have already developed avenues for meeting their needs, which can be used during a PHE to address health care needs. For example, hyperlocal responses to COVID-19 testing and vaccinations were critical for increasing access to these public health interventions during the pandemic, especially among historically marginalized populations (Thoumi et al., 2021). A report describing hyperlocal response during the COVID-19 pandemic described three guiding principles for hyperlocal response (Thoumi et al., 2021):

• Tailoring the approach to address the unique barriers to uptake that are experienced by the community;
• Delivering services with attention to linguistic and cultural needs and preferences and Americans with Disabilities Act accessibility; and
• Using partnerships and community-engaged decision making.

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⁹ The information about the CACTIS Foundation in this section is based on a presentation to the committee by Hirsch Handmaker, Sustaining Essential Health Care Services Related to Intimate Partner Violence During Public Health Emergencies, Meeting 3B, April 4, 2023.

Many communities that provide services to women experiencing IPV have adopted a Coordinated Community Response (CCR) approach that could be used during a PHE as part of a hyperlocal response. The CCR approach involves coordinating a combination of services made available to women who experience IPV, such as shelters, advocacy, and legal protection (Shorey et al., 2014). This approach was initially developed to address the needs of individuals engaging in IPV and was adapted to coordinate services for those experiencing IPV (Gamache, 2012). Coordination councils are a cornerstone of the CCR approach. A coordination council representing

different agencies and sectors involved in addressing IPV (e.g., advocates, police, IPV care providers, the court system, and faith and community organizations) works to ensure that the person experiencing IPV can access services across systems, helping to navigate these multiple systems and increasing awareness of and access to services (e.g., plenary orders of protection), and minimizing the burden on the person experiencing IPV (Allen et al., 2013; Gamache, 2012; Javdani and Allen, 2011). These central bodies for coordination can be embedded in emergency planning and management teams.

Cross-sector collaborations can be bolstered through continued investment in implementing and nurturing partnerships and policies that explicitly promote collaboration. In particular, disaster health responders should partner more deeply with social service providers and IPV-related community-based organizations. These partnerships would allow for improved coordination and sustainment of strategies for enhancing collaboration including formal partnership agreements, clear protocols that facilitate bidirectional referrals, and opportunities for cross-training health care and agency staff (Gmelin et al., 2018; IPV Health Partners, 2017). Health centers and support services agencies’ organizational readiness can be assessed using checklists to assist sites in reviewing protocols and practices relevant to care for IPV survivors, staff support and training, clinical workflows, accessibility of educational materials, inclusion of diverse populations, and data collection (IPV Health Partners, 2017). Supporting the implementation of incremental changes within health systems and support services agencies can be accomplished through collaborations that promote quality improvement (Miller-Walfish et al., 2021). Agencies can also be trained to integrate health services into their intake procedures and workflow (Gmelin et al., 2018).

SUPPLIES FOR INTIMATE PARTNER VIOLENCE CARE IN PUBLIC HEALTH EMERGENCIES

Several federal systems exist to supply disaster health responders during emergencies. These include:

• the Strategic National Stockpile (SNS), which maintains a supply of key medical supplies and countermeasures;
• the medical supplies deployed with Disaster Medical Assistance Teams (DMATs), which are intended to provide basic and lifesaving health care for roughly 72 hours; and
• the resources included as part of a Federal Medical Station’s (FMS’s) deployment kit.

While these caches are typically supplemented by supplies maintained by private and SLTT actors, kits meant for acute deployment (such

as DMAT and FMS kits) are pre-packaged and standardized. They are designed to help responders provide care in austere settings where the supplies they bring are the only health care supplies available. Therefore, such caches include necessary equipment and supplies to address essential health care—including the needs of IPV survivors during the initial response period.

The global humanitarian crisis response field has generated evidence for the types of supplies that can be cached to address IPV care needs. The United Nations Population Fund (UNFPA) maintains guidelines, the Inter-Agency Emergency Reproductive Health Kits for Use in Humanitarian Settings, most recently updated in 2019, that comprehensively describe necessary supplies and their use across a variety of women’s health needs (UNFPA, 2019). Inter-Agency Emergency Reproductive Health (IARH) kits are designed for use in the initial response phase of a PHE and are tailored to the knowledge, competencies, and qualifications required to use each of the supplies in the kit. Different kits exist for different types of care. Examples include a post-rape treatment kit, oral and injectable contraception kit, and sexually transmitted infection kit (UNFPA, 2019). It is important to note that certain settings in the United States may encounter challenges with procuring specific and vital supplies for IPV care, such as emergency contraception. Even so, cached supplies need to be rapidly deployable in any type of PHE. An IARH-like approach of breaking down supply lists by function may be useful for training and checklist development.

TRAINING STAFF FOR INTIMATE PARTNER VIOLENCE CARE IN EMERGENCIES

Those who provide health care services during PHEs have diverse needs, and the contexts they serve vary greatly. This section addresses the need to train disaster health responders and IPV care providers in IPV identification and care and strategies to manage stress and reduce the likelihood of burnout. Also discussed is the Health Resources and Services Administration’s (HRSA’s) training strategy, which emphasizes cross-collaboration between health care systems and agencies serving those who have experienced IPV (HRSA, 2023).

Training Disaster Health Responders

Health care professionals, emergency medical services, police officers, and community health workers may all be considered disaster health responders in a PHE. Disaster health responders, both in health care and community settings, need to be able to recognize the signs and symptoms of IPV and feel confident in addressing IPV. Critical education and training

needs for IPV care providers and disaster health responders in a PHE are summarized below.

Training in trauma-informed approaches to addressing IPV is critical for disaster health responders. The Centers for Disease Control and Prevention’s Office of Readiness and Response collaborated with the Substance Abuse and Mental Health Service Administration National Center for Trauma-Informed Care to develop training for disaster health responders in PHEs that can be used for addressing IPV (CDC, 2020b). The training identified six principles that guide a trauma-informed approach (CDC, 2020b):

• safety;
• trustworthiness and transparency;
• peer support;
• collaboration and mutuality;
• empowerment and choice; and
• cultural, historical, and gender issues.

Given the intersectional identities of women experiencing IPV, the syndemic context of IPV (i.e., co-occurrence with other traumas, behavioral health issues such as substance abuse, and health conditions such as HIV), and the disproportionate burden experienced by historically marginalized groups, such as racially and ethnically minoritized women and lesbian, bisexual, transgender, and queer (LGBTQ+) populations, practitioners have encouraged an intersectional and culturally responsive approach to training in trauma-informed IPV care (Kulkarni, 2018). Training needs to engage the populations served in the development and evaluation process to ensure responsiveness to identities, context, and culture.

Just-in-Time Training

Despite preparedness planning, disaster health responders may need additional preparation for the setting and type of care needs of the PHE community, underscoring the need for just-in-time training (Weiner and Rosman, 2019). Just-in-time disaster health care training is an opportunity—perhaps the only opportunity—to reinforce prior disaster knowledge and convey other vital information about the PHE, including:

• the response setting,
• the current operational status and capacity of local health care facilities,
• other health care disaster response capacity on hand,
• local condition-specific health care practices,
• the disaster team and individual roles,

• unique vulnerabilities of the population,
• the types of patient care expected due to the PHE, and
• the environment and duration over which patients are likely to present (Weiner and Rosman, 2019).

Just-in-time disaster training, delivered as close to deployment as possible that includes local knowledge of the community and the hazard, is critical to providing effective and safe care (Weiner and Rosman, 2019). Such training is crucial for health care professionals needing more expertise or experience in PHEs and austere settings or in the care needs specific to the community. Just-in-time training can be tailored to the needs of the PHE and the community. It represents a unique opportunity to provide IPV-specific education and training.

Training Health Care Professionals

Many training options for health care professionals to respond to IPV can be used during PHEs. The National Resource Center on Domestic Violence has created a collection of educational materials related to IPV care and disaster planning (VAWnet, 2021). However, most of this guidance is targeted at IPV and domestic violence programs. The collection does include one educational item for personnel involved in disaster preparedness and response (VAWnet, 2021). However, systematic reviews of IPV training have found that although these educational strategies may positively affect health care professionals’ attitudes toward individuals experiencing IPV, there is limited evidence about how these affect the identification of IPV and safety planning (Kalra et al., 2021). To increase its effectiveness, clinician education needs to be part of an ongoing process integrated with a comprehensive approach (Ambikile et al., 2022). A literature review of studies about training programs for health care providers suggested that existing programs could be enhanced by conducting initial and ongoing training to increase clinician self-efficacy in screening for and addressing IPV, building institutional support and promoting institutional champions, implementing screening protocols, and providing immediate access to advocacy and other support services (Ambikile et al., 2022). Although these principles have been evaluated in a health care context, they can be expanded to different contexts and clinicians, such as community health workers during a PHE, when health care professionals may be less accessible (Saboori et al., 2022).

Training about evidence-based protocols and promising practices to address IPV needs to be tailored to clinician type and context. Examples include:

• evidence-based prevention curriculum offered in schools and other settings that address dating violence (e.g., Dating Matters; see Niolon et al., 2019);
• universal screening for IPV among women of reproductive age in health care settings that involves validated screening tools and referral to ongoing support services (USPSTF, 2018);
• cross-sector collaboration and referral protocols between health centers and service agencies (Brown et al., 2023; Miller-Walfish, 2021; Scott et al., 2023);
• dangerousness assessment and safety planning, such as the Lethality Assessment Program for police officers, which involves screening and immediate connection to a domestic violence advocate (Messing et al., 2015);
• the Coordinated Community Response Council for hyperlocal responses (Shorey et al., 2014);
• emerging interventions based on information and communications technologies (El Morr and Layal, 2020);
• empowerment-based advocacy (Trabold et al., 2020); and
• treatment for psychological and somatic symptoms of trauma survivors, such as cognitive–behavioral therapy (Arroyo et al., 2017; Trabold et al., 2020).

A recent Cochrane review assessed the effectiveness of training programs that sought to improve health care professionals’ identification of and response to IPV against women, compared with no intervention, wait-list, placebo, or training as usual (Kalra et al., 2021). Within 12 months post-intervention, the evidence suggests that IPV training may improve IPV care providers’ attitudes toward IPV survivors, their self-perceived readiness to respond to IPV survivors, and their knowledge of IPV (Kalra et al., 2021). Additional research is needed to determine the longer-term effectiveness of the training, as well as the impact of the training on the health and well-being of abused women.

Project Catalyst is a demonstration project focused on developing statewide leadership teams to promote health center and IPV agency collaborations and disseminate healing-centered approaches to care for survivors of IPV seeking care in community health centers (Brown et al., 2023; Scott et al., 2023). This emphasis on cross-sector collaboration is evident in the updated HRSA IPV Strategy, and research-informed materials, including training guides and evaluation tools. These tools are available from the National Training and Technical Assistance Program called the Health Partners on IPV and Exploitation (Futures Without Violence, 2023).

Wellness and Anti-Burnout Training

IPV care providers and disaster health responders experience secondary traumatic stress, burnout, and compassion fatigue, which are exacerbated in a PHE (Benincasa et al., 2022; Ragavan et al., 2022; Vagni et al., 2022). All clinicians and stakeholders need training for addressing potential burnout and compassion fatigue as well as supportive environments that do not contribute to burnout. Mindfulness-based interventions are an evidence-based approach to reducing stress and improving well-being among health care providers that could be beneficial for IPV care providers (Lomas et al., 2018). However, these strategies need to be couched within a systems-based approach that identifies and targets known external factors driving burnout while simultaneously including clinician and patient feedback (NASEM, 2019).

HRSA Training Strategy

Training IPV care providers and implementing system-level policies and protocols are essential components of ensuring the preparedness of health systems to address IPV and related health consequences. The 2023–2025 HRSA Strategy to Address Intimate Partner Violence focuses on coordinating efforts to strengthen infrastructure and workforce capacity. It emphasizes that training is essential to promote culturally informed and trauma-informed care practices as well as improve skills and knowledge (HRSA, 2023). The strategy recommends integrating training for IPV care into existing programs and providing training and technical assistance specific to IPV to the health care workforce. The National Training and Technical Assistance Program, called Health Partners on IPV + Exploitation,¹⁰ provides training on trauma-informed services, education, and tools for building partnerships, policy development, and integration of processes to promote prevention and increase referrals to services for individuals at risk for and experiencing IPV as well as exploitation (including human trafficking). Specifically, this training program works to implement and strengthen collaborations between health centers and agencies serving those who have experienced IPV.

Care Setting–Specific Protocols and Training

The limited existing protocols and training programs specific to essential health care services for IPV in PHEs underscores the need to develop such interventions. In keeping with an all-hazards framework, programming is needed that is rapidly deployable, that can be harmonized across

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¹⁰ https://healthpartnersipve.org/ (accessed September 4, 2023).

different care settings, and that can provide relevant and applicable but broad guidance.

The development of protocols needs to take an all-hazards approach. However, no one form of guidance will suit all situations. Tailoring protocols to address the contextual needs of populations and organizations will be beneficial, particularly for ensuring the equitable implementation of care practices (Brownson et al., 2021; Powell et al., 2017). Tailoring protocols to specific areas such as medically underserved areas, health care professional shortage areas, mental health professional shortage areas, areas served by Indian Health Services, community health centers, Federally Qualified Health Centers, the National Disaster Medical System, and HRSA need to be considered.

Training for Equitable, Culturally Aligned, and Linguistically Aligned Services

Some populations experience inequities in the consequences of IPV as well as systemic barriers to accessible health care related to IPV. These include minoritized racial/ethnic populations, immigrants, individuals with limited English proficiency (LEP), and individuals with disabilities.

Federal civil rights laws require federally funded emergency response and recovery services to provide language access to individuals with LEP as well as accommodations for individuals with disabilities¹¹ (DHS, 2019). The Department of Health and Human Services has provided a checklist with guidance for how to ensure language access and effective communication strategies during a PHE, which can be applied when designing and implementing essential IPV services (HHS, 2018). This includes:

• determining language and dialects spoken by individuals with LEP, who are hard of hearing, or have another disability requiring communication support in the community where services are being rendered;
• partnering with local community groups and organizations that are already serving these populations;
• coordinating with media to develop tailored messages for these groups related to the PHE; and
• providing language assistance, including access to interpreters using effective practices.

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¹¹ See Public Health Service Act, Public Law 78-410, 78th Congress (July 1, 1944); Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 100-707, 100th Congress (May 22, 1974); Post-Katrina Emergency Management Reform Act, Public Law 109-295, 109th Congress (October 4, 2006); Executive Order 13166, August 11, 2000.

IPV care providers can provide culturally aligned social and health care services in PHEs. One way to ensure the delivery of culturally aligned services is to hire and train staff to develop expertise in culturally relevant care. Some services may not be culturally acceptable to specific populations, so new models of service with additional options may be needed. For example, protecting the family’s reputation and stigma related to divorce have been shown to serve as barriers to Hispanic, Asian, and African immigrants seeking traditional IPV services in the United States (Hulley et al., 2023; Keller and Brennan, 2007). When designing interventions for diverse populations, it is essential to understand the varying sociocultural views concerning abusive relationships, expectations for leaving these relationships, the process in which women seek and obtain help, and perceptions of what would be helpful and safe (Barrios et al., 2021). Additionally, a more representative physician workforce can increase trust that patients have in the medical system and in their personal physician, leading to improved health outcomes (Gomez & Bernet, 2019; Jetty et al., 2022; Snyder et al., 2023).

Health care systems can ensure that services are culturally aligned by engaging racially, ethnically, and culturally diverse IPV care providers in the design and delivery of these services. A diverse health care workforce is a key strategy to addressing health inequities. Research has found that racially and ethnically minoritized clinicians are more likely to provide services to underserved communities, improve cultural and language concordance and effective communication, foster trust in clinicians and health care systems, and advocate for the needs of the populations they represent (HRSA, 2006).

Similarly, it is important to ensure that the IPV services being provided are salient to the cultural preferences of diverse groups of women during a PHE. Research has suggested that the designs of IPV services such as shelter and advocacy programs are not always inclusive for minoritized populations, which can lead to myriad barriers to help-seeking and engagement in services for historically marginalized and unserved populations (Kattari et al., 2017). The cultural tailoring of existing services could help enhance access and the effectiveness of these services. For example, in a recent evaluation of two IPV screening and prevention programs for Black women under community supervision in New York, researchers found that the protocol that included a culturally aligned navigator resulted in a 14-fold increase in engagement in IPV-related services (Goddard-Eckrich et al., 2022).

Expanding the Role of Nursing in Intimate Partner Violence Disaster Response

Nurses represent the largest health care workforce in the United States, making it imperative that the nursing workforce fully engage in disaster

management (Smiley et al., 2023; Veenema et al., 2016). In health care settings where IPV survivors may present, nurses are often the first point of contact. They most frequently conduct initial triage and intake, and they generally spend more time with the patient than other health care team members.

In health care settings affected by disasters, nurses are critical at all phases of the disaster management cycle. Evidence from nurses during the COVID-19 pandemic, such as a national survey conducted by the American Nurses Association early in the pandemic, reported a lack of access to personal protective equipment; inadequate knowledge and skills related to pandemic response; a lack of decision rights as pertaining to workflow design, staffing decisions, and allocation of scarce resources; and a fundamental disconnect between frontline nurses and nurse executives and hospital administrators (ANA, 2020; Veenema et al., 2020). Longstanding efforts for nursing education in disaster preparedness and response have been sporadic, limited, and often focused on training activities related to specific disasters rather than being instilled as a standard and ongoing aspect of nursing education (Veenema et al., 2016). The recent National Academies of Sciences, Engineering, and Medicine consensus study report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, specifically emphasizes that strengthening nurses’ capacity to support disaster preparedness and PHE response is a pathway “to enhance nursing’s role in addressing SDOH [social determinants of health] and improving health and health care equity” (NASEM, 2021, p. 248).

One innovative solution for increasing the availability of IPV care providers is implementing a protocol for an on-call, telehealth Sexual Assault Nurse Examiner (SANE). This could be especially relevant for federal response teams, who operate under a federal health care license and therefore would not have the same state licensure challenges as would SLTT teams or volunteers (HHS, 2017). Alternatively, state-level on-call SANE teams could be established that also cover overwhelmed emergency departments during non-disaster times. Additionally, Disaster Medical Assistance Teams could develop and offer IPV training through online modules accessible to all team members.

SPACE AND SHELTERING IN PUBLIC HEALTH EMERGENCIES

Guidance on Sheltering

The U.S. government and international organizations have developed standards for providing safe, equitable, and dignified shelter for populations affected by a disaster. While only some of these documents offer specific guidance for ensuring the safety of women and girls, many of the standards provided can help prevent IPV during sheltering.

At the federal level, the U.S. government has typically preferred that emergency sheltering for disaster survivors occur in facilities with large open spaces, such as schools, churches, and community centers (FEMA, 2021). Privacy for individuals and families is particularly challenging in these congregate spaces, also known as communal shelters in some literature. The risk of assault, abuse, and other forms of violence may increase in communal shelters, particularly at night (IASC, 2017). One review of international literature suggested that this may be due to the lack of physical divisions or boundaries, which remove the safety that some may associate with having a home (Aryanti and Muhlis, 2020). International standards have generally recommended that shelters provide adequate privacy between families (IASC, 2017; Sphere Association, 2018). At the same time, some level of openness in a shelter may allow for natural and communal defenses against violence, including IPV (Aryanti and Muhlis, 2020).

Federal disaster authorities have been flexible in allowing for non-congregate sheltering in appropriate situations. Most notably, the Federal Emergency Management Agency (FEMA) expanded public assistance funding for state and local governments’ sheltering efforts to include non-congregate sheltering during the COVID-19 PHE (FEMA, 2021). Other federal policies and practices that can be extended to emergency shelters include respecting and providing services to sheltering individuals based on their gender identity; the development of clear procedures for sheltering individuals to report threats, violence, and other safety concerns; and reducing financial barriers to shelter access. These have been recommended as part of the Department of Housing and Urban Development’s (HUD) Emerging Practices to Enhance Safety at Congregate Shelters (HUD, 2022). These guidelines were originally created for shelters for people experiencing homelessness, but they could apply to protecting the safety of people experiencing IPV who go to disaster shelters. Similar efforts to apply these HUD and FEMA policies may allow state and local governments flexibility and guidance for protecting people experiencing IPV during emergency sheltering.

International organizations have offered more specific guidance on how to ensure the safety of women and girls during sheltering. Many of these are specifically aimed at preventing IPV and other gender-based violence (IASC, 2017; Sphere Association, 2018). These include

• siting the shelter far from any violence or conflict that may put women and girls at risk;
• allowing for adequate privacy, particularly during bathing, changing, laundry, and menstrual hygiene management;
• ensuring that the shelter is well lit in all areas at all times, especially near toilets and chore areas; and

• avoiding overcrowding, which may increase the risk of IPV in the shelter.

The United Nations Inter-Agency Standing Committee developed a checklist for assessing gender equality in site selection, design, construction, and shelter allocation (IASC, 2017). While much of the language in the checklist is gender-binary, it is important to ensure that the experiences of transgender and gender-diverse people are considered in shelter planning.

CHALLENGES ASSOCIATED WITH SHELTERING

The guiding principles and recommendations for domestic violence shelters can be combined with those for PHE shelters to meet sheltering needs for those experiencing IPV during a PHE. The common characteristics between domestic violence and PHE shelters include having a welcoming space, accepting all those in need, (e.g., regardless of COVID-19 vaccination status or immigration status), and offering a safe setting (CDC, 2021; WSCADV, 2016). Screening protocols need to account for children and pets, the accessibility of the shelter (physical, linguistic, and cultural), the individual’s health history (medical and substance use), and potential cultural, religious, and dietary needs, as well as transportation and safety concerns (WSCADV, 2016). Screening for IPV and safety concerns can still be prioritized if a shelter is open to the general population (e.g., not a domestic violence shelter) (Jenkins and Phillips, 2008).

The COVID-19 pandemic demonstrated that shelters can adapt steady state guidelines to the PHE context. This may involve screening for infection and trauma exposure, setting additional guidelines, supplementing communal shelters with non-congregate shelters such as hotels to provide social distancing, and making personal protective equipment accessible to clinicians and residents (CDC, 2021). The Centers for Disease Control and Prevention (CDC) Shelter Assessment Tool can be used to conduct an environmental health assessment, which addresses areas ranging from basic individual needs for food and water to wellness needs, such as pet companions (CDC, 2020a). When combined with tools for domestic violence, the CDC tool could address the intersecting needs of IPV and PHE survivors.

CHAPTER SUMMARY

The systems, supplies, staff, space organizing approach for disaster response seeks to ensure that service providers have the systems, supplies, staff, and space necessary to carry out their operations. IPV care during PHEs can be organized through this approach as well. Systems and settings that currently exist to support disaster response can be adapted to serve

people experiencing IPV. For example, federal medical stations, Health Care Coalitions, and alternative care sites can all be designed for IPV care. Health care settings and community-based organizations have also developed models to treat IPV during PHEs such as the COVID-19 pandemic. These examples offer guidance for planning, operationalizing, and sustaining essential health services for IPV during PHEs.

REFERENCES