**Promising Practices for Title X-supported Family Planning Clinics:**

**Preventing Family and Intimate Partner Violence**

**Contract Number 282-98-0019,**

**Task Order 13**

**Submitted to**

**Pankaja Panda, PhD, MPH**

**Task Order Officer**

**Office of Population Affairs**

**US Department of Health and Human Services**

**1101 Wootton Parkway, Suite 700**

**Rockville, MD 20852**

**Submitted by**

![](media/image1.wmf){width="2.0006944444444446in"
height="0.5423611111111111in"}

**Centers for Public Health Research and Evaluation**

**2101 Wilson Blvd., Suite 800**

**Arlington, VA 22201**

**The Study Team: Anne Powers, PhD (lead); Joanne Abed, PhD; Tiffiny**

**Bernichon, BA; Holly Carmichael, BA; Kathleen Crowley, MA; Rodolfo
Matos, MAA; and Kendra Versendaal, BA**

**September 2005**

#  

# Acknowledgements

This report presents findings from a two-year long study of family and
intimate partner violence prevention activities in Title X-supported
family planning clinics conducted by the Battelle Centers for Public
Health Research and Evaluation in Arlington, VA.

The study could not have been completed without the leadership and
technical support of the Office of Population Affairs, in particular
Pankaja Panda, the Task Order Officer, and Susan Moskosky, the Director
of the Office of Family Planning.

The study team would like to thank the many clinic directors and health
care providers who participated in the study for their thoughtful
comments and reflections about family and intimate partner violence
prevention in their clinics, as well as for their hospitality in hosting
the study team during the site visits. The promising practices suggested
in this document could not have been identified without their help. In
addition, we would like to thank the Regional Program Consultants and
state Title X grantees who were key informants for the project and
provided insights and ideas about family and intimate partner violence
prevention from the regional and state perspectives.

# Introduction

Family and intimate partner violence (FIPV) includes acts of physical,
sexual, and psychological violence and deprivation, occurring largely
between family members and intimate partners, usually although not
exclusively taking place in the home.[^1] FIPV encompasses child
maltreatment, intimate partner violence and elder abuse. Victims of FIPV
are primarily women and children, although men can also be victims.
Those at particular risk for violence are young women between the ages
of 16 and 24[^2] and women living in the lowest income households.[^3]
Pregnant women are also at high risk for FIPV, with physical abuse more
likely to occur for the first time or to escalate during pregnancy.[^4]

Conducting FIPV prevention activities in Title X-supported clinics
offers a unique opportunity to reach populations particularly vulnerable
to FIPV. The Title X program is the only federal program devoted to
providing access to contraceptive and reproductive health services to
all who need them, with priority given to low-income and uninsured
persons. The Title X program provides reproductive health services to
approximately 5 million people each year. Nearly 80% of clients are
under the age of 30. For many, Title X clinics are the first point of
access to the health care system and to primary providers of health care
services.[^5]

In 2001, a survey of 843 Title X-supported clinics by the Centers for
Disease Control and Prevention and Battelle found that 83% of these
clinics routinely screen for FIPV. More than one-half have written
protocols, procedures, or guidelines for identifying, treating, and
referring clients who are experiencing FIPV.[^6] To assist the majority
of Title X-supported clinics undertaking FIPV prevention activities in
enhancing their programs, and to encourage the remaining clinics to
institute FIPV prevention activities, the Office of Population Affairs
and Battelle conducted a study to identify promising practices in FIPV
identification and prevention.

## **What is a Promising Practice?** 

A promising practice is a program, activity, or strategy that has worked
in one organization and shows promise of becoming a best practice with
long-term sustainable impact.[^7] Identifying a promising practice in
one setting and disseminating it to other settings where it can be
replicated helps to address an issue -- in this case FIPV -- in the new
setting while saving valuable resources such as time and money.
Disseminating promising practices in FIPV prevention in Title
X-supported clinics will help clinic directors, staff and health care
providers more successfully identify clients experiencing FIPV and
respond to the needs of these clients. In the long run, disseminating
promising practices may prevent new cases of FIPV and eliminate or
ameliorate existing cases of FIPV, thereby saving valuable clinic
resources.

Each of the promising practices suggested in this document has been
considered against criteria recommended by the Joint United Nations
Programme on HIV/AIDS (UNAIDS) to evaluate best practices. [^8] These
criteria are:

-   *Effectiveness*  Does the practice work? Does it produce the
    intended outcome?

-   *Ethical Soundness*  Is the practice within the bounds of accepted
    conduct or rules of behavior? Can it be enacted using the resources
    of the organization? Is the potential for causing harm nonexistent
    or minimal?

-   *Relevance*  Is the practice directly related to or in support of
    the objective? Does it 'fit' within the operating environment of the
    organization or agency?

-   *Efficiency*  Does the practice produce the desired outcome with
    reasonable expenditure? Is the benefit/cost ratio favorable?

-   *Sustainability*  Can the practice be implemented over time and
    continue to be effective? Does the practice build capacity within
    the organization or among beneficiaries?

To contribute to the identification and prevention of FIPV in Title
X-supported clinics, promising practices are suggested in four areas:

-   *Training*  Training health care providers and other clinic staff
    in screening for FIPV and responding to the needs of clients who are
    experiencing FIPV is an important part of any clinic's prevention
    activities. Health care providers often supply clients with the
    support and the means to prevent FIPV. Training assists health care
    providers in these activities.

-   *Screening and Intake*  Screening for FIPV takes many forms. Most
    clinics screen patients with one or more questions on an intake
    form. Many clinics and health care providers supplement the written
    screening tool with verbal questions and conversations with clients.

-   *Clinical Evaluations*  Many health care providers maintain that
    identification of FIPV typically occurs during the course of the
    exam and other interactions with patients rather than during
    screening.

-   *Follow-up and Referral*  Helping a client move away from a
    situation where they are experiencing FIPV can be a lengthy and
    difficult process. Providing long-term support is a necessary
    feature of the process.

> Real-world practices identified at the participating Title X-supported
> clinics are highlighted in information boxes throughout this document.

# Identifying Promising Practices

Several methods were used to identify the promising practices
recommended in this document. These included interviews with health care
providers and clinic directors at Title X-supported clinics, interviews
with state and federal employees who are knowledgeable about the Title X
program and FIPV, and site visits to Title X-supported clinics.
Information collected during these activities was supplemented by a
literature review of FIPV and reproductive health issues with an
emphasis on clinical practices and considerations.

## **Interviews with Health Care Providers and Clinic Directors**

Open-ended, unstructured, in-person interviews were conducted with 9
clinic directors, 17 clinicians, 2 health educators, and a vice
president in charge of training. Seven of the clinic directors are also
clinicians. The clinicians interviewed are primarily nurse
practitioners, but also include three physicians and several registered
nurses and social workers. The interviews lasted between 20 minutes and
two and one-half hours. Clinician interviews were usually shorter than
clinic director interviews. Though unstructured, the interviews covered
four primary areas of interest: clinic policies and protocols, routine
screening procedures for FIPV, health care provider and staff training
programs, and collaboration with community organizations. Challenges and
facilitators to identifying and responding to FIPV were also discussed.

## **Interviews with State and Federal Employees**

To obtain a different perspective on FIPV prevention activities in Title
X-supported clinics, open-ended, unstructured telephone interviews were
conducted with 9 state employees who oversee the Title X program in
their state and 8 federal employees who are Program Consultants for
Department of Health and Human Services (DHHS) regions across the United
States. The state employees were chosen because they represent the same
states where visits and tours of Title X-supported clinics were
conducted and where the health care providers and clinic directors are
employed. One state in each of 9 of the 10 DHHS regions was represented.
The federal Regional Program Consultants represented 8 of the 10 DHHS
regions. Similar to the health care provider and clinic director
interviews, clinic policies and protocols, routine screening procedures
for FIPV, health care provider and staff training programs, and
collaboration with community organizations were discussed with the state
and federal employees. In addition, they were asked about the challenges
and facilitators to identifying and responding to FIPV.

## **Tours of Title X-supported Clinics**

Visits to 9 Title X-supported clinics were conducted and tours taken of
the facilities. Clinics were selected and invited to participate in the
study so that the final group achieved a mix of location, organization
type and community type. The clinics are located in 9 of the 10 DHHS
regions and included four county health departments, three Planned
Parenthood clinics, and two community health centers. Five served
primarily urban or suburban populations and four served primarily rural
populations. All of the clinics were receiving Title X funds at the time
of the visit. Two members of the research team visited each clinic. The
clinic director conducted a tour of the facility, and the research team
observed the waiting rooms, examination rooms, consultation rooms,
restrooms, laboratories, and offices. The research team noted the
experience from the patient's point of view, looked for information
(posters, brochures, flyers) about FIPV in the clinic locations, and
considered the privacy of each location where clients might disclose
FIPV in writing or verbally. A description of each participating clinic
as well as a summary of each clinic's FIPV practices concludes this
document.

## **Literature Review**

The research team conducted a literature review of peer-reviewed
journals, published books and articles, documents produced by
professional organizations, and web-based documents published from 1999
to 2005, although a few seminal documents published prior to 1999 were
also included in the review. The focus was on FIPV and reproductive
health, including contraception, pregnancy, sexually transmitted
diseases and human immunodeficiency virus (HIV), with an emphasis on
clinic considerations and documents. In particular, four types of
clinical documents were sought out -- protocols and guidelines for
clinicians, tools for screening and prevention, clinical training
methods, and programs and evaluated interventions for FIPV prevention.
In total, 166 documents were included in the literature review set.

The promising practices suggested in this document are based primarily
on the experiences, practices and ideas of the health care providers and
clinic directors who participated in the study but are supplemented by
the observations and ideas of the state and federal employees who
participated as well as the information gleaned from the review of the
literature.

# Promising Practices -- Training

Health care providers represent one of the most important factors in
identifying and responding to FIPV. The study team found that even at
clinics with only basic FIPV prevention programs, clinicians still made
a significant contribution to FIPV prevention as caring and
knowledgeable health care providers. Training health care providers in
screening for FIPV, awareness of the risk factors for FIPV, recognizing
the signs of FIPV, and responding to the needs of clients experiencing
FIPV is arguably one of the most important steps clinics can take to
prevent FIPV. Of the clinics visited for this study, six of the nine had
formal training programs for health care providers. The methods ranged
from ½-hour videos to multi-day programs taught by staff from community
organizations specializing in FIPV.

The most common training method was through annual one- to two-hour
in-service presentations or lunch meetings, with periodic updates
provided through the same means. The clinics participating in the study
typically developed their own training, although several pre-packaged
training programs for health care providers are available for less than
a few hundred dollars. Health care providers were open to FIPV training,
and those that had received training found it to be useful.

## **Key Training Elements**

Although FIPV has physical manifestations and medical implications, FIPV
is dissimilar in many ways to other conditions that health care
providers may encounter while treating patients. FIPV has social,
behavioral, psychological and economic factors that make resolution of
FIPV difficult. Health care providers experience barriers when dealing
with FIPV such as fear of offending patients, cultural and communication
differences, fear of endangering patients, lack of information about
resources for patients experiencing FIPV, limited time to work with
patients experiencing FIPV, fear of legal involvement, and frustration
about how difficult FIPV can be to 'fix.'[^9] Promising training
programs incorporated elements that recognized these factors such as:

-   Helping health care providers overcome anxiety about talking to
    clients about FIPV

-   Including role plays and practical approaches and tips to working
    with clients experiencing FIPV

-   Focusing on improving provider self-efficacy about screening for and
    responding to FIPV

-   Stressing the fact that helping clients experiencing FIPV sometimes
    takes longer to achieve results than is true for other health
    concerns and that resolution sometimes never occurs but that clients
    still need support

-   Teaching health care providers about making safety plans with
    clients

-   Incorporating frequent updates and reminders as research shows that
    brief, one-time trainings are sometimes ineffective[^10]

-   Including input from local experts in FIPV and representatives from
    community organizations providing FIPV services

# Promising Practices -- Screening and Intake

Most clients' first encounter with a clinic's FIPV prevention program is
during intake and screening. Every clinic that participated in this
study uses one or more standard questions (either written or verbal) to
screen for FIPV. These questions are administered at initial intake and
repeated at least annually for most clinics. Some clinics repeat the
questions at every visit. A second verbal screening with more in-depth
questions, or screening by a health care provider, occurs when the
client indicates abuse on the intake form or the health care provider
suspects violence. Procedures for the second screening tend to be unique
to each clinic. It is typically done by the primary health care provider
but some clinics employ social workers, social service coordinators or
Sexual Assault Nurse Examiners to talk to clients who are at-risk for
FIPV.

The greatest challenge noted by the health care providers and clinic
directors who took part in this study was ensuring the privacy of
clients during standard screening and intake procedures. Privacy and
confidentiality are always important considerations in providing health
care but especially important with FIPV because a loss of privacy or
confidentiality could put a client at risk for violence. All of the
clinics visited by the study team take actions to protect clients'
privacy. Clients are usually screened in private as standard procedure
or moved to private areas when FIPV is suspected. Some of the clinics
the study team toured have areas where clients and providers can be
overheard. Health care providers are aware of this and have methods to
overcome the lack of privacy. For example, in one clinic where an exam
room is not private, the health care provider completes the physical
examination in one room and then moves the patient to another for
'consultation,' portraying this as a standard procedure.

# Promising Practices -- Clinical Evaluations

After screening and intake, clients are seen and examined -- usually
when alone -- by a health care provider. Most of the health care
providers who took part in this study see this as the primary
opportunity to talk about FIPV and assess clients' FIPV risk. These
health care providers are skeptical about the truthfulness of clients'
responses to FIPV screening questions, and some research suggests that
this skepticism is warranted.[^11] Clients are sometimes reluctant to
admit FIPV in standard screening questions and, when they do, the
admission often refers to a past situation. Promising practices related
to clinical evaluations include using: standard no admittance policies
for partners and families; in-home programs as an opportunity to
identify FIPV; health care provider experience and instincts; and
designating one or two key people in a clinic to respond to FIPV cases.

Nearly all of the health care providers the study team spoke to,
particularly those most experienced in FIPV, mentioned using experience,
close observation and their clinical 'instincts' to identify FIPV in
their clients. Aside from physical signs such as abrasions, bruising and
swelling on the face, abdomen, breasts, arms and hands, clinicians also
looked for signs such as:

-   Failure to make eye contact

-   Fear of being alone with the clinician and other clinic staff

-   Flat affect

-   Following instructions too carefully

-   Extreme discomfort or pain during vaginal exams

-   Dislike of being touched in any way

-   Frequent visits for unexplained complaints

-   General dislike of or defensiveness about screening questions

-   Evasiveness or limited answers to questions

-   Alcohol or drug abuse

-   Frequent changes in residence or living situation

-   Extreme concerns about privacy and confidentiality

-   Patterns of communication and non-verbal behavior between partners
    who are present during the visit

Some clinicians said they "just know" something is wrong and use their
experience and a caring manner to help the client reveal the situation
in her/his own way.

In many of the clinics the study team visited, one or two individuals
are the experts or 'go to' people for FIPV. This may be an artifact of
the procedures used to identify clinics that were asked to participate
in the study because all the clinics asked were known to be undertaking
some FIPV prevention activities. Possibly these clinics agreed to
participate because of a common interest in or concern about FIPV by
someone at the clinic, and these individuals were naturally the clinic's
FIPV expert.

Nevertheless having someone who has training and expertise in FIPV is a
useful resource. Sexual Assault Nurse Examiners, social services
coordinators, social workers, and clinic directors served in this role.
These individuals support health care providers by screening at-risk
clients or those whom clinicians identified as suspect FIPV cases,
working with clients by providing information and referrals, and making
safety plans with clients experiencing FIPV. The FIPV experts also
provide FIPV training and updates to other staff as well as interacting
with community organizations specializing in FIPV. For example, the
clinic in Region V has hired an advocate from a local rape crisis center
to work as their resident outreach worker. The clinics in Regions I, V,
VI, and VII have each hired a Sexual Assault Nurse Examiner -- on a
full- or part-time basis -- to assist in providing services to clients
experiencing FIPV.

# Promising Practices -- Follow-Up and Referral

Methods for following up with clients identified as experiencing FIPV
and providing referrals to agencies that provide services to individuals
experiencing FIPV are critical components of an FIPV prevention program.
Yet these are challenging activities for Title X-supported clinics and
health care providers because they often require already scarce
resources such as time, staff, space and money.

Collaboration with organizations and other agencies that specialize in
providing FIPV and other services beyond those offered by the Title
X-supported clinic is among the most important methods of providing
follow-up and referral services to clients experiencing FIPV. In
essence, community collaboration represents a means for clinics to
extend their services to include the ongoing support that clients may
need. All of the clinics that took part in this study rely on some type
of community collaboration to assist them in their FIPV prevention
activities. The rural clinics found identifying collaborators to be more
challenging than did the urban clinics because of the limited number of
organizations in their respective areas. Clinicians in rural areas, as
well as state and federal staff, noted this as a particular concern with
FIPV as safe houses and crisis centers are few in these communities and
their locations sometimes well known to all residents. Despite this
limitation, all of the rural clinics had community partners. The Region
II clinic (an urban clinic) is featured in the Real-World Practice box
because it is part of an anti-violence community coalition. Other
community collaborations include:

-   The Region I clinic partners with the local shelter and the state
    coalition against sexual and domestic violence.

-   The Region III clinic works with local businesses and the local
    college to raise the community's awareness about FIPV.

-   The Region IV clinic works with the sheriff and hospital systems in
    neighboring communities on issues involving children.

-   The Region V clinic partners with the YWCA and works with a mental
    health clinic, a substance abuse center and a rape crisis center on
    particular cases and mutual referrals.

-   The Region VI clinic works with the local hospital and schools, the
    safe house, and local churches to provide services for women and
    children in crisis.

-   The Region VII clinic refers cases to two local crisis centers and
    works with local schools and some PTAs to raise awareness about
    FIPV.

-   The Region IX clinic partners with a women's anti-violence
    empowerment organization on staff training as well as working with
    youth groups and Hispanic and Asian community organizations on other
    activities.

-   The Region X clinic works with a women's empowerment organization, a
    family support group and two safe houses to respond to FIPV cases in
    the community.

In addition to working with community partners to extend their services,
clinics and health care providers employ practices that allow them to
follow up with clients about whom they are concerned. For example,
clinics use a variety of approaches when recording FIPV on a patient's
chart. Some elect to record nothing about FIPV to protect patients'
privacy, relying on health care provider memory to follow-up with
patient at the next visit. By making no entries, there would be no
record of the FIPV if the charts were viewed by an unauthorized person,
stolen or subpoenaed. Other clinics use coded entries to record FIPV on
the chart so that only staff can understand the entries. Then at a later
appointment, any health care provider can follow-up with the client.
Still others use a code known only to patients and designated health
care providers. Coded records are useful particularly when computerized
records are kept, preventing unauthorized access to FIPV records. The
Region II clinic uses an integrated computer program for screening and
records management. FIPV records are password-protected and accessible
to be used for follow-up with clients but cannot be accessed by anyone
who is not authorized. To maintain the client's privacy and safety
further, this clinic also establishes an alternate address to send
correspondence and alternate contact information to reach the client
following identification of FIPV.

# Summary of Participating Clinics

## **Clinic A:** County Public Health Department

> Location and Population Density: City location serving a rural
> population
>
> Race/Ethnicity of Population: Mixed Hispanic and Native American
>
> FIPV Activities

-   Training: A 1-2 day training curriculum is provided to clinicians
    annually by the state. This training was developed by the state and
    in accordance with federal guidelines. Training updates are
    incorporated into monthly staff meetings. As a rural clinic, staff
    must travel some distance to attend trainings.

-   Screening and Intake: All patients are screened at initial intake,
    and annually thereafter, as part of the state health history form.

-   Clinical Evaluation: If abuse is identified or suspected, the health
    care provider privately and verbally reviews the intake form with
    the patient in the exam room and discusses indication or suspicion
    of abuse. Also all prenatal and postpartum visits include verbal
    screening during each visit.

-   Follow-up and Referral: After abuse is indicated, the nurse manager
    meets with the patient in a private office after the exam and offers
    counseling and referral information. The patient is provided with
    options about what to do and where to go when domestic violence
    occurs. Follow-up occurs after the exam when the patient's situation
    is deemed very serious and the nurse is concerned about the
    patient's safety and well-being.

## **Clinic B:** Community Health Center 

> Location and Population Density: City location serving a rural
> population
>
> Race/Ethnicity of Population: Primarily Anglo
>
> FIPV Activities

-   Training: Formal training in FIPV is provided annually to all staff
    at the clinic. This training includes a review of protocols and
    reporting laws and a presentation about FIPV by a guest speaker from
    a community partner. Staff members also receive updates on FIPV
    issues during lunch meetings. These updates last about one hour and
    are conducted quarterly. For the future, health care providers have
    requested additional training in the form of "worst-case scenario"
    role plays.

-   Screening and Intake: All patients are privately screened with a
    written questionnaire in the exam room by the medical assistant at
    each visit, time permitting.

-   Clinical Evaluation: Verbal screening is performed by the health
    care provider during the exam in cases where the patient has either
    indicated abuse or the clinician suspects abuse. Information
    pertaining to FIPV is entered into the chart in code and stored in a
    locked cabinet apart from the patient's medical file for protection
    purposes. Computer records are password-protected.

-   Follow-up and Referral: For patients identified as having
    experienced FIPV, the clinician arranges a meeting with the social
    worker to perform a safety assessment. This assessment is used to
    identify whether or not it is safe for the patient to return home.
    The social worker then makes appropriate referrals to community
    partners.

## 

## **Clinic C:** Family Planning Clinic 

> Location and Population Density: City location serving an urban
> population
>
> Race/Ethnicity of Population: Primarily Anglo
>
> FIPV Activities

-   Training: All staff members are given the opportunity to attend
    conferences and lectures on topics related to FIPV. Clinicians can
    attend both state-sponsored training and local training. Some nurses
    also attended a DHHS conference that focused on FIPV. Local training
    is provided by the YWCA and takes 50-60 hours to complete. The
    curriculum includes onsite training, role playing, general education
    and lectures by guest speakers. Staff spoke positively about the
    training they had received, but expressed a desire for additional
    educational opportunities focused on FIPV.

-   Screening and Intake: Screening occurs at initial intake, and
    annually thereafter, as part of the health history and social
    history forms.

-   Clinical Evaluation: Clinicians privately and verbally screen only
    when the intake form indicates abuse or they feel someone is at risk
    or shows signs of FIPV. A clinic volunteer who also works with the
    local YWCA is called upon as needed.

-   Follow-up and Referral: Once the client confirms abuse, the Social
    Services Coordinator discusses options with the client. Police
    escorts and Child Protective Services are called if needed. Shelter
    is found for the client if possible. Telephone numbers and a
    referral list are given to clients not willing to be transferred to
    a shelter.

## **Clinic D:** Community Health Center

> Location and Population Density: City location serving an urban
> population
>
> Race/Ethnicity of Population: Mixed African-American and Hispanic
>
> FIPV Activities

-   Training: Training is provided annually to all clinic staff. The
    45-minute in-service training is not based on a formal curriculum.
    The material presented focuses primarily on signs and symptoms of
    FIPV.

-   Screening and Intake: FIPV screening is mandatory for all initial
    patient visits and all prenatal visits. Policy also requires all
    patients to be screened annually. This screening is performed
    privately by a medical assistant or social worker with a written
    questionnaire.

-   Clinical Evaluation: Health care providers follow-up affirmed or
    suspected cases of FIPV with a verbal screening.

-   Follow-up and Referral: Clients identified as experiencing abuse are
    referred to a social worker who counsels client on various options.
    If the client does not want immediate help, the social worker
    provides them with information they can refer to at a later time. If
    the client requests immediate help, a referral to a partner
    organization is made. Hotline information is provided to clients via
    discreet business cards.

## 

## **Clinic E:** Family Planning Clinic 

> Location and Population Density: City location serving an urban
> population
>
> Race/Ethnicity of Population: Primarily Anglo
>
> FIPV Activities

-   Training: No training related to FIPV is provided to the general
    clinic staff. The clinic employs a Sexual Assault Nurse Examiner
    (SANE) who has received formal training in FIPV.

-   Screening and Intake: All patients are screened at initial intake
    with a patient history form that includes several questions related
    to FIPV.

-   Clinical Evaluation: If patients indicate FIPV during the written
    screening, or FIPV is suspected, the health care provider follows-up
    privately and verbally before the exam. If the health care provider
    needs help with a case, the Sexual Assault Nurse Examiner is
    consulted.

-   Follow-up and Referral: No formal referral process is currently in
    place. If a minor is experiencing domestic violence, the authorities
    are called. The clinic workers provide all other cases with
    materials and brochures developed specifically for these instances.

## **Clinic F:** County Public Health Department

> Location and Population Density: Suburban location serving a rural
> population
>
> Race/Ethnicity of Population: Primarily Anglo
>
> FIPV Activities

-   Training: Staff have the option of viewing a ½-hour video on FIPV
    when hired. Though staff used to receive annual updates to this
    training, these updates have not been kept up recently. Staff
    reported a desire to have additional information and training on the
    topic of FIPV.

-   Screening and Intake: All patients are screened with two questions
    on the intake screening tool.

-   Clinical Evaluation: The clinician uses the Maternal Case Management
    Assessment Tool to privately and verbally screen during exam if
    abuse is indicated or suspected. "Shoe cards" are handed out to
    clients experiencing abuse.

-   Follow-up and Referral: In situations of affirmation of abuse during
    private in-home visits, the nurse talks privately about safety plans
    and community resources if the patient is ready. If not, the nurse
    plans further visits with the patient to monitor the situation.

## 

## **Clinic G:** County Public Health Department

> Location and Population Density: Suburban location serving a mixed
> suburban/rural population
>
> Race/Ethnicity of Population: Primarily African-American
>
> FIPV Activities

-   Training: No formal training is provided to staff by the County
    Health Department. Some clinicians have received training from other
    sources.

-   Screening and Intake: All clients fill out a health history form at
    the intake desk. This form includes a question related to FIPV
    incidence.

-   Clinical Evaluation: If a client responds to the written FIPV
    screening affirmatively, or if the clinician suspects FIPV, the
    client is privately and informally screened during the exam.

-   Follow-up and Referral: Once abuse is identified, the clinician
    provides the patient with the name and number of the local shelter
    or refers the client to the Health Department's Mental Health
    Division. To protect clients, Health Department staff do not know
    the location of the local shelter but will facilitate contact with
    the shelter via the telephone for at-risk clients.

##  

## **Clinic H:** Family Planning Clinic 

> Location and Population Density: City location serving an urban
> population
>
> Race/Ethnicity of Population: Mixed Hispanic, Asian and
> African-American
>
> FIPV Activities

-   Training: All clinical and frontline staff receive training created
    by the clinic's managing organization, based on a national protocol
    and incorporating state-specific requirements. There are currently
    two different curricula used: a two-hour course and a one-day
    course. The curricula include training on medical aspects, policy
    aspects and social aspects of FIPV. The clinic also tries to send
    all staff to a national FIPV education program. Clinic training
    updates typically occur in October for *Domestic Violence Awareness
    Month*, but may also be conducted more regularly if the clinic sees
    a spike in its FIPV-patient load.

-   Screening and Intake: All patients are screened at intake with a
    written form at every visit. If the client answers affirmatively to
    any of the screening questions, a health services specialist
    follows-up with a verbal screening and alerts the clinician.

-   Clinical Evaluation: If a patient has been identified as or is
    suspected of experiencing abuse, the clinician privately asks about
    FIPV during the exam. Information regarding FIPV is recorded on a
    separate form that is not part of the patient's chart. The
    information on this form is protected and will not be copied.

-   Follow-up and Referral: After abuse is confirmed, the clinician
    informs the client of the clinic's mandatory reporting obligations
    and the client's privacy rights. The clinician then follows up with
    the client to facilitate and inform the client of their options and
    provide referrals and resource information. If the client indicates
    she/he would like assistance, the clinician refers them to a
    community FIPV partner and provides resource information related to
    the organization. If the client would like to make an official
    report, the clinic coordinates among staff to arrange a time where
    the client will be safe and the reporting will be kept private.

## 

## **Clinic I:** County Public Health Department

> Location and Population Density: City location serving a rural
> population
>
> Race/Ethnicity of Population: Mixed Anglo and African-American
>
> FIPV Activities

-   Training: No training is provided.

-   Screening and Intake: All patients fill out an intake form that
    includes a question regarding FIPV.

-   Clinical Evaluation: Informal verbal screening is performed
    privately by the health care provider if abuse is indicated or
    suspected. Patients' charts include informal, non-specific notes
    about FIPV for confidentiality purposes.

-   Follow-up and Referral: Patients identified as, or suspected of,
    experiencing FIPV are given written and verbal information by the
    clinic director who is also a nurse practitioner. A hotline is
    offered for counseling and information. Counseling and follow-up are
    arranged at another center if patient privacy is a concern. At the
    next visit, the clinician attempts to discern if abuse is continuing
    by talking with and observing the patient.

[^1]: Krug EG et al., eds. *World Report on Violence and Health*. World
    Health Organization, 2002.

[^2]: Bureau of Justice Statistics Special Report (NCJJ 178247), US Dept
    of Justice, Office of Justice Programs, 2000.

[^3]: Erwin J and Vidales G. *Domestic Violence: People of Color and the
    Criminal Justice System. A Case for Prevention.* Family Violence
    Prevention Fund, 2001.

[^4]: McFarlane J, Parker B, Soeken K, and Bullock L. Assessing for
    abuse during pregnancy; Severity and frequency of injuries and
    associated entry into prenatal care. *JAMA* 1992;267:3176--3178.

[^5]: Office of Population Affairs, Office of Family Planning. Available
    at: http://opa.osophs.dhhs.gov/titlex/ofp.html

[^6]: Battelle. *Evaluation of Public Health Care Providers' Training,
    Screening and Referral Practices for Pregnancy-Related Violence.* A
    report submitted to the Centers for Disease Control and Prevention,
    National Center for Chronic Disease Prevention and Health Promotion,
    Division of Reproductive Health. May 2002.

[^7]: DHHS, Administration for Children and Families., Available at:
    http://www.acf.hhs.gov/programs/ccf/resources/gbk_bp/bp_gbk_ov.html

[^8]: UNAIDS Best Practices Collection. Available at:
    http://www.unaids.org/en/resources/publications/best+practice+collection.asp

[^9]: Garimella R, Plichta S, Houseman C, and Garzon L. Physicians'
    beliefs about victims of spouse abuse and about the physicians'
    role. *J of Women's Health and Gender-Based Med,* 2000;9;
    Walton-Moss B and Campbell J. Intimate partner violence:
    Implications for nursing. *Online J of Issues in Nursing*. 2002;
    7:6.

[^10]: Perrin K, Boyett T and McDermott R. Continuing education about
    physically abusive relationships: Does education change the
    perceptions of health care practitioners? *J of Continuing Educ in
    Nursing.* 2000; 31:269--274.

[^11]: Ramsay J, Richardson J, Carter Y, Davidson L, and Feder G. Should
    health professionals screen for domestic violence? *British Med J.
    2002;325*