Survivor Perceptions of Well-Being After Working with Domestic Violence Advocates in Healthcare

Domestic violence services are typically short term and crisis-oriented, leaving survivors unsupported when outcomes of abuse are long term or chronic; In combination with the nature of disclosure laws, this short term approach to services reduces survivor autonomy and options. Research on alternatives to partitioned services such as integrated approaches or co-located advocates present in shelters and healthcare settings is limited. This study explores the survivor-perceived effects of working with such an advocate on physical, mental, and emotional health. Findings suggest integrated approaches are valuable across all health domains to survivors, including, importantly, those living with difficult to treat conditions such as chronic pain. Recommendations are made to consider survivor health as complex and interrelated, avoid siloed service provision, protect survivor choice by continuing to reduce the gap between services and survivor needs and increasing access to confidential support. SURVIVOR PERCEPTIONS OF WORKING WITH DV ADVOCATES 3 Survivor Perceptions of Well-Being After Working with Domestic Violence Advocates in Healthcare More than one in three women in the United States have experienced sexual violence, physical violence, stalking, or some combination of the three by a romantic or sexual partner according to the Centers for Disease Control and Prevention’s 2015 National Intimate Partner and Sexual Violence Survey (Smith et al., 2018). The United States Department of Justice defines Intimate Partner Violence (IPV) as “physical, sexual, or psychological harm by a current or former intimate partner or spouse,” a definition this paper is inclusive of but not limited by. This paper will use the term Domestic Violence (DV) to denote both IPV and any impacts of violence that are experienced by other parties such as children. Studies that used IPV terminology will be retained for fidelity. Concerning an inclusive definition of DV, of the women that experience rape before 18, more than a third (38.8%) were raped by a relative other than a spouse (US DOJ, 2000). The National Center for Injury Prevention and Control (2003) reports the costs of intimate partner rape, physical assault, and stalking at over $5.8 billion a year. There is a strong body of literature demonstrating the increased health costs of women who experience physical, sexual, and emotional abuse (Bonomi et al., 2009), demonstrating the essential need for effective prevention and treatment models for DV. There are myriad potential ramifications of surviving DV across physical, psychological, and social domains that may develop into acute and/or chronic health issues (Riedl et al., 2019; Campbell, 2002). The World Health Organization's (2019) ​International Statistical Classification of Diseases and Related Health Problems​ (11th ed.; ICD-11) defines chronic pain as “pain that persists or recurs for longer than 3 months. ” Factors such as the severity or presence SURVIVOR PERCEPTIONS OF WORKING WITH DV ADVOCATES 4 of a physical assault are not necessarily connected to chronic pain outcomes as directly as is assumed in a healthcare context (Tiwari et al., 2013). Despite the interrelated nature of DV outcomes, services are typically partitioned and therefore less effective than could be possible (mehrotra, Kimball, & Wahab, 2016). Literature Review Domestic Violence Outcomes on Health Physical health. ​ The literature has an abundance of evidence supporting the direct link between severe physical and/or sexual assault and health problems in women (Carlson, 2005). The physical consequences of DV include musculoskeletal and gastrointestinal disorders, sexually transmitted diseases, and chronic pain (Riedl et al., 2019; Campbell, 2002). More recently, it has been found that less severe acts of physical violence are also associated with health problems, spurring new research that has begun to discover the impact of mental health on previously unexplained DV outcomes (Carlson, 2005). Coker and colleagues (2000) determined that psychological IPV was associated with arthritis, chronic pain, migraine, stammering, sexually transmitted infections, chronic pelvic pain, and stomach ulcers. Mental health. ​ Post-traumatic stress disorder, depression, substance abuse, and suicidality are among mental health outcomes for survivors (Campbell, 2002; Evanson, 2006). However, the relationship between DV and mental health outcomes is not as unidirectional as once assumed. A critical finding by Sutherland, Bybee, and Sullivan (1998) regarding women experiencing “intimate violence” revealed that injuries themselves had no significant effect on physical symptoms, yet the effects of abuse on physical symptoms appeared to be mediated SURVIVOR PERCEPTIONS OF WORKING WITH DV ADVOCATES 5 through anxiety and depression. None of these health problems can be neatly partitioned; they are complex and interrelated. Mental health and physical health. ​ Tiwari, Fong, Chan, and Ho (2013) surveyed 300 women from DV shelters in Hong Kong who screened positive for physical, psychological, or sexual abuse by a current or former partner and found the injury severity of survivors in their study did not have a significant effect on chronic pain severity, while the severity of sexual abuse had a significant direct effect on chronic pain severity (β = .20, 95% CI = 0.03-0.37, p < .05). There is evidence that DV is a common worldwide experience, suggesting that the experience of women in Hong Kong are shared by women across the world (Garcia-Moreno et al., 2006). A study on the relationship between PTSD symptoms, IPV, and immune function in uninsured women in Baltimore found that “the mental health effects of IPV help to explain how or why there are differences in physical health and immune function outcomes in abused women” (Woods et al., 2005, p. 170). The connection between DV and chronic pain is especially important considering how difficult chronic pain can be to treat, how long lasting its effects are, and its associated cost (Rashbaum & Sarno, 2003). Coker and colleagues (2000) found that “psychological IPV was as strongly associated with the majority of adverse health outcomes as was physical IPV” (p. 451). DV services need to be broadened to manage the compounded and entangled needs of survivors. State of Domestic Violence Services Despite evidence to suggest that services for survivors must coordinate and work simultaneously across societal levels (Dutton et al., 2015; Campbell, 2002), it is much more likely that a survivor encounters short term services isolated to DV needs such as safety SURVIVOR PERCEPTIONS OF WORKING WITH DV ADVOCATES 6 planning, legal advocacy, and shelter services (mehrotra, Kimball, & Wahab, 2016). When DV services do address medical or mental health needs, they are typically focused on immediate and acute medical interventions or siloed mental health regimens (Campbell, 2002). mehrotra, Kimball, and Wahab (2016) have attributed this “fetishization of safety” to the criminalization of DV, and caution that such a paternalistic and binary approach can strip survivors of self-determination, mimicking the power circumstances of the relationship originally in question (p. 157). As Lindhorst, Meyers, and Casey (2008) find, it is essential that DV survivors are provided with the financial resources necessary to exercise their self-determination, making it crucial that even mechanisms such as welfare provision take the effects of DV into account rather than acting in isolation. Interventions are considered less successful by survivors when they operate as detached entities, as Poleshuck and colleagues (2018) found in their community-based participatory research study. Gap in Literature There is a core body of literature concerning the physical health outcomes of DV and a growing portion demonstrating the implications of mental and emotional circumstances on physical outcomes and survivor quality of life. Though there is ample evidence that the existing siloed approach to survivor services is not satisfactory, there is limited information about survivor experience of integrated interventions. This study aims to examine survivor-perceived effects of working with a community-based advocate co-located in shelter and healthcare settings in Oregon. Project Background SURVIVOR PERCEPTIONS OF WORKING WITH DV ADVOCATES 7 The data in this study expanded on the earlier implementation of the Safer Futures model where community-based advocates are co-located to create partnerships and break down silos between IPV agencies and health care providers (Kimball et al., 2018). These advocates are paraprofessionals certified through 40 hours of IPV-specific training and placed in rural, low-resource environments that would not otherwise have been able to afford social workers operating on-site. In accordance with the call for blended services, the project was designed to increase screening and access to IPV services in health care settings (Kimball et al., 2018). The agencies work with health care workers, training them in universal screening and next steps. In light of the budding evidence to suggest that the needs of DV survivors can be better met through more integrated treatment, this paper will examine the survivor-perceived effect of working with a co-located, community-based advocate across physical, mental, and emotional health. Methods In order to assess survivor experience, data were collected through a Survivor Health Follow-up Survey administered to DV survivors by advocates for six months. This survey was developed in partnership with Portland State University and five community-based DV agencies to gain a better understanding of the influence of working with a community-based advocate on DV survivor health. The survey gathers information on survivor perception of their overall physical, mental, and emotional health, specific health issues including pain, anxiety and depressi