"Breaking the Silence -- Public Health's Role in Intimate Partner Violence Prevention"

Uploaded by CDCStreamingHealth on 20.06.2012

ISKANDER: Good afternoon.
I'm John Iskander
with the Office of the Associate Director for Science,
and it's my pleasure to welcome you
to the June session of CDC Public Health Grand Rounds.
Before we move on to today's important session
on intimate partner violence, or IPV,
a note about upcoming Grand Round sessions.
Next month's session on global tobacco control
has been moved to July 24th at 1:00 P.M.
For information about all upcoming topics,
please consult the Grand Rounds website.
A reminder that continuing education credits
for Grand Rounds
are available for multiple professional disciplines.
Details are available through the website listed here,
as well as through the Grand Rounds Website.
For our viewers' information, an article summarizing
the newborn screening Grand Round session
was published two weeks ago in the MMWR.
The article can be viewed and downloaded at cdc.gov/mmwr.
We have also partnered with Science Clips
and the CDC Public Health Library
to feature scientific articles
relevant to intimate partner violence and public health.
This month's selections made by
CDC subject matter expert Thomas Simon
delve more deeply into aspects of IPV, including economics,
clinical screening, the role of alcohol
and are available at cdc.gov/scienceclips.
I also wanted to bring your attention
a past CDC museum exhibition entitled "Off the Beaten Path."
"Off the Beaten Path" presents the work of 28 artists
from 24 countries,
addressing the issues of violence against women and girls
around the world
and their basic human rights to a safe and secure life.
Visit the CDC museum website for more information.
Grand Rounds could not take place each month
without contributions
from numerous public health professionals,
including these individuals
whom I would like to acknowledge at this time.
Today's CDC speakers include Dr. Howard Spivak
and Dr. Lynn Jenkins.
Today's partner expert speakers include Kristi VanAudenhove
from the Virginia Sexual and Domestic Violence
Action Alliance
and Debbie Lee from Futures Without Violence.
It's now my pleasure
to introduce CDC director Dr. Thomas Frieden.
FRIEDEN: Many years ago, my wife co-founded
and then for 15 years ran a center for battered women.
Over those 15 years, we supported
and sometimes temporarily housed families in crisis
who were escaping
from abusive, violent, and dangerous home situations.
The first responsibility of government
is to provide for a safe and secure environment
for all of its citizens.
And as we work on interpersonal violence,
I think we increasingly recognize
that means not only violence on our streets or workplaces,
but also violence that occurs at home.
Interpersonal violence is widespread.
It affects women, men, and children,
and for every population it touches,
it has profound implications.
For children, there's now strong evidence
that there are lifelong health and mental health consequences.
For the economy, there are significant consequences
in terms of productivity, in terms of absenteeism,
in terms of safety at the workplace.
We have a big challenge.
The first is to accurately monitor
the level of interpersonal violence
and then disseminate that information,
our core mission being,
starting as always with surveillance,
documenting a problem, being sentinels for health.
The next is to identify
what works for prevention and mitigation
and then to work with partners to scale up those strategies.
One of the biggest challenges in this area
is not only the silence and lack of attention
that the issue gets in comparison with its importance,
but also the difficulty both methodological,
and, in some cases, philosophical
behind establishing rigorous surveillance
to figure out what works in prevention
and then to scale that up.
So, I'm very much looking forward to this Grand Rounds
and to future work identifying
not only the nature and scope of the problem
but the nature and ability to scale up effective strategies
to prevent and intervene.
Thank you.
ISKANDER: Our first speaker today is Dr. Howard Spivak.
SPIVAK: Good afternoon.
Early in my career, I was invited to participate
in a panel on violence prevention
at the Harvard School of Public Health.
The person who spoke before me, a woman named Sarah,
started by telling the story of a young woman
who was married right out of college
and within six months
found herself isolated from her family and friends,
pushed to quit her job, and was experiencing
a steady stream of physical and emotional abuse
from her husband.
When she tried to share this with her family,
the response was, "It must be something you're doing.
Your husband is handsome, successful,
and taking good care of you.
Be nicer to him."
she was entirely dependent on her husband for money,
which he dolled out in small amounts.
Isolated from her friends, she had little social contact
other than her husband, who was demanding
and controlling about most everything.
She was afraid to leave fearing what he might do to her,
and where could she go anyway?
This went on for two years before she was finally able
to accumulate a small amount of money
and the courage to one afternoon leave the house
with a shopping bag full of clothing,
buy a bus ticket, and leave the city.
As Sarah was describing
how this woman began to turn her life around,
working in a shoe factory and eventually going to law school,
it was suddenly clear to me that she was telling
her own story.
This person who I had known for several years
as a strong, confident, and successful
assistant district attorney had experienced this?
How could that be?
I found myself looking out across the auditorium,
one very much like this one, wondering how many others
were sitting out there with similar stories.
How many times had I sat in an auditorium
or on a bus or at a party
next to or near somebody with a story like this?
All of my preconceived notions were clearly inaccurate,
and why did I know so little about this?
Fortunately, we know much more than we did at that time,
but this was the beginning of my realization and understanding
of the magnitude and depth of this largely hidden problem.
And it is common, for Sarah is just one of millions
of women and men with stories like this.
Intimate partner violence involves physical violence,
sexual violence, threats of physical or sexual violence
and psychological abuse,
including stalking by a current or former partner.
It can occur among opposite or same-sex couples
and can range from a single incident
to an ongoing pattern of violence.
According to CDC data, more than 12 million women and men
are victims of rape, physical violence,
or stalking by an intimate partner each year.
Women are two to three times more likely than men
to experience injury from partner violence.
They are also more likely to experience
a fear of physical violence and sexual violence from a partner
and twice as likely to be killed by their partner than men.
Violence between partners can start at an early age.
Approximately 10% of high-school students nationally
report being physically hurt by a boyfriend or girlfriend
in a one-year period
according to CDC's Youth Risk Behavior Survey,
and we know that these early experiences with dating violence
increase the risk of future partner violence in adulthood.
Experiences with violence
can have effects that last a lifetime.
Partner violence has been linked to a growing list
of mental health conditions, such as depression,
Post-Traumatic Stress Disorder, and suicidal behavior.
The list of chronic health problems
associated with this exposure is growing, as well,
and includes such conditions as Asthma, Heart Disease,
hypertension and stroke.
Partner violence also results in a number of negative sexual
and reproductive health consequences.
Many of these health effects are the result of health risk
and detrimental coping behaviors such as
binge drinking,
smoking and other substance abuse,
as well as the reduced use of preventive health care.
The costs of partner violence are considerable.
The estimated annual cost is over $8 billion
in medical and mental health costs,
as well as lost productivity,
and this does not include the significant cost
to the legal and criminal justice systems,
social welfare programs, and other services
that are a consequence of partner violence.
Partner violence is seldom the result of one factor
but rather is often the product
of individual, social, and environmental factors.
Some of the factors that increase risk
for perpetrating partner violence
include a history of engaging
in anti-social and aggressive behavior,
heavy drinking,
witnessing or experiencing violence as a child,
marital conflict, and economic stress.
Partner violence is also more likely to occur
in communities with high rates of poverty and disadvantage
and where cultural and social norms support violence.
As is true of many public health issues,
central in our role to preventing partner violence
is a collection of data to drive action.
We collect information
to identify key populations at risk,
inform our prevention efforts, track the problem over time,
and evaluate the impact and outcome of prevention efforts.
One such effort is the
National Intimate Partner and Sexual Violence Survey,
which is one of the CDC's newest surveillance systems
and will highlighted by the next presenter,
Lynn Jenkins.
A second is the National Violent Death Reporting System,
which collects detail data on violent deaths from 18 states,
drawing information from medical examiner,
coroner, and police reports
and linking them together
to form a complete picture of these events.
NVDRS records
an average of 450 intimate partner violence homicides
of women, men, and children each year.
Public health also has an important role
in supporting research to inform prevention efforts.
This includes conducting research
to better understand the risk and protective factors
associated with perpetrating partner violence,
identifying which programs, practices, and policies
buffer or alleviate these risks,
including policies and population level strategies
related to reducing the availability of alcohol,
improving economic development in disadvantaged communities,
and countering common stressors
related to intimate partner violence such as
employment, housing, and availability of social supports.
We also need research to determine
how to best scale up effective approaches
and ensure widespread adoption.
In addition to research,
we are also investing in capacity-building efforts
that are setting the stage for communities
to do ground-level work.
This involves data-driven planning in communities
to assess needs,
building support for primary prevention of partner violence,
and developing tools
and providing training and assistance
to identify, implement, and evaluate strategies.
One example of this work
is the CDC's Domestic Violence Prevention Enhancement
and Leadership Through Alliances Program, or DELTA.
You will hear a detailed example of this from our
third speaker, Kristi VanAudenhove.
There is a limited but growing evidence base
on preventing partner violence.
Many programs change knowledge and attitudes.
Few change behaviors.
Strategies include youth and parent focused programs,
therapeutic approaches with at-risk couples,
community based programs, economic and policy approaches.
Those that have demonstrated effects on behavior
in rigorous trials address teen dating violence.
Less is known about effective programs with adult populations.
However, by helping teens learn
how to establish healthy, nonviolent relationships,
we can potentially reduce later partner violence.
One of our large investments is Dating Matters,
which seeks to address the gaps in research and practice with a
comprehensive program for youth, their parents, educators,
and the neighborhoods in which they live.
The program, which is engaging the local public health sector,
is using evidence-based programs for students and their
parents and supporting skills learned with educator training,
local policy development,
and a youth-focused communication campaign
that uses social media and text messaging.
It also has an urban focus, and to date,
there has been little evidence about what works
in preventing dating violence in urban communities
with high rates of crime and economic disadvantage.
The program is being delivered in 45 middle schools
across four cities and includes a rigorous evaluation,
as well as cost analysis.
And the goal of the program
is to promote respectful, nonviolent relationships
and decrease emotional, physical, and sexual violence.
As we have learned in all of our violence prevention efforts,
partner violence is a complex problem
that cannot be addressed by a single program
or by public health strategies in isolation.
Ultimately, the prevention of partner violence
requires collaboration with criminal justice,
education, health services, business, foundations,
community organizations, media, and leadership at all levels.
Public health has a solid history
of being effective conveners of multidisciplinary
and multi-sector initiatives and efforts
and must play a role
in the reduction and elimination of partner violence.
I would now like to introduce Dr. Lynn Jenkins.
JENKINS: Thank you, Howard.
I'm very happy to be here
to talk to you today about a new surveillance system,
The National Intimate Partner and Sexual Violence Survey,
what we call NISVS.
NISVS represents a major advance
in our ability to describe and monitor sexual violence,
intimate partner violence, and stalking on an ongoing basis.
There are a number of strengths
that make this distinctive from any other surveillance system.
Specifically, the study's questions are asked
in a health context rather than a criminal justice context.
The survey asks more than 60 behaviorally specific questions
referenced over the lifetime,
as well as the 12 months prior to the survey.
The sample includes
both landline telephones and cellphones,
utilizing the latest technology and advances
in telephone survey methods.
The NISVS sample is also designed to generate
the first-ever simultaneous national and state level
estimates of these problems.
NISVS data collection began in January of 2010 and is ongoing.
In the first year of data collection,
we obtained more than 16,000 completed interviews,
comprised of more than 9,000 women
and nearly 7,500 men.
More than half, 55% of the NISVS interviews,
were conducted via cellphones.
The 2010 survey was supported by CDC with additional
support from The National Institute of Justice
and The Department of Defense.
Subsequent data collection years are funded by CDC.
Prior to the NISVS 2010 summary report,
the most recent public health surveillance data
on these issues
were from The National Violence Against Women Survey
that had been conducted in the mid 1990s.
Therefore, NISVS provides new benchmark prevalence estimates
for intimate partner violence.
Data from 2010 indicate that approximately one in four women
and one in seven men in the U.S.
have experienced severe physical violence
by an intimate partner at some point in their lifetime.
This includes, for example,
instances of being slammed into something,
hit with a fist or something hard,
beaten, or hurt by choking or suffocating.
As you heard Howard describe,
the definition of intimate partner violence, IPV,
includes physical, sexual, and psychological aggression,
including stalking.
In order to encompass this broad definition,
we have developed a composite measure of IPV
that includes any physical violence,
including slapping, pushing, and shoving,
along with more severe physical violence,
as well as rape and/or stalking.
Using this composite measure,
more than one in three women in the U.S.
have experienced one or more of these behaviors
by an intimate partner.
Of these women,
72% reported being fearful when these things happened,
62% were concerned for their safety,
and 28% missed at least one day of work or school
as a result of this violence.
This violence starts at a very young age.
Among women who ever experienced rape,
physical violence, and/or stalking by an intimate partner,
more than one in five, 22%,
experienced some form of IPV for the first time
between the ages of 11 and 17 years.
Nearly half, 47%,
first experienced IPV when they were 18 to 24 years of age.
As described previously when we used a composite measure
of intimate partner violence,
more than one in four U.S. men have experienced
physical violence,
including slapping, pushing, or shoving,
as well as rape and/or stalking by an intimate partner
at some point in their lifetime.
Of these men,
18% reported being fearful when these things happened,
16% were concerned for their safety,
and 14% missed at least one day of work or school
as a result of this violence.
Among men who ever experienced rape, physical violence,
and/or stalking by an intimate partner,
15% experienced some form of IPV for the first time
between the ages of 11 and 17 years.
39% first experienced IPV when they were 18 to 24 years of age.
NISVS allows examination
of the contribution of each form of violence
and the overlaps across forms of violence.
Among victims who reported intimate partner violence,
you can see that the forms of violence experienced
and the overlaps among them vary by sex.
For women,
57% reported experiencing physical violence only,
while 92% of men reported
experiencing physical violence only.
For women, 4% reported being raped by an intimate partner,
and 3% reported being stalked,
and 9% reported experiencing both rape and physical violence.
14% of women and 6% of men
reported experiencing both physical violence and stalking.
13% of women
reported experiencing all three forms of violence
by an intimate partner at some point in their lifetime.
A range of immediate impacts and longer-term health
consequences were assessed in NISVS.
These are the first national estimates of health consequences
related to these forms of violence.
Overall, 81% of women and 35% of men
who reported experiencing intimate partner violence
at some point over the course of their lifetime
reported at least one health or other impact
related to that violence.
More specifically, of women who ever experienced rape,
physical violence, and/or stalking by an intimate partner,
42% reported injuries
and 63% reported
experiencing Post-Traumatic Stress Disorder symptoms.
Of men who ever experienced rape, physical violence,
and/or stalking by an intimate partner,
14% reported injuries
and 16% reported
experiencing Post-Traumatic Stress Disorder symptoms.
NISVS also allows us to look at
the prevalence of physical and mental health outcomes
among those with and without a history of rape or stalking
by any perpetrator, not just intimate partners,
or physical violence by an intimate partner.
And with regard to longer-term health consequences,
women who experienced these forms of violence
were significantly more likely
to report having Asthma, Irritable Bowl Syndrome,
and Diabetes.
Both women and men
who experienced these forms of violence
were significantly more likely to report frequent headaches,
chronic pain, difficulty sleeping,
activity limitations,
and poor self-assessed physical and mental health
compared to women and men
who did not experience these forms of violence.
Because nearly 70% of women and more than half of men
who ever experienced IPV
first experienced some form of this violence
prior to their 25th birthday,
NISVS data highlights
that we must begin our prevention efforts early.
As well, it is clear
that preventing these forms of violence
will dramatically improve the lives of women and men
in the U.S.,
and our other speaker will address some strategies
and opportunities for prevention.
Planned next steps for the NISVS data specifically
include the publication of a report
describing sexual violence, stalking,
and intimate partner violence by sexual orientation
and a report that provides more in-depth information
on intimate partner violence,
including further exploration of differences
between the experiences of women and men.
To obtain additional information about NISVS,
please visit our website.
I thank you very much
for the opportunity to share this information.
It is now my pleasure to introduce Kristi VanAudenhove.
VANAUDENHOVE: 33 years ago,
I began working in this field as an undergraduate intern.
I had grown up in a violent family,
and I found healing as I did the work.
I found passion and mentors and inspiration
in the vision of a world without violence.
Nearly a decade ago,
that passion and inspiration were rekindled
when I saw an announcement about an opportunity
to collaborate with the CDC to develop the capacity of
state domestic violence coalitions
to more effectively prevent intimate partner violence.
Before the DELTA collaboration with the CDC,
coalitions were seeking to end domestic violence
by achieving two priority goals --
safety for victims and accountability for perpetrators.
State domestic violence coalitions
are membership organizations
of community-based domestic violence programs.
We provide training, support, and resources
to those member agencies
and often to other community professionals, as well.
Over the years,
I've taken many walks on this beach by my home
on the Rappahannock river
contemplating the lessons of DELTA,
which as Dr. Spivak noted,
was designed to help coalitions
prioritize preventing intimate partner violence
and to build their prevention capacity and infrastructure.
I'm going to speak primarily to Virginia's experience,
so let me speak just a moment to describe Virginia.
As I'm reminded by my partner's family
at holiday dinners on a regular basis,
my knowledge and appreciation is limited
because I am not a Virginian.
And that may be what you need to know about Virginia.
Virginians are fiercely proud of their history.
Instituting major cultural changes can be challenging.
From the national perspective,
there appears to be some support for the assertion
that Virginia is different than the rest of the nation.
Before DELTA,
the coalition might have heralded
the publication of the NISVS data
by crediting a policy or practice unique to Virginia
for what appears to be a significantly lower likelihood
of being a victim of rape, physical violence,
or stalking by an intimate partner.
Because DELTA has taught us some appreciation for data
and respect for those who understand and interpret it,
we will be paying attention to these numbers over time
and seeking guidance from our partners
on how best to interpret and apply this information.
In Virginia in 2011,
nearly 64,000 calls were answered
by domestic violence hotlines.
Over 21,000 men, women, teens, and children
received face-to-face services,
6,600 people received emergency shelter,
and more than 3,000 families requested shelter
when shelters were completely full.
Overall, demand for services has increased more than 10% a
year for each of the past three years.
This increase in demand has come at a time
when federal, state, and private funding
have all been declining,
creating a very stressed intervention system
and underscoring the need for prevention.
DELTA has provided four key ingredients
for building the prevention infrastructure in Virginia --
funding, time, structure, and expertise.
Funding has made it possible
to add 2.5 full-time prevention staff at the coalition
and one at each of our four community sites
to do the work of prevention.
Time in the form of multiyear collaborative agreements
has been an invaluable ingredient --
time to learn to build a collaboration
with the CDC and with other states
to plan and to build new skills.
Structure has made the funding and the time
stretch even further.
The CDC team has provided training, technical assistance,
and valued collaboration all along the way.
Finally, adding expertise that we had not previously had
to the mix
is what has made this recipe really turn out well.
The first thing DELTA did
was to change how we think about prevention.
In public health, we're familiar with an analogy
that describes people being swept up in a river
needing rescue.
Intervention is the act of pulling people from the river
so they don't drown.
Prevention is the act of moving upstream
to figure out why people are getting into the river
and addressing the source of the problem.
Attention is created
when you propose to take people out of their intervention roles
and send them upstream to search out the problem
when there are still people drowning.
When you can send folks upstream
prepared to tackle both the immediate problem
and the longer-term solution because
you've talked with folks being pulled out of the river
and have good evidence about the problem and the solutions,
the intervention team becomes
a valued part of the prevention process.
DELTA required
the participation of coalition executive directors.
That addition became key in promoting cross-training
and including plans with sustained prevention efforts
in our coalition's strategic plan.
Virginia's prevention team
and all staff and governing body members
were trained on the principles of prevention,
as well as the desired outcomes
of our state intimate partner violence prevention plan.
The trainings, meetings, regular calls, and e-mail
made it possible for staff in Virginia
to learn from and communicate with CDC staff,
as well as our colleagues in other coalitions.
This structure accelerated our capacity building,
providing ready assistance whenever it was needed.
We set out to create a sound evidence-informed plan
with a strong evaluation component
in hopes that some of the prevention initiatives
in Virginia
would prove to be right for more rigorous research.
At the start of DELTA, the collaborative considered
nearly 100 intimate partner violence prevention programs
as models for primary prevention
and found that none truly were evidence informed.
There were education programs that had been well evaluated,
but they focused only on individuals
and were orientated toward intervention
and early reporting of abuse, not prevention.
There were
innovative multi-strategy prevention projects
that had yet to be evaluated.
As the first decade of DELTA comes to an end,
there are nearly 100 statewide
and community prevention programs
to consider for future research.
These include initiatives focusing on college students,
high school age, and African-American youth.
Early on, the CDC added empowerment evaluators
as a part of the team in each state to the DELTA mix
to guide us through a planning and implementation process
that included evaluation from the start.
This approach established the role of evaluator
as an active participant in prevention.
The concept of empowerment evaluation
was perfect for domestic violence coalitions.
Power and control are central to our work because
the abuse of power is at the core of domestic violence.
Similarly, the movement has placed a high value
on the lived experiences of survivors
as sufficient evidence for action.
Bringing empowerment evaluation to the table
made it clear that power would be shared
and affirmed the experiences of survivors
would be considered a valuable form of evidence
in planning for prevention.
This formed the bridge
that made the science and advocacy partnership possible.
We've been building capacity
in four communities across Virginia.
The axiom "we teach what we need to learn"
has never been truer.
As we have taught rooms full of advocates,
law enforcement officers, and educators what we are learning
about intimate partner violence prevention,
the learning expands.
We share a common understanding of protective factors.
We've all learned more
about developmentally appropriate strategies
in our work with youth,
and we've developed systems
to determine the effectiveness of those strategies.
We've been building a statewide community of practice
that includes not only the local DELTA projects
but any of the domestic violence programs
our community professionals that would like to participate.
College campuses have been particularly eager
to participate,
and young people organizing on campuses
have embraced the concept
of a public health approach to prevention.
Now, it is not unusual
to hear them scrutinizing a cool new idea.
Is it just a one-time activity?
Is it based on a sound understanding
of risk and protective factors?
It isn't public health nirvana.
If the idea is really cool,
they are still likely to go for it.
But, it's a good start for young people
who have developed a healthy appreciation
for what it takes to really build healthy relationships.
Our Red Flag Campaign campuses have been taught
how to use a targeted media campaign
to gather with a series of carefully designed
educational programs and activities,
to do more than just raise awareness,
to change bystander behavior
when someone sees that first red flag for dating violence.
A prevention mindset has permeated our staff,
many of whom are pictured here.
This shapes the partnerships we consider
and the questions we ask.
For example,
we are working with several local law enforcement agencies
to consider how better data could be collected
when they respond
to domestic violence felonies, homicides, and suicides,
data that could inform law enforcement practice,
improve community responses,
and promote
prevention orientated understanding of perpetration,
another example of work that we are beginning
in partnership with young adults with
developmental disabilities.
These young adults are at high risk
of sexual and intimate partner violence
in part because their parents don't always imagine
the possibility that they will be in relationships.
We'll be working statewide on strategies
to educate parents of children with developmental disabilities
about how they can support healthy relationships.
Prevention is now integrated
throughout the work of our coalition.
It's the basis of our new vision statement.
It's prominent in our strategic plan.
It shapes the way we do our work each and every day.
We're now working with partners
who share our goals around preventing violence,
promoting healthy relationships,
and celebrating healthy sexuality.
Over the next 10 years,
we plan to create the Building Healthy Futures Fund
to expand prevention work across the state,
funded partially through sales of a specialized license plate
with the message "peace begins at home."
I want to express our gratitude to the CDC
for opening the door to this collaboration
for sharing dedicated program staff,
science officers, and leaders.
It's now my pleasure to introduce Debbie Lee.
LEE: Good afternoon.
I started my work with Futures Without Violence 30 years ago
by going to San Francisco General
to work with battered women, train emergency room staff,
and create protocols.
For the past four years, I've helped lead Start Strong,
a dating violence prevention program aimed at middle school,
and I have tried out my theories on my middle-school-age
son much to his chagrin,
particularly when I had a small focus group of his friends
inside our van.
[ Laughter ]
Some of you will know us by our old name,
Family Violence Prevention Fund.
We have a 30-year history of developing innovative strategies
to prevent domestic dating and sexual violence in child abuse.
We develop programs to reach men and youth
and transform the way health care providers, police, judges,
employers, and others address violence.
Through partnerships with the CDC
and state domestic violence and sexual assault coalitions,
Futures has worked to expand the commitment
to primary and universal prevention strategies.
Several prevention programs such as DELTA, Dating Matters,
and Start Strong are examples of major initiatives
that work to change social norms
and move beyond the individual level.
Most recently, we worked with the CDC
to change surveillance questions to gather better data
in building the case, particularly for youth.
Today I want to highlight the progress we've made
with health professionals as partners
and the recent policy changes
to prevent and address intimate partner violence.
Then I will talk about programs and policies
to reach new audiences, men, and youth.
Since 1993,
we have been the Department of Health and Human Services'
National Health Resource Center on Domestic Violence.
Starting with 12 emergency departments
throughout the country,
it was the first time that doctors, nurses,
social workers, and domestic violence advocates
sat at the table together as equal partners
to address changes in health care practice.
We have worked to build a consensus
of recommended practice on domestic violence
with health care leaders
based on their needs, what they are willing to do,
and understanding the health system's capacity for change.
We have made changes
to improve professional schooling and training,
medical records, charting and coding,
as well as encouraging community partnership,
policy, and leadership development.
As a result of the recognition
that intimate partner violence is a public health issue,
we saw domestic violence become integrated
in several of the affordable care act programs.
For example, beginning this August,
health plans will cover screening and counseling
for lifetime exposure
to domestic and interpersonal violence
as a core preventative health benefit,
so we are producing a tool kit that will help providers
safely identify, assess, and refer victims to local programs.
Insurance companies will be prohibited from denying coverage
to victims of domestic violence as a pre-existing condition.
And the Affordable Care Act will provide resources to states
to address intimate partner violence,
particularly in-home visitation programs.
In addition to changes from the Affordable Care Act,
intimate partner violence screening
and clinical interventions
have been shown to improve
the health and safety of women and teens
seeking care in reproductive and adolescent health settings,
which was recently recognized
in the U.S. Preventative Service Task Force Review.
In looking at the Affordable Care Act opportunities,
our organization is working on a variety of practice
and policy recommendations.
Much can be done to support existing programs and services
based on age, developmental stage, and gender norms.
Our hope is that clinical guidelines
for violence prevention,
which promote assessment, grief counseling, and referral
are incorporated into publicly funded programs
and school-based health centers,
incorporated in well-women visits and ob-gyn exam,
and during other key visits in reproductive, adolescent,
and behavioral health settings
and included in payment reform efforts
to reimburse for onsite counseling
and support services for patients at risk.
Moving to talk about work with youth and men,
we are also the national program office of Start Strong
Building Healthy Teen Relationships Initiative,
which has explored innovative and practical solutions
to prevent teen dating violence
and promote healthy relationships
among middle-school youth.
These communities represent great diversity
from the Bronx to the state of Idaho.
They include health organizations
like the Boston Public Health Commission
and a number of domestic and sexual assault organizations.
The initiative has utilized a social ecological model,
employing one of two
evidence-based in-school curricula
and change school district policy.
Some of their most creative work has included strategies
that engage school personnel, parents, older teens,
and other youth influencers
and created social marketing and addressed social norms.
There are a number of insights we have had
as a learning community.
First, the middle school years are a key target age group
because many youth begin dating
and start establishing romantic relationships
for the first time.
This is a period of social emotional learning
and empathy maturity.
It is the time
when peer and social influences are increasing,
and at this age,
most youth are still responsive to their parents.
Because tweens and young teens
still look to certain adults and older peers for guidance,
much of our attention focused
on reaching parents of vulnerable youth
and utilizing high-school students as influencers.
As youth mature, we need to move
the bullying education that kids are getting in elementary
school to healthy relationships promotion
and teen dating violence prevention.
Schools themselves are calling for coordination of bullying,
sexual harassment, and teen dating violence policies.
Schools have been the hub
in order to meet youth where they are.
Messages offered at school are reinforced at community centers,
movie theaters, sporting events,
and other places where young people congregate.
The experience of shaping
anti-violence and pro-healthy relationship initiatives
can turn youth into committed activists
who become credible messengers.
Many of the Start Strong communities
have developed youth/adult partnerships
that build youth expertise
and help adults understand youth culture.
Online and mobile communication
is an integral part of the lives of youth
and a focal point of their social engagement.
Incidents of digital dating abuse,
cyberbullying, and sexting have frightened many parents
and caught the attention of authorities.
Online and mobile technology do not cause abuse,
but they make it easier for hurt and angry youth
to harm the reputation and mental health of others.
Social media, however, can be used
to teach youth responsible technology use,
promote appropriate bystander behavior,
and disseminate powerful prevention messages.
I also want to share with you
some of the innovative strategies to engage youth
implemented by Start Strong Boston
of the Boston Public Health Commission.
For example, they saw the public conversation
opportunitiesi n the 2009 dating violence incident
involving pop star idols Chris Brown and Rihanna.
Their survey on the incident, which made headlines,
found that nearly half of Boston youths surveyed
said she was responsible for what happened,
while 52% said they were both to blame.
Start Strong Boston also went on
to hold a summit for parents and youth
to promote healthy relationships and prevent teen
dating violence through a discussion about breakups.
These are just a couple of the examples
of our community's innovative strategies.
I encourage you to check out startstrongteens.org
to see more.
I want to highlight That's Not Cool,
the public education campaign -- national --
that uses digital examples
of controlling, pressuring, and threatening behavior
to raise awareness about and prevent teen dating abuse.
Its target are teens ages 13 to 15.
The website is the hub of the campaign
and engages teens in a variety of activities
about power and control in their relationships,
including interactive videos, games,
callout cards which they can text to each other,
and a tool which allows teens
to create their own unique animated characters.
The campaign was sponsored and co-created
by the Department of Justice's
Office of Violence Against Women,
The Advertising Council, and Futures Without Violence.
Eight of the Start Strong sites also use this campaign.
Another public education campaign
is Coaching Boys into Men,
which engages men to talk to boys in their lives
about violence against women being wrong.
The coach's program includes a 12-lesson curricula
where coaches teach their young male athletes
about the importance of respect, integrity,
and nonviolence on and off the field.
Findings from a recent randomized control trial
in 16 Sacramento high schools
showed a significant increase in boys' intentions to intervene
when witnessing disrespectful or abusive language or behavior.
Coaching Boys into Men coaches expressed greater confidence
to talk with their athletes about healthy relationships and
to intervene when witnessing disrespectful behaviors.
Congress is considering
extending the Violence Against Women Act
for another five years.
The legislation would continue Project Connect,
which has brought together health providers,
public health professionals, and domestic violence advocates
to make changes in adolescent health,
home visitation, and family planning programs.
It would create
a new teen dating violence prevention program
with elements common and complementary
to dating violence and Start Strong.
Finally, There is a new purpose area
that would support funding to states
for prevention and education.
We're hopeful that the final Violence Against Women Act
will be signed this year
and will retain these important prevention sections.
I've seen progress over the past 25 years
with the adoption of interventions
by health care systems,
particularly evidenced-based interventions
in reproductive and adolescent health settings,
and now we have key policy opportunities
to fund this transformation.
I'm excited by the recent focus on men and youth
through programs such as Start Strong,
Dating Matters, and Coaching Boys into Men.
And we look forward to continue work together
with CDC and other partners to end intimate partner violence.
Health and public health leaders
and community partners such as yourselves
are key to promote healthy relationships
and create futures without violence.
Thank you.
[ Applause ]
SPIVAK: We're now open for questions.
We couldn't have been that clear.
[ Laughter ]
BALDWIN: Grant Baldwin, Injury Center.
I wonder if you could speak --
it was an excellent presentation --
about how you message --
one of the things that was very compelling to me
is the notion of the impact of violence across the life course
and how you look -- maybe this question is for Debbie --
how you look at a youth not exposed to violence
and with the sort of evidence-based programs
how their life course changes.
The trajectory of their life is very different
from a middle-school student named Robert or Jen,
how their life is divergently variable
if they are not exposed to violence
and how you utilize that
in sort of messaging and getting energy around
violence prevention.
LEE: Wow. That's a big question.
I will say that most of our work
has been around sort of an universal approach.
So, what I will say is that, one, over the life course,
you really do -- we do really have to pay attention
to where kids are at.
When you talk about teen dating violence, in our case,
when we were doing our program in middle school,
sometimes it had resonance and sometimes it did not at all.
I mean, kids, if they're not there yet,
they really don't get it,
but they do get --
they are all about fairness at middle school
about teachers being fair, kids being fair to one another.
And so they are really --
there is a lot about this healthy relationship
and sort of my right, your right as a middle school student
about what you can expect, what you have the right to.
So, again,
that developmental stage is really, really important.
I think, again,
because we were coming from a universal point of view,
that resonated with kids who were at risk or not at risk,
talking about fairness, talking about --
also at middle school talking about bystanders.
That was a very interesting learning point of view
that we found
that kids weren't always willing or knowing what to do,
as being a bystander,
but they did have a judgment to make.
And so, for that,
I think there's a lot of future work to think about,
and there have been some great programs --
Green Dot, other ones -- that are moving towards that.
And teaching kids where -- they often say --
well, yeah, they often say they know what's going on
in lots of other friends' lives but not in their own,
which may not always be true,
but that's what they're saying, too.
MAN: Two questions.
First, I believe the YRBS data over the last few years
has shown some trends in dating violence.
I'm wondering if you can comment on those,
any theories behind what may be causing any changes
with the patterns that we're seeing, and second,
in the evaluation of criminal justice interventions,
there have been mandatory arrests
or hot-spot attempts to identify families
that have called once or more than once
and more referrals or interventions,
have there been any analysis of these that would help understand
what makes for an effective partnership
with the criminal justice system?
JENKINS: I think that we're not entirely sure
what's driving the changes in the YRBS data.
I think one thing that we have been sort of
really cognoscente about and I know Debbie mentioned it,
is that the question about teen dating violence
had a lot of components, it wasn't very clear,
and so it was not a really good measure.
And so we're thrilled now
that the new question on teen dating violence in YRBS
will give us much better data
and we'll have more certainty that we know
what we're talking about when we look at the data.
Sorry. I apologize.
But I don't think that we know precisely what is behind that.
VANAUDENHOVE: So, in speaking to the question
about the criminal justice interventions
and the impact as part of our planning process to do
our statewide intimate partner violence prevention plans,
we were really encouraged to talk with communities,
with law enforcement professionals
about the trends that they were seeing,
to also look at the research on policies.
And going back even to the question about middle school
to talk to survivors about the experiences they had had
as middle school, high school, young adults
in terms of what interventions made a difference.
What we know is that exposure
doesn't universally have the same impact on people.
And so what could we learn about what was helpful to people
who made it and were part of this system helping,
and what could we learn from folks who are still struggling?
And so I think that
the lessons around the criminal justice system
from the research and from the experiences we heard
seemed to be connected to consistency of enforcement,
consistency of implementation
that the nuances of policy from state to state
may not be as significant
as how communities embrace and enforce those policies,
and that certainly came through in talking to victims
and perpetrators, as well.
And so those kinds of things
then became part of our DELTA communities,
as part of their prevention initiatives are also
engaging their criminal justice system partners,
and how can you do your piece
to implement effectively and consistently
the policies that we do have?
WOMAN: Kristi, I appreciate you raising sort of the inherent
tension between prevention and intervention,
and unless we have an influx of funds
that allows us to do both
at the level we would want to and that we need to,
I was wondering if you have any sort of best practices
or good examples whether it's from Virginia or Debbie.
You may have some as well
in terms of how that tension can be handled in a good way.
So how is it that we can address both
when we, in fact, need to address both
at least for the foreseeable future
until prevention is really effective
and we have less of a need on the intervention side?
VANAUDENHOVE: I feel like you all taught us a lot
about how to do that.
And it had to do with going out and engaging people
who had been involved in intervention
and helping them to see a value to
and some hope for doing prevention,
and it became --
you know, it's not magic in every community,
but for the communities where it's working,
it became a cycle that folks working in intervention
are doing that with a prevention mindset,
and so they see their opportunities,
whether it's for direct intervention
or for data collection or for partnering differently,
and similarly,
the folks doing prevention are doing that
informed by what's happening with intervention,
and it becomes a cycle that feeds itself.
And as we have new opportunities like the one I
talked about with young people with developmental disabilities,
we immediately went to the place
of here is the intervention opportunity
and here's the prevention necessity.
We're going to do both.
LEE: I do think that there are different approaches
for people who are in the trenches, too,
just simple things like about what we're doing with children
who are absolutely in our shelters, et cetera.
It still does take some resources,
which is our challenge,
but I think that there are --
once people really grasp the frame of prevention,
it's much easier to see ways you slip it in.
And I think just bringing those questions in
and bringing in healthy relationship discussions,
teaching moms how to do that can be a big step.
ISKANDER: I would like to thank all of our speakers.
I would like to thank Dr. Frieden,
and we will see our attendees here and our viewers
in five weeks on July 24th for Public Health Grand Rounds
on global tobacco control.
Thank you.