Violence Assessment and Follow-up In Public Health Data Sets

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1 Violence Assessment and Follow-up In Public Health Data Sets Background Summer, 2012 This project was initiated to explore existing data on assessment of violence in the lives of women seeking services via the Maternal Child Health (MCH) Funded Perinatal Care Program (PNCC), the Wisconsin Women, Infants and Children s Nutrition Program (WIC), and responding to the Pregnancy Risk Assessment and Monitory Survey (PRAMS). In addition, the documentation of referrals for violence, when violence was identified as a risk factor, was evaluated. Project outcomes included: 1. To establish baseline measure of how often and when women are asked the questions pertaining to violence on assessments for WIC or MCH/Medicaid funded (PNCC) services. 2. To determine patterns of referral for women responding that there is interpersonal violence in their lives. 3. Analyze and monitor responses in PRAMS to questions of abuse before, during and after pregnancy. 4. Create an effective information campaign targeted at public health professionals working with clients enrolled in WIC and MCH/PNCC. 5. Create resources for public health professionals to assess and refer clients. 6. Continue to monitor and evaluate public health performance in assessing and responding to violence in client lives. 7. To establish policy recommendations for systems change to normalize standards of assessment and referral for violence in public health settings. Violence is shown to be associated with a wide-range of impacts on the health and wellbeing of individuals and communities. Violence and abuse is an unrecognized underlying cause of acute and chronic disease, early mortality, high risk behavior choices, and can threaten academic success and economic stability. Additional research has identified the impact of constant stress on the architecture of the developing brain that results in changes in social, emotional, cognitive, and neurobiological function. Exposure to violence, whether current or past, is linked to reproductive coercion, sexually transmitted disease, teen pregnancy, poor pregnancy and birth outcomes, compromised infant child bonding, and a decrease in the level of parenting skills. It is our hope, that by demonstrating this through Wisconsin s current data collection systems, that public health practice will grow in its consideration of violence as a determinant of health. SPHERE, and PRAMS Page 1

2 Related Data About Violence Among Women in Wisconsin National Intimate Partner and Sexual Violence Survey (NISVS) 1 results report national and state level data on lifetime experiences of rape, physical violence and/or stalking. According to NISVS, 36% of women in the United States reported these experiences, and 48% of women have experienced at least one form of psychological aggression, either in the form of expressive aggression (partner acted angry in a way that seemed dangerous) or coercive control (limiting money, contacts, or access to contraception). (Table 1) Table 1: Estimated Victimization of Sexual Assault, National Intimate Partner and Sexual Violence Study, 2010 Lifetime Prevalence Rape, Physical Violence, and/or Stalking by Intimate Partner National Prevalence Wisconsin Prevalence 36% 32% Equals 714,000 Wisconsin women > 18 years Adverse Childhood Experiences (ACE) Study and related research 2 provides information on the prevalence of violence in the lives of children and correlations to health outcomes as an adult. (Figure 1) Participants completed a confidential survey about experiences of childhood maltreatment and family dysfunction; a positive answer to a question is a point towards an ACE score, with significant correlation to compromised health outcomes at an ACE score of 4 or more. Participants approved access to their Figure 1 The ACE Study began in 1997 as collaboration between Kaiser Permanente HMO and the Centers for Disease Control and Prevention. It recruited over 17,000 patients enrolled in the San Diego area undergoing routine physical examinations. ( medical records, providing researchers with a wealth of information to examine ACE experiences and multiple mental, physical, behavior outcomes, and on academic achievement, financial and social stability. In 2010 an ACE Module was added to the Wisconsin Behavior Risk Factor Survey. In 2012, a report of the first year of data was released, documenting that 56% of the adult population reported having experienced at least one ACE, and 14% have a score of 4 or more ACEs 3 (Table 2) 1 Center for Disease Control and Prevention, National Intimate Partner and Sexual Violence Survey ( Adverse Childhood Experiences Study, Center for Disease Control and Prevention, cdc.gov/nccdphp/ace 3 O Connor, C., Finkbiner, C., Watson, L. (2012) Adverse Childhood experiences in Wisconsin: Findings from the 2010 Behavioral Risk Factor Survey, Madison, WI: Wisconsin Children s Trust Fund and Child Abuse Prevention Fund of Children s Hospital & Health System. ( SPHERE, and PRAMS Page 2

3 Table 2: Wisconsin and National ACE Scores ACE SCORE Kaiser Study Wisconsin, 2010 ACE score of at least one 64% 56% ACE score of four or more 12% 14% ACEs in Wisconsin are equally distributed among males and females, except for sexual abuse where 16% of women reported being sexually abused and 7% of men (Figure 2). ACEs occur in clusters, with 61% of those reporting one ACE also reporting two or more. Certain ACEs tend to indicate a greater likelihood of other traumatic experiences. For example, among adults who as a child lived with a parent or other household member who was in jail, 69% have four or more ACEs. Figure 2: Prevalence of Individual ACEs in Wisconsin, 2010 Incarcerated Household Member 6% Sexual Abuse 11% Mental Illness in Household 16% Violence between Adults 16% Physical Abuse 17% Separation/Divorce 21% Substance Abuse in Household 27% Emotional Abuse 29% Source: Adverse Childhood Experiences in Wisconsin: Findings from the 2010 Behavioral Risk Factor Survey Violence and Pregnancy in Wisconsin Multiple public health programs focus on the needs of pregnant women, babies and children. Violence has a direct impact on outcomes for those populations. Healthy pregnancies, including the choice to become pregnant, can be compromised by exposure to violence as a child or adult. Children born into environments of violence have an ACE Score of at least 1 at birth. Current literature on violence and pregnancy indicates that: Violence can influence when and how a pregnancy occurs (pregnancy coercion, birth-control sabotage, control of pregnancy outcomes). 4 4 Miller, Elizabeth and Silverman, Jay G., Reproductive coercion and partner violence: implications for clinical assessment of unintended pregnancy, Expert Review of Obstetrics & Gynecology, September SPHERE, and PRAMS Page 3

4 Pregnancy itself can evoke initiation or increases in violence. Pregnancy may also shield a woman from violence, which may provoke multiple and frequent pregnancies as a form of protection. Experiences of violence and coercion are common among pregnant teens 5. ACE was associated with 19% of men involved in a teen pregnancy. 6 Women who have experienced violence while pregnant or before may have prolonged hormonal levels related to fight or flight reactions; these cross the placenta and can impact fetal brain development and chemical balance that affect cognition and behaviors throughout life. Pregnant women in abusive relationships are at higher risk of late entry into prenatal care, low maternal weight gain, infections, high blood pressure, vaginal bleeding, and maternal stress. Homicide is emerging as a leading cause of pregnancy-related deaths. Child sexual abuse or experiences of sexual violence as an adult can inform the experiences of pregnancy, labor, delivery and mother/infant bonding. Memories triggered by touch and examinations during prenatal care may delay seeking services. The process of labor itself can trigger memories of abusive experiences and loss of control. Responses to labor may be out of proportion and may prolong the duration. Post-partum adjustment to infant demands can mimic the control an abuser had and decrease infant bonding. Infant care during the night may bring back experiences of nighttime abuse. In February 2012, the American Congress of Obstetrics and Gynecology released a committee opinion that called for physicians to screen all women for intimate partner violence at periodic intervals, including during obstetric care (at the first prenatal visit, at least once per trimester, and at the postpartum checkup), offer ongoing support, and review available prevention and referral options. 7 Expanding to include assessment of experiences of violence of the pregnant women from childhood with follow-up can help to prepare clients for some of the negative responses noted above. SPHERE Documents Assessment and Referral of Violence among MCH PNCC Clients The Secure Public Health Electronic Record Environment (SPHERE) is used by agencies receiving MCH Block Grant funds to document perinatal care coordination and also by some agencies providing Medicaid Prenatal Care Coordination services. During Hills, SD, et al, The Association Between Adverse Childhood Experiences and Adolescent Pregnancy, long term psychosocial consequences, and fetal death, Pediatrics, February Anda, RF, et al. Adverse Childhood Experiences and Risk of Paternity in Teen Pregnancy, Obstetrics and Gynecology, American College of Obstetricians and Gynecologists, Committee Opinion, Committee on Health Care for Underserved Women, Intimate Partner violence, #418, February, 2012 SPHERE, and PRAMS Page 4

5 2010, 19% of women screened on prenatal assessment reported experiences of violence (Table 3). Table 3: SPHERE Results, Women Assessed for Violence, SPHERE Question Yes response, Prenatal Assessment* Yes response, Postpartum Assessment** Have you ever been physically, sexually, verbally, or emotionally abused by a partner or someone close to you? 2,282 19% 116 2% Referral made within 30 days of a prenatal or prenatal ongoing assessment indicating abuse. Results in postpartum assessment are 2010 only. Missing or unknown % 2% In 2010, for the 40 Yes responses to the question: 8 were referred 2 were not 11 declined 6 receiving services 13 missing/blank 1,154 *12,134 unduplicated prenatal clients **8,693 unduplicated postpartum clients with at least one prenatal initial or prenatal ongoing monitoring 300 days earlier or less indicating abuse. As anticipated, women who reported experiences of abuse were at higher risk for behaviors and conditions that can complicate pregnancy and care-giving (Table 4). Women who experienced abuse report higher levels of concern about money, job security for themselves and their partner, concern about their own and their partners drinking or drug use, and having partners who were in jail. The children born into these environments, by definition, have at least one ACE. Table 4: SPHERE Results, Women Assessed for Prenatal and Postpartum Services, Prenatal/Postpartum Assessment Question Abused* 13% Not Abused* Before pregnancy, did you smoke cigarettes? 62% 44% Since you have been pregnant, have you smoked cigarettes? Since your pregnancy ended, have smoked cigarettes? 46% 28% 44% 21% SPHERE, and PRAMS Page 5

6 Prenatal/Postpartum Assessment Question Abused* Not Abused* In the three months before your pregnancy, did you use any form of alcohol? Since you have been pregnant have you used alcohol? Since your pregnancy ended, have you used alcohol? Have you had problems with depression or received counseling or medications for mental health concerns? (prenatally) Since your pregnancy ended, have you been bothered by feeling down, depressed, or hopeless? 54% 38% 14% 7% 19% 7% 66% 27% 48% 11% Prenatally, rates current stress level High. 30% 13% Postpartum, rates current stress level High. 36% 7% *Abused is a positive response to Have you ever been physically, sexually, verbally, or emotionally abused by a partner or someone close to you? Not Abused is a negative response to the question. ROSIE Documents Assessment and Referral of Violence Among WIC Clients The ROSIE data system is used by Wisconsin Women, Infants, and Children (WIC) Clinics to collect data required by the US Department of Agriculture, and to evaluate and direct program planning. WIC provides nutritious foods, nutrition education (including breastfeeding promotion and support), and referrals to health and other social services to participants at no charge. WIC serves low-income pregnant, postpartum and breastfeeding women, and infants and children up to age 5 who have a nutrition risk and meet income guidelines. Initial and ongoing assessments of nutrition risk are made by the WIC certifier. Victim Battering (defined as violent physical assaults on the woman) is a WIC nutrition risk factor, and is determined by the response to the health assessment question How do you rate your current stress level? If the WIC applicant states that their stress level is medium or high, the WIC certifier may ask a probing question as to why she said that. If the participant shares that battering is the reason, and it occurred within the past 6 months, the certifier can assign the victim battering risk factor. This question is not required as part of the nutrition risk assessment, and consequently it is not consistently asked across the state. Because of the lack of denominator there is no opportunity to calculate a percentage or rate of WIC clients who respond that they have been battered. Information about referrals is similar; from , there were 118 referrals made for domestic abuse, but again a denominator is lacking as to how many women were asked about referrals or reported battering. Referrals are recorded separately and not necessarily linked to the battering risk factor. SPHERE, and PRAMS Page 6

7 Figure 3 shows how many women seen prenatally at WIC were assigned the Victim Battering risk factor and how many seen at postpartum visit, by year. In 2011, 249 WIC clients reported violent physical assault in the previous 6 months at prenatal assessment and 179 at postpartum assessment. Figure 3: Women Enrolled in WIC reporting Victim Battering, ROSIE, From about 13,000 women received prenatal services annually and 15,000 were seen for postpartum visits. PRAMS Documents Assessment and Referral for Violence Among Postpartum Women The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants in Wisconsin. PRAMS employs a mixed mode data-collection methodology; up to three self-administered questionnaires are mailed to a sample of mothers, and non-responders are followed up with telephone interviews. Self-reported survey information is linked to selected birth certificate data. PRAMS provides data not available from other sources about pregnancy, birth outcomes, and the first few months after birth (Table 5). Table 5: Wisconsin PRAMS PRAMS QUESTIONS During the 12 months before you got pregnant, were you: Pushed, hit, slapped, kicked, choked or physically hurt in any way by an exhusband or ex-partner? Physically hurt in any way by your husband or partner? During your most recent pregnancy, were you: Pushed, hit, slapped, kicked, choked or physically hurt in any way by an exhusband or ex-partner? % positive responses Total White Black Hispanic Other 4.6% 3.8% SPHERE, and PRAMS Page 7 3.6% 2.6% 12.1% 10.3% 6.7% 5.9% 4.9% 4.7% 2.7% 1.9% 7.1% 3.0% 4.9%

8 PRAMS QUESTIONS % positive responses Total White Black Hispanic Other Physically hurt in any way by your husband or partner? 2.8% 2.0% 6.5% 3.8% 3.9% Source: Wisconsin PRAMS Pregnancy Risk Assessment Monitoring System, , Bureau of Community Health Promotion and Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services The PRAMS data differs from ROSIE and SPHERE in two important ways. The PRAMS respondents are a random sample of all mothers who gave birth, inclusive of all socioeconomic levels; the WIC and PNCC programs have income eligibility requirements for participation. The PRAMS survey is completed by the individual within the privacy of their home; the WIC and PNCC assessments are generally done in a clinic setting, most often via an interview. The PRAMS questions probe more deeply at when violence was experienced, and by whom. Conclusion and Recommendations The implications for ignoring experiences of violence in the lives of women has both immediate impact increased risks for complicated labor and delivery, child maltreatment, low birth weight, homicide and life-time implications related to risk behavior choices, compromised medical and physical health outcomes, social and economic instability for both the mother and child. Mothers with ACEs are at higher risk of perpetuating the cycle of ACE experiences. Children born into a home where violence is occurring, where at least one member of the household is in jail, has mental health issues, uses drugs or drinks, begin life with at least one adverse childhood experience, are at a higher risk of raising that score, and inherit the burdens that often come with ACEs. The cost of not assessing and responding to experiences of violence is high and longlasting. Public costs of low birth weight and pre-term infants is documented, as are the costs for treatment and recovery, incarceration, mental and physical health interventions, increased dependence on public support, and lower education and the resulting opportunities for income and employment stability. These costs continue as more children are born into these experiences and the cycle continues. Public health addresses a number of the areas that result from experiences of violence. Public health emphasizes prevention. Addressing violence is a strategy that is far upstream in the prevention continuum encompassing both prevention and intervention. It breaks the cycle of violence and abuse, and promotes the skills for supportive parenting and the growth of healthy and centered children. SPHERE, and PRAMS Page 8

9 Recommendations The following recommendations are directed at systems level change in identifying, responding to, and preventing trauma. The system can be at any level: Programmatic, community, agency, state or local. 1. Increase use and documentation of questions related to experiences of violence for women seeking public health services. a. Revise PNCC/WIC questionnaires and schedules to assure compliance with ACOG protocol (experiences of abuse assessed at prenatal visits, once per trimester, and the postpartum checkup). b. Establish performance measures or competencies based on timely assessment, referral, and follow-up. c. Consult with DHS Division of Access and Accountability to consider the use of violence related and/or ACE questions on PNCC assessments. 2. Promote the assessment of childhood experiences for adult clients as a tool in strengthening and supporting recovery, creating positive environments for children. a. Explore opportunities for the revision of existing questionnaires to incorporate ACE questions or expand assessment of experiences of violence across a lifetime. b. Promote evaluation of ACE responses to other assessed outcomes. c. Provide information on models for screening for violence in public health settings, including technology. 3. Increase capacity for assessment, referrals and follow up. a. Promote training on trauma-informed care. b. Develop guides for a community referral/response matrix for trauma. c. Explore use of initiatives for trauma informed foster parenting as a model for training of public health staff. 4. Continue with data collection and analysis of assessment and referral of interpersonal violence in public health settings. a. Promote the regular use of SPHERE and WIC report function to provide regular assessment of data. b. Utilize ongoing analysis of PRAMS data related to reports of violence and prenatal/postpartum experiences. c. Consider an annual report utilizing this information as baseline to evaluate systems and outcome changes. d. Promote evaluation of documented experiences of violence with health outcomes through multiple data sources. SPHERE, and PRAMS Page 9

10 Program staff in the Bureau of Community Health Promotion contributing to this report: WI Women, Infants, and Children s Nutrition Program, Connie Welch, Jodi Klement Secure Public Health Electronic Records Environment, Susan Kratz MCH funded Prenatal Care Coordination, Katie Gillespie Pregnancy Risk Assessment Monitoring System, Kate Kvale WI Injury and Violence Prevention Program, Sue LaFlash SPHERE, and PRAMS Page 10