Family Violence

According to Reuters, March 14, 2008, the Centers for Disease Control and Prevention (CDC) states 23.6 percent of women and 11.5 percent of men reported being a victim of family violence at some time during their lives. In San Diego County in 2007, there were 18,839 reports of domestic violence incidents. Family violence is a major public health problem that affects the health and wellbeing of women, men, youth, and children. During pregnancy, family violence has been associated with poor outcomes for mother and infant. Poor maternal outcomes include minimal or no prenatal care, low-weight gain, low self-esteem, depression, substance abuse, and Post Traumatic Stress Disorder (PTSD). Poor outcomes for the infant include premature delivery and low birth weight. In addition to being a public health issue, family violence is a medical issue, and, as physicians, cases may be identified in your practice settings. Hopefully, the experiences outlined below will help you to implement a screening tool in your own settings.

Children exposed to family violence during childhood have negative social-emotional and physical health problems. These include depression, anxiety, poor self-esteem, aggression, poor peer relations, poor school performance, physical health symptoms, under-immunization, and youth risk behaviors.

San Diego County Health and Human Services Agency (HHSA) nursing staff interact with multiple clients on a daily basis during home visits and in clinic settings. Given the number of clients that San Diego County nurses interact with presents an opportunity to identify family violence situations that some of our clients may be experiencing. Public health nurses (PHNs) in San Diego County make an average of 35,000 home visits per year. Home visiting historically has been an essential component of public health nursing practice. The Nurse-Family Partnership (NFP) Program is an evidence-based PHN home visiting model, which has many positive outcomes for families, one being a reduction in child abuse and neglect. The County of San Diego has twelve NFP PHNs, which visit 300 first-time, low-income pregnant women per year. After delivery, the PHN continues to visit the mother through the infant’s second year of life.

In August 2007, a family violence workgroup was formed to identify a universal screening tool for family violence, develop a protocol for the use of this tool, and plan training in order to assist nursing and ancillary staff to develop a deeper understanding of family violence and the effects of violence on families. The workgroup consisted of all levels of public health nursing staff representing each of the six Regions in HHSA, the Sexually Transmitted Disease (STD) Clinic, and staff from the Office of Violence Prevention (OVP).

Studies have shown reliance on self-disclosure or selective screening to identify family violence may result in missed opportunities for identification, intervention, and potential prevention of further incidents. In addition, disclosure rates increase by 60 percent if women understand the legal implications of disclosing, confidentiality issues, and state-mandated reporting requirements. The objectives for choosing a universal family violence screening tool are to increase identification of family violence; increase resources, support and education to families; increase safety for families; and decrease morbidity.

In order to identify an appropriate screening tool for PHNs to use, various domestic violence screening and assessment tools used in clinical settings, emergency departments, and other types of settings were examined. Items reviewed for every tool included the domain (basic or full screenings/assessments); age and stage of client when administered (adult/teen/pregnant); administered by self, professional, or both; family violence experience/training needed by professional administering the tool; languages in which the tool is available; validity/reliability of tool; and length of time to complete the tool.

In February 2008, the workgroup identified the Abuse Assessment Screening Tool (AAS) as the universal tool to be used by field PHNs and nurses in the STD clinic. The AAS is a valid and reliable five-question screening tool, proven to be as effective as longer tools in identifying victims of violence. The tool is used in a nurse interview assessment style rather than as a self-report tool. The tool may be used on adults, teenagers and pregnant women.

If any of the five questions on the AAS is answered with a “yes,” then the tool is considered positive for identifying family violence. The PHN will then administer the Danger Assessment (DA) Tool, which is a more in-depth assessment tool. The DA Tool was developed by Jacquelyn C. Campbell, PhD, RN, with the Johns Hopkins University School of Nursing. Dr. Campbell is considered a national expert in the field of family violence. The DA Tool was developed to assist women come to the realization that they are in a very dangerous relationship. This tool was chosen by the San Diego County, HHSA family violence workgroup as a more in-depth assessment tool to further assist clients involved in family violence.

In addition to identifying a universal family violence screening tool and developing a protocol for the use of the tool, the workgroup provided a training in partnership with the Laying a Foundation for a Safe Start Conference held in March 2008. This was a two-day training in which one full day focused on the basics of family violence, mandated reporting, childhood effects of family violence, and the protocol for the universal screening tool. For this particular day of training, 320 people attended, representing PHN and nursing staff from HHSA, community based organizations, criminal justice, mental health agencies, schools, and hospitals.

Field PHN staff began using the AAS as a universal screening tool in April 2008. Since that time, 180 newly identified cases of family violence have been identified. Possibly the PHN experience with universal screening for family violence will encourage some readers to implement screening in their own practice settings. Both of the screening tools discussed in this article are freely available in the public domain (though the DA Tool requires training).

For more information about the universal screening tool, and/or a bibliography contact Linda Lake at Linda.Lake@sdcounty.ca.gov or at (619) 515-4207.

San Diego County Health Statistics

• During FY 2006–07, there were over 5,200 calls to the San Diego countywide DV hotline [1 (888) DV LINKS] with over 30 percent of those calls including requests for shelter and/or safety planning (Source: County of San Diego, HHSA, Office of Violence and Prevention, 2007).
• In 2007, a sample of 222 San Diego domestic violence victims completed the Danger Assessment Tool during the intake process for DV advocacy services. Over 44% reported their partner had threatened to kill them and 47% said their partner had attempted to strangle her/him (Source: County of San Diego, HHSA, Office of Violence and Prevention, Domestic Violence Services for Families Program, 2007).

To request additional health statistics describing health behaviors, diseases and injuries for specific populations, health trends and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 285-6479. To access the latest data and data links, including the Regional Community Profiles document, go to www.sdhealthstatistics.com.