By: Hila Akbari, Belinda Xu, Sarah Iskin
Trigger warning: This article discusses themes of intimate partner violence (IPV), including descriptions of physical and emotional abuse. Please exercise caution if you find such topics distressing and consider your well-being before reading further. Support resources are available at the end of the article; please do not hesitate to seek help if you or someone you know is in need of help.
In the pivotal role of bridging healthcare services, Community Health Workers (CHWs) are often the first point of contact for individuals seeking care. CHWs are accessible and trusted within their communities. Studies indicate that CHWs are more likely than clinicians to have direct, repeated contact with patients, placing them in a crucial position to recognize signs of intimate partner violence (IPV) and provide essential support [1,2]. Despite the critical nature of their position, many CHWs lack readiness for IPV identification and prevention, impairing their ability to effectively intervene [3]. Given the frequency and gravity of IPV encounters in community settings, there is a pressing need for CHWs to be equipped, ready, and responsible for identifying and addressing IPV with the right tools and knowledge at their disposal.
“‘Community health worker’ is an umbrella term and includes community health representatives, promotors, peers, and other workforce members who are frontline public health professionals that share life experience, trust, compassion, [and] cultural and value alignment with the communities where they live and serve.” —National Association of Community Health Workers [4]
Understanding IPV
IPV is a pervasive issue within romantic relationships, encompassing a range of abusive behaviors that have profound and lasting impacts. About 25% of women and 10% of men experience physical violence, sexual violence and/or stalking while enduring an IPV-related impact during their lifetime [1]. This violence can manifest in various forms, from isolated incidents to persistent and severe patterns spanning years.
The persuasiveness of IPV is not just an isolated challenge; it is influenced by broader social determinants of health which include non-medical factors such as income, social status, education, and employment conditions. These determinants play a critical role in shaping the risk factors associated with IPV by impacting individuals’ vulnerability to and capacity for addressing violence. The intersectionality of IPV further complicates its nature, where factors such as state violence, institutional abuse, and the violence of social exclusion intersect, rendering certain populations more susceptible to IPV [5].
Signs & Symptoms
CHWs occupy a unique and pivotal role within communities, placing them in a distinctive position to identify IPV due to their close and trusted relationships with individuals they serve. CHWs are often seen as confidantes, making them more likely to be approached by potential IPV survivors. Their regular interactions with patients allow them to notice changes in behavior, signs of physical abuse, or emotional distress [6].
The signs and symptoms of IPV are varied and complex, encompassing physical, emotional, and behavioral indicators. Survivors of IPV may present with physical injuries on several locations of the body such as cuts, bruises, fractures, and sprains. The accessibility of the face makes it a common area for injury. When reviewing a patient's medical history, recurrent physical injuries can be a strong indicator of IPV. It is also crucial to listen carefully to patients’ explanation of their injuries, as the details provided may not align with the injury’s type or location. For female patients, a history of frequent urinary tract and genital infections, sexually transmitted diseases, unwanted pregnancies, and terminations of pregnancy are indicators for IPV [6].
Emotional symptoms can be subtle and manifest as changes in mood or personality. Victims often struggle with their mental health; they can exhibit signs of depression, anxiety, low self-esteem, symptoms of post-traumatic stress disorder (PTSD), or sleep disorders. Both physical and psychological trauma can result in cognitive difficulties where patients have difficulty concentrating, recalling information as well as presenting with hearing and vision problems. Through conversation with patients, signs of emotional distress including persistent sadness, fearfulness, or excessive worry, especially about pleasing, or not upsetting their partner can indicate IPV. Additionally, there is a high prevalence of alcohol and substance abuse amongst IPV survivors [6].
Survivors will often depict a combination of the signs and symptoms as discussed above. CHWs need to be attentive to these signs and approach the situation with empathy and without judgment. Developing a trusting relationship with survivors of IPV is the necessary key that allows for safe conversations regarding available resources and support to occur naturally.
Initiating the Conversation
To ensure safe inquiries, the initial step involves creating the conditions necessary for a private conversation space. This foundational measure sets the stage for effective communication strategies. Amongst these, motivational interviewing (MI) strategies have been shown to be an effective method to engage with survivors of IPV to establish trust between them and CHWs while also encouraging them to take initiative towards positive change. This approach centers around the individual with the goal of inducing behavioral change by strengthening self-esteem and self-motivation. MI can aid survivors in overcoming denial and to begin their journey by taking the necessary steps to address their circumstances regarding IPV [7].
It is important to recognize that survivors of IPV can be in different places mentally and emotionally depending on the current situation of their relationship. These relationships typically depict a pattern where tension builds up followed by an acute violent event which is then proceeded by a honeymoon phase. Due to this fluctuating pattern, IPV survivors find themselves at various places in their relationship where they may feel ecstatic and in love and other times hurt from the abuse [6]. This is a crucial factor to consider when approaching IPV survivors as it can affect their willingness to discuss their situation and seek help. The key is for CHWs to establish trust with IPV survivors so that eventually when they are ready, they can be guided towards the necessary resources to aid them in making small steps towards change.
8 steps to use MI techniques to engage with survivors of IPV:
Establish Trust:
Create a safe environment for interactions,
Assure confidentiality and safety, and
Approach the individual in a non-confrontational and nonjudgmental way.
Ask open ended questions and inquire in phases about IPV and safety:
Questions to prompt a discussion regarding IPV [6]:
“How are things at home?”
How do you and your partner get along?”
Questions about the patient’s safety [6]:
“Do you feel safe at home?”
“Does your partner control or try to control the things you do?”
“Has your partner harmed or threatened to harm you?”
Reflect upon the feelings of the IPV survivor [7]:
Show genuine empathy and compassion for the patient’s experiences and challenges related to their given situation.
Avoid putting the survivor on the spot or under pressure.
The main goal is to establish trust between CHW and survivors and avoid pushing patients to act right away if they are not ready.
Avoid a confrontational approach as it can lead to defensiveness, and
Respect patient's readiness for change.
Make sure to take a validating approach. Show recognition for the survivors' strength for speaking up and take steps to make them feel empowered [6]:
Use self-motivating statements to elicit patients' own motivation for wanting to address their IPV situation and have them articulate their own reasons as to what they envision changing for their future [7],
Reinforce patient’s sense of autonomy by highlighting their resilience and strength,
Avoid asking “why” questions, as they can come off as judgmental and victim blaming, and
Avoid asking suggestive questions where you imply a certain answer rather than leave space open to the survivor's true perspective.
By assessing patients' readiness for change, collaborate with them in identifying small achievable steps which can be taken to increase their well-being and safety [7].
Offer resources:
CHWs should have a list of local and national resources readily accessible. The end of the article lists a fillable PDF that you can modify and there is also a list of provincial to national resources available to IPV survivors at the end of the article.
End the conversation by establishing trust and openness to future conversations.
CHWs hold a pivotal role in identifying and addressing IPV. Their unique position enables them to engage with individuals at the community level, offering a frontline response to this pervasive issue. By cultivating an environment of trust and confidentiality, vigilantly recognizing signs of IPV, and employing a trauma-informed approach, they offer meaningful support to survivors. Their proactive involvement not only aids in immediate intervention but also contributes to the larger goal of preventing IPV. As CHWs continue to educate themselves and raise awareness within their communities, they reinforce the collective effort needed to combat IPV. It is imperative that they, along with the wider community, unite in this cause, striving towards a future where every individual can live free from fear and violence. Together, significant strides can be made in the lives of those affected by IPV.
Additional Training
The VEGA Family Violence Education Resources: VEGA (Violence, Evidence, Guidance, and Action) Project pan-Canadian, evidence-based guidance and education resources to assist healthcare and social service providers in recognizing and responding safely to family violence.
Canadian Midwives Recognize and Respond to Family Violence Resource Toolkit: The toolkit includes tip sheets, tools, backgrounders, and scenarios to support learning and practice of trauma-informed care. The information can be used as stand-alone resources or with other related resources in the toolkit.
Resources
VEGA IPV Resources Template (printable): This template is fillable so that each CHW can enter resources and support for their specific location.
VEGA IPV Documentation Guide (printable): This template offers a step-by-step pathway for documenting IPV.
Government of Canada Resources: Contains national, provincial, and virtual resources.
References
Saboori Z, Gold RS, Green KM, Wang MQ. Community Health Worker Knowledge, Attitudes, Practices and Readiness to Manage Intimate Partner Violence. J Community Health. 2022;47(1):17-27. doi:10.1007/s10900-021-01012-0
Anguzu R, Cassidy LD, Nakimuli AO, et al. Healthcare provider experiences interacting with survivors of intimate partner violence: a qualitative study to inform survivor-centered approaches. BMC Womens Health. 2023;23(1):584. doi:10.1186/s12905-023-02700-w
Renner LM, Wang Q, Logeais ME, Clark CJ. Health Care Providers' Readiness to Identify and Respond to Intimate Partner Violence. J Interpers Violence. 2021;36(19-20):9507-9534. doi:10.1177/0886260519867705
Using California’s Community Health Worker Initiatives to Address Intimate Partner Violence, Blue Shield of California Foundation. https://blueshieldcafoundation.org/sites/default/files/publications/downloadable/CHW%20Issue%20Brief%20Final%20FINAL%20(002).pdf. Published 2023 Mar. Accessed 2024 Mar.
Tolmie J, Smith R, Wilson D. Understanding Intimate Partner Violence: Why Coercive Control Requires a Social and Systemic Entrapment Framework. Violence Against Women. 2024;30(1):54-74. doi:10.1177/10778012231205585
Mikhael V, Ghabi R, Belahmer A, et al. Intimate partner violence: Defining the pharmacist's role. Can Pharm J (Ott). 2023;156(2):63-70. doi:10.1177/17151635231152450
Soleymani S, Britt E, Wallace-Bell M. Motivational interviewing for enhancing engagement in intimate partner violence (IPV) treatment: A review of the literature. Aggress Violent Behav. 2018;40, 119-127. doi: 10.1016/j.avb.2018.05.005
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