Performance Improvement 1999. Evaluation of the WomanKind Program: Support Systems for Battered Women

02/01/1999

Highlights
This study was conducted to document the extent to which the Minnesota-based WomanKind program influenced the quality of intervention by health care providers to victims of intimate partner violence (IPV)(1). The WomanKind program is based on the premise that the health care setting offers a unique opportunity to intervene and offer support, options and referrals to IPV victims. WomanKind has been successful in training health care providers in hospital and clinic settings and in establishing an ongoing supportive connection between the health care setting and community resources. The evaluation was conducted by the National Center for Injury Prevention and Control, of the Centers for Disease Control and Prevention (CDC). WomanKind volunteer advocates, hospital staff, and IPV victims were the target populations in this evaluation. It was found that the WomanKind program had a significant positive influence on the knowledge, attitudes, beliefs and behaviors of hospital staff. WomanKind training provided an understanding of the magnitude and scope of the IPV problem, increased health care providers' sensitivity, empathy, and willingness to screen patients for IPV, and prepared these providers for appropriate and timely intervention and referrals. This study provides strong evidence that specialized staff development training along with dedicated on-site client services has a positive impact on the knowledge, attitudes, beliefs and behaviors of health care providers interacting with IPV victims.

Purpose
The purpose of this study was to conduct an evaluation of the Minnesota-based WomanKind program to identify the extent to which this program influenced the quality of intervention provided by health care professionals to IPV victims. Specifically, the study assessed the program on four critical variables: (1) the extent to which health care providers reported increased capacity and motivation to screen and identify IPV victims; (2) reported confidence in their ability to assist IPV victims; (3) increased documentation in patient records of the physical and mental health consequences of violence; and (4) referrals to the on-site WomanKind program.

Background
Intimate partner violence (IPV) is a substantial public health problem for Americans that has serious consequences and costs for individuals, families, communities and society. Recent efforts have been made to increase resources to address gaps in knowledge and to improve services for victims, perpetrators and child witnesses.

In a study of emergency department visits by women, over half of all women in the study have experienced IPV at some time in their lives, while 11% of those with current husbands or boyfriends gave IPV as the reason for the visit. Non-lethal IPV results in financial losses to victims, conservatively estimated to be $150 million per year. Medical expenses accounted for at least 40% of these costs.

Preliminary research by CDC on the WomanKind program suggested that when IPV victims access the health care system, including emergency departments, they are rarely asked questions about the cause of their injuries, medical symptoms or any available support system. Findings indicated that, for the most part, IPV victims are simply treated for the medical problem and discharged. These same health care providers also became frustrated when the victim returned again and again for treatment of injuries or symptoms.

The WomanKind program began with the realization that the health care setting offers a unique opportunity for intervention with IPV victims. However, it was discovered that health care professionals may not respond appropriately to these situations for several reasons: (1) they have little or no training about IPV, (2) they are uncomfortable intervening with a victim, (3) they do not see such intervention as a part of their role or responsibility, (4) they have limited time to assess or assist the victim, and (5) they believe that their efforts ultimately will have little effect.

WomanKind is based on the premise that health care professionals intervene at a point where abuse and violence can be identified, support and education can be provided, and the victim can learn of options and community resources available. WomanKind is a hospital-based program that provides services to IPV victims in combination with education and training for health care providers. The WomanKind program consists of five full-time professional staff and a cadre of trained volunteer advocates, all of whom are available 24 hours per day, 7 days per week.

WomanKind applied the public health concept of early intervention and prevention in order to design services that would ultimately improve the health care response to IPV victims. Routine screening, identification, intervention, and appropriate referrals may result in prevention of more serious injuries, prevention of mental health/psychiatric symptoms, and prevention of abuse to children.

Methods
Three populations were under study for this evaluation: hospital staff, IPV victims (clients), and WomanKind volunteer advocates. The research team used a variety of methodologies to obtain an in-depth understanding of the WomanKind program. Although specific to each population, the research instruments were designed to measure similar information from each group. Five hospital sites were selected for the program evaluation. The WomanKind program was in place in three of the five hospitals, and the other two other hospitals were selected as comparison sites. Professional staff from three hospital departments participated: Emergency Departments (ED), Intensive Special Care Unit (ICU) and the Obstetric/Gynecology Unit (OB/GYN). Limited training by WomanKind staff was provided to interested staff at the comparison hospitals near the end of the study.

Surveys and interviews were the methods used to gather data from participants. Surveys were developed to measure knowledge, attitudes, beliefs and behaviors (KABB) of hospital staff, volunteer advocates, and IPV victims. Data were collected over a two-year period beginning January 1995 and ending March 1997. Baseline data were collected at the beginning of the study from all participating staff. Pretest and post-test surveys were administered prior to and following training conducted by WomanKind staff. Additionally, follow-up surveys were administered to all participating staff at specified intervals during the two-year assessment period.

To measure the importance of training on hospital staff knowledge, attitudes, beliefs and behaviors (KABB), a 51-item survey was administered to hospital staff. The scales that were developed measured: (1) self-efficacy for identification and interaction with IPV victims (2) self-efficacy for referral and services, (3) staff understanding of violent relationships, (4) staff role and responsibility to address IPV, (5) self-reported behaviors concerning screening and intervention, (6) staff preparation to assist IPV victims, and (7) beliefs in the importance of victim autonomy.

To assess curriculum materials used in training, all curriculum materials were reviewed, the curriculum developer and trainer were interviewed, and the training sessions were observed twice by the researchers. Training was provided consistently at the WomanKind hospitals over the two-year evaluation period. Approximately 400 hospital staff participated in 70 training sessions.

An important variable examined the perception that the health care providers held about the efficacy of the WomanKind program. The researcher conducted interviews with a sample of the participating staff at the five hospitals using open-ended questions.

A random sample of 2,531 emergency department records were reviewed to determine the extent to which hospital staff documented possible abuse in the medical record and offered victims referrals to WomanKind for services.

New WomanKind volunteer advocates received a month-long intensive training program and completed a 42-item version of the evaluation instrument.

To gather data on the clients' (IPV victims') perception of the WomanKind program's effectiveness, surveys were also administered at 3-month intervals to IPV victims who received WomanKind services over the course of the study. Participants were women who had acknowledged IPV and had been referred to the WomanKind program.

Findings
Results from the evaluation indicated that the WomanKind program had a positive effect on the knowledge, attitudes, beliefs and behaviors of both hospital staff and volunteer advocates in terms of their awareness of IPV as a problem, and in their understanding of the role of all health care providers in addressing this problem.

WomanKind training also proved effective in heightening the hospital staff's awareness of the extent to which IPV affects their patients, and the provider's vital role and responsibility in responding effectively to the needs of the IPV victim. In addition, the hospital staff reported heightened awareness in their understanding of the dynamics of IPV, their willingness and ability to identify patients who are IPV victims, and to offer referrals to the on-site WomanKind program. Hospital staff in the WomanKind hospitals reported increased knowledge and positive attitudes about the role they played in addressing IPV in contrast to staff in control hospitals, who reported little or no increase.

Total scores on the hospital staff surveys were significantly higher for the WomanKind hospitals than for the comparison hospitals at all time intervals during the study. In addition, staff at the WomanKind hospitals scored significantly higher than staff at the comparison hospitals on four of the scales: (1) self-efficacy for referral and services, (2) self-reported behaviors, (3) staff preparation, and (4) victim autonomy.

Trained hospital staff who had previous exposure to IPV (through education or personal experience) had significantly higher mean scale scores than those without this previous experience. Specifically, six scores were statistically significant: (1) self-efficacy for identification and interaction with victims of abuse, (2) self-efficacy for referral, (3) understanding of abusive relationships, (4) responsibility to address IPV, (5) self reported behaviors, and (6) staff preparation. These findings indicate that the WomanKind training is effective in helping staff develop confidence in their ability to recognize and communicate effectively with victims of domestic abuse.

During 10 months of the evaluation, 1,719 IPV victims were identified and referred to the WomanKind program, while only 27 IPV victims were referred to trained social workers at the comparison hospitals. Chart review results indicated that emergency staff at the intervention hospitals provided appropriate documentation of IPV in patient records twice as frequently as emergency staff at the comparison hospitals.

Findings indicated that training increased the WomanKind volunteer advocates' confidence in their ability to provide advocacy and support to IPV victims. Their knowledge and competence in making appropriate community referrals for IPV victims increased. Self-reports from volunteer advocates indicated that the training helped them understand the issue of IPV and its effects on the victim and family members.

Use of Results
This study underscores the efficacy of a well-structured, comprehensive, multi-disciplinary effort in the delivery of services to IPV victims. The results of this evaluation document that specific training on the dynamics of IPV, screening, identification, and intervention provide the knowledge and skills that enable health care providers to respond more appropriately to IPV victims. It also suggests that the WomanKind program may be useful as a model prototype for both inpatient and outpatient health care settings. This study provides strong evidence that specialized staff development training along with dedicated on-site client services has a positive impact on the knowledge, attitudes, beliefs and behaviors of health care providers interacting with IPV victims

AGENCY SPONSOR: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

FEDERAL CONTACT: Lynn Short, Ph.D.

PHONE NUMBER: 770-488-4285

PERFORMER ORGANIZATION: Macro International, Silver Spring, MD