A Theory-Based Health Intervention for Women After Leaving Research Funded by Partnerships in Health Systems Improvement Canadian Institutes of Health Research New Brunswick Health Research Foundation 2009-2012

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Study Partners ◦ Liberty Lane Inc, Fredericton ◦ GNB Women’s Issues Branch ◦ GNB Department of Health

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Investigators ◦ UNB

◦ GNB ◦ UWO ◦ UBC

Judy Wuest, Nursing Marilyn Merritt-Gray, Nursing Marilyn Hodgins, Nursing Jo Ann Majerovich, Health Clinic Norma Dubé, Women’s Issues Branch Marilyn Ford-Gilboe, Nursing Colleen Varcoe, Nursing

THE SERVICE, CLINICAL & RESEARCH PROBLEM

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Intimate partner violence (IPV) affects 1:3 Canadian women

“Leaving” is seen as the solution thus few supports exist beyond the crisis of leaving  Women face ongoing intrusion from 

◦ Echoes of past & ongoing abuse ◦ ‘Costs’ of getting help ◦ Undesirable life changes ◦ Physical and mental health problems

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The negative effect of IPV on women’s health persists LONG after leaving

◦ Poorer health than Canadian women in general of similar age ◦ Higher rates of chronic pain, pre-hypertension, depressive symptoms, PTSD symptoms  Women who leave have many strengths 

Poor match between usual health services and women’s strengths & needs ◦ Higher use of health services with little relief

Health problems need early intervention, treatment and follow-up to prevent worsening  Few interventions exist that focus on women’s health after leaving 

i-HEAL Intervention for Health Enhancement After Leaving

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Complex, theoretically-driven primary health care intervention for women who have left abusive partners Delivered by a nurse in partnership with a domestic violence outreach worker over 6 months (12-14 meetings) Seeks to improve women’s health and quality of life by: ◦ Reducing intrusion ◦ Enhancing women’s capacity to limit and manage intrusion (knowledge, resources & skills)

INTRUSION

Ongoing Abuse

Undesirable Life Changes

Costs of Help

Interferes Health Effects

Managing Basics Managing Symptoms

Safeguarding

Strengthening Capacity Cautious Connecting Renewing Self

Regenerating Family

Intervention Principles Safety First

• Women’ s emotional and physical safety will be promoted in all interactions.

Health

• Women’s physical, emotional and spiritual health will be prioritized

Woman Centered

• Women will direct the pace, what is given priority, and who is involved

Learn from Other Women

• The intervention theory based on survivors’ experience will be used to help women reflect on, reframe and name their concerns and priorities

Women in Context

• Attention will be focused on the woman in the context of her “family” and network of close relationships as she defines them

Calculated Risks ‘Costs’

• Women will be supported to assess, judge, and take calculated risks necessary for moving forward • ‘Costs’ of getting help, including from interventionists will be assessed and limited

Strengths

• Women’s strengths and capacities will be recognized, drawn upon, and further developed

Support

• Women will be helped to seek and obtain support from community resources and to deal with barriers.

Advocacy

• Interventionists will work to reduce intrusion from other services and resources

“Getting in Sync” 1. Review intake data 2. Discuss the theory 3. Listen to her story 4. Review the topics

One Month

“Working Together” 1. Explore Intrusion 2. Share Options 3. Strengthen Capacity • Safeguarding • Managing Basics • Managing Symptoms • Renewing Self • Regenerating Family • Cautious Connecting

Four Months

“Moving On” 1. Review experience 2. Reflect on Changes 3. Envision New Life 4. Emphasize Capacities 5. Plan closure

One Month

The Components

Safeguarding 

Helps her better anticipate, avoid and manage crises and the emotional fallout of crises…to build her sense of security  Validates her potential safety risk and her right to feel secure  Reinforce her need and right to secure personal boundaries  Work through safety tools to help her refine her ‘assessment of risk’ skill (Danger assessment)  Build emotional safety tools, ability to ‘ground self’  Clarify how telling her trauma story may threaten her emotional safety

Managing The Basics 

Involves helping her get, manage and sustain what she and her family needs to sustain themselves  Start with her hopes for the future  Rethink your assumptions and what we have been taught professionally & challenge her to rethink what is BASIC  Energy range -10 to +10  Be careful not to crush her dream energy & fledgling hopes  Be ready to be tested and to advocate on her behalf  You need to be able to clearly answer the question..why does she need leisure resources and health care access any more than other single mothers?

THE BASICS ASSESSMENT TOOL Housing

Health care

GP & needed specialists

Medication & therapies

Leisure

The Basics

Energy -10 to +10?

Hopes for the future ____________ Food Personal Things Income

Clothing etc Credit

Major Issues:

April 14, 2010 iHEAL

Transportation

Current Primary Goal:

Childcare

THE BASICS ASSESSMENT TOOL Medications covered but can’t afford OTC meds or vitamins.

“Horrible” apartment but can afford it and it works ($600 a month + utilities)

Can’t afford dentist- no prevention for several years now

Housing

Needs new glasses – no coverage

Health care

“What is that?” Last vacationed when I was 10!

GP & needed specialists

Medication & therapies

Leisure Never considered before tired most of the time. Changes to PJs when gets home, finds it hard to get through day at work

Transportation

The Basics

Energy

Very tight but proud of how able to manage

Has car- inspected but no winter tires, insurance bill next month. Considering letting it go but is off bus line and work is a distance

Food Personal Things Income

A worry but OK until Fall when major bills land Part-time work at call center and grocery store Hoping to go back to school in Fall this year or next to take LPN course April 14, 2010 iHEAL

To get where you want to go

Childcare

Clothing etc Credit

Worried about Xmas coming Discovered Frenchy’s (second hand clothing store

Ok for now. Kids in school and older ones look after younger

Major Issues:

Worried about fall and winter coming with increased costs (car and Xmas) and decreased energy

Current Primary Goal:

To have an occasional treat for herself and her family

Managing Symptoms 

Help her build confidence in the prevention and management of symptoms  Secondary prevention strategies within our scope of practice  Help her make sense of her symptoms eg. PTSD, chronic pain, insomnia, GI problems, medication effects  Help her access relevant health services  Build symptom management skills  Medication coaching  Health info ‘Cheat sheets’

Cautious Connecting 

Help her build an increased sense of belonging & connection  Issues of trust: reinforce the healthy withholding of trust  Help her work through her relationships that are important to her but strained!!!!  Family of origin issues as an adult  Build understanding of healthy relationships  Help her ‘harness the system’ and support

Renewing Self 

Help her begin individual restoration and build on her potential Making herself a priority! Highlight her hopes, wishes and dreams Name and highlight her strengths & gifts Self soothing and comfort strategies…how are they working for her??  Difference of living free and living better  What is getting in the way? Abusive echoes? Stuck in the abuse (why me, shame, guilt etc)?    

Regenerating Family 

Help her reclaim ‘family’, strengthen ways to get the work of home done and develop better ways to ‘get along’  Routines, rules and new standards  Help her build, rework and refine her personal and family storyline

THE RESEARCH STUDY

PROGRESS TO DATE

Participant Profile (n=13) Time out in months (average; range)

15 (4 to 35)

Age (average; range)

40 (23 to 62)

Number with dependent children

9

Employment Full time Part time

4 2

Social Assistance in past 6 months

4

Abuse History Ongoing harassment (ex) Child abuse Sexual assault (not ex)

12 7 10

Transition house last 12 mos

3

Needed to see a doctor past month

11

Family doctor visit last month

7

Other GP (ER or Walk in Clinic)

8

Health Profile (n=13) Suicidal thoughts last month

4

Suicide attempts past year

1

High Blood Pressure

3

Lost 30 days or more due to pain last 6 months

7

Health Problems in the past month Sad/depressed Fatigue Difficulty Sleeping Back Pain Headaches/Migraine Swollen Joints General Aches & Pains

12 12 12 10 11 8 10

PTSD Screen in (DTS & DSM) DTS > 100

11 2

Currently smokes

3

Alcohol use a problem in past year

4

Street or Rx drug use problem in past year

3

CHALLENGES & LEARNING AS WE GO!

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Site Selection ◦ Readiness, stability ◦ Openness to another new initiative ◦ Provincial approval not enough

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Training ◦ Facilitating a shift to theory-based practice ◦ Dialogue – how is this different from usual good practice ◦ Recognize and draw on the expertise of the interventionists ◦ Build the team

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Getting Started ◦ Working in the ‘real’ world ◦ Women in crisis; suicide assessments; timelines

We have so much more to learn, but this feels very good so far! Questions?? [email protected]