The Impact of Family Violence on Child Health Lois Magnussen, EdD, Professor Jan Shoultz, DrPH, Prof

1
The Impact of Family Violence on Child
HealthLois Magnussen, EdD, ProfessorJan
Shoultz, DrPH, ProfessorUniversity of Hawaii
School of Nursing and Dental HygieneUniversity
of Hawaii School of Nursing and Dental
HygieneUniversity of Washington Center for Women
and Gender Health Research NIH/NINR
5 P30 NR004001-13 University of California at
Los Angeles (UCLA) NIH/NINRT32 007077, P30
NR005041 NIH/NINR 1 R15 NR009424-01A2
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Focus of the Presentation

• The problem of family violence.
• Findings from research about violence within the
  family within cultures in Hawaii.
• Recent literature on impact of family violence on
  children.

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The Problem

• An international study conducted by the World
  Health Organization has confirmed that violence
  against women is a widespread phenomenon
• Rates of IPV ranged from a low of 15 percent in
  Yokohama, Japan, to a high of 71 in rural
  Ethiopia (Garcia-Moreno, 2006).
• Between one-fifth to two-thirds of women
  interviewed said that it was the first time they
  had ever spoken of the abuse to anyone.

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IPV in the US

• Annually, IPV is responsible for 40 50 of all
  murders of women in the US (1300 deaths).
• 25 of women reported being assaulted either
  sexually or physically during their lifetime
• In 2000 total costs associated with nonfatal
  injuries and deaths - more than 70 billion.
• 64.4 billion (or 92) was due to lost
  productivity.
• 5.6 billion was spent on medical care for the
  more than 2.5 million injuries

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IPV in Hawaii

• In Hawaii between 1995 and 2004 there were 57
  murders of women from IPV
• In 2007 there were 6 murders of women
• In 2008 there were 9 murders related to IPV
• In the first 4 months of 2009 there have been 4
  deaths from IPV

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Health Effects of IPVin Women

• Injuries from assault
• Chronic health problems (backache, headache,
  irritable bowel syndrome)
• Increased unintended pregnancies, low
  birthweight babies
• Higher rates of STDs
• Higher rates of depression, anxiety, PTSD,
  suicide
• Higher immune response (measured by cortisol
  level) results in autoimmune disorders

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Child Exposure to Domestic Violence

• 3.3 10 million children are exposed to DV each
  year.
• Reporting requirements are unclear.
• Only Alaska defines DV in the presence of a child
  as child abuse.
• Seek advice locally about legal interpretations
  and resources.
• Zink, et al., (2004). What are Providers
  Reporting Requirements for Children who Witness
  DV? Clin Pediatr. 43, 449.

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The CBPR Team
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Background of the Research in Hawaii

• Differences between cultural perspectives may
  lead to barriers that prevent IPV care.
• The Community Based Participatory Research (CBPR)
  team includes
• 3 Community Health Centers and DVAC
• UH School of Nursing and Dental Hygiene

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Mission Statement

• To move community needs and concerns forward
  with participation, action, and research through
  a trusting and respectful long-term commitment
  between the University of Hawaii School of
  Nursing Dental Hygiene and the community health
  center partners of Kalihi Palama Health Center,
  Kokua Kalihi Valley Comprehensive Family
  Services, Waianae Coast Comprehensive Health
  Center, and the Domestic Violence Action Center.

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Research Approach

• Critical Social Theory
• The theoretical foundation for this study was
  Critical Social Theory (CST), a post-modern
  philosophical perspective that acknowledges that
  some voices are privileged and others are
  marginalized.
• Community Based Participatory Research
• The use of the community based participatory
  research (CBPR) approach to this study was
  consistent with the perspective of CST. An
  expected outcome of CBPR is the attainment of new
  knowledge that guides actions.

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Progress towards Understanding

• Retrospective Chart Review (n337)
• Systematic Review of Literature (10 years)
• 2 Pilot Studies (Chuukese Samoan women)
• NINR (R15) Study (Chuukese, Native Hawaiian,
  Filipino)
• Publications
• Retrospective Chart Review
• 2 Pilot Studies
• CBPR Solutions Paper
• Literature Review

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CHCs and Populations

• Three CHCs selected populations of concern
• Native Hawaiian (WCCHC)
• Filipino (KP and DVAC)
• Chuukese (KKV)
• Samoan (KKV)

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Qualitative Quantitative Methods

• CBPR team adapted Acceptability of Violence Tool
  from the literature identified qualitative
  questions.
• Tools were translated from English to specific
  language and back translated to English
• Bi-lingual facilitators conducted focus groups
  and individual interviews
• Data analysis conducted by entire team.

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Native Hawaiian - Demographics

• Age n ()
• 21-29 yrs 3 (30)
• 30-39 yrs 4 (40)
• 40 yrs 3 (30)
• Education
• lt HS 0 (0)
• HS 2 (20)
• gt HS 8 (80)
• Business/Tech 1 (10)
• Some College 4 (40)
• College Grad 3 (30)
• Married 5 (50)
• Employed 6 (60)

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Native Hawaiian - Demographics

• Income n ()
• lt 10,000 1 (10)
• 10,000-14,999 1 (10)
• 20,000-24,999 1 (10)
• 30,000-39,999 2 (20)
• 40,000-49,999 2 (20)
• 50,000 3 (30)
• of Children
• 0-3 5 (50)
• 4-7 4 (40)
• Blank 1 (10)
• Hawaii Residency (1 blank)
• 27 61 yrs 9 (90)
• Primary Language
• English 10 (100)

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Native Hawaiian

• Acceptability of Violence
• Self Family 0-3 4-6 7-9
• Low Med High
• Within cultural group OK for
• partners to hit each other 4 0 1
• Were you brought up to believe
• OK for partners to hit 2 0 3
• How OK do you think it is for
• partners to hit each other 5 0 0
• Partner Family
• Within partners cultural group OK
• for partners to hit each other 1 1 2
• Was your partner brought up to
• believe OK for partners to hit 1 0 3
• Partner thinks its OK to hit 1 0 4
• Missing Data

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Native Hawaiian Perceptions

• It Starts in the Home
• Learned in the family
• Experience in childhood
• Understood as how it suppose to be
• Womans obligation to keep the family together
• Learned in the community
• IPV is perceived to be a violent experience
• Verbal and emotional abuse perceived to be
  something the woman can handle.
• Perpetrator as victim

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Native Hawaiian - Responses

• Defend the Collective
• Dealt with in the family
• Take care of the family at all times
• Do not burden other extended family members
• Point of enough is enough
• Dealt with by self
• It was like, drop the kids off, figure your
  life out, and when you got it together, call us
  back and you can come get your kids. As I got
  older, I made a few bad choices and I ended up in
  a very violent relationship and it was to the
  point where I just felt I grew up, family
  business is family business and don't shame the
  family. And so I tried to hold my family
  together as much as I could until I couldn't and,
  after years of going through that I finally said,
  enough already, this is enough

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Native Hawaiian - Needs

• Re-Connect with Cultural Base
• Re-establishing relationships
• Self, others, spirit, natural elements, cultural
  practices, place/community
• Leaving a legacy
• I'm part Hawaiian, who needs to reconnect with
  self. I know how to do it, and that is to get
  back to where I came from, which is to the land,
  put my energy and my thoughts into what I'm doing
  with the land, whether it's working in the lo'i,
  watering the yard, whatever the case may be,
  dancing. And it helps me to realign myself back
  to where I should be in my life.

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Filipino Participants

• 10 women ranging in age from 34 52 years
• 5 were married or living with a partner
• 2 Single
• 3 were separated or divorced
• Children individually between 2 and 7 none
  currently pregnant
• 9 were employed 1 unemployed
• Income
• 2 less than 10,000
• 5 were within 30 - 39,000.
• 3 - was within 40 - 49,000.

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Filipino

• Acceptability of Violence
• Self Family 0-3 4-6 7-9
• Low Med High
• Within cultural group OK for
• partners to hit each other 3 0 2
• Were you brought up to believe
• OK for partners to hit 5 0 0
• How OK do you think it is for
• partners to hit each other 4 1 0
• Partner Family
• Within partners cultural group OK
• for partners to hit each other 2 0 3
• Was your partner brought up to
• believe OK for partners to hit 3 0 2
• Partner thinks its OK to hit 4 0 1

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Filipino

• Perceptions and Responses
• Seen as a fight or argument a private matter
• Women are physically weaker so men take advantage
• Violence attributed to alcohol or drug use or
  blamed on infidelity
• Virtue of quiet suffering or martydom
  (Christian Belief)
• Afraid of deportation

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Filipino perceptions and responses

• If petitioned by partner is eternally indebted
• Will call on God to give me strength
• Burden of Shame not for self but for family,
  neighbor, country
• Mind your own business, dont air your dirty
  laundry
• Generational and cultural gap younger vs. older
  Filipinos US born vs. Filipino Immigrants
• Families in US and PI will experience retribution
  if IPV is reported

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Immigration Patterns to Hawaii

• Six thousand Micronesians live in Hawaii-
  Chuukese only 1 segment of the population
• There has been an increase in population in
  Hawaii recently related to political agreements
• Health and social issues have resulted
• Samoans represent 2 of the population of Hawaii

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Chuukese Participants

• 15 women ranging in age from 25-63 years of age.
  
• 6 were married 2 lived with partner
• 3 were separated 1 was single
• 3 were widows
• Children - between 1 and 10 - none currently
  pregnant.
• 9 women were employed - 6 unemployed.
• Income
• 13 - less than 10,000
• 1 - 15,000-19,000
• 1 - 25-29,000

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Chuukese

• Acceptability of Violence
• Self Family 0-3 4-6 7-9
• Low Med High
• Within cultural group OK for
• partners to hit each other 5 0 0
• Were you brought up to believe
• OK for partners to hit 5 0 0
• How OK do you think it is for
• partners to hit each other 5 0 0
• Partner Family
• Within partners cultural group OK
• for partners to hit each other 5 0 0
• Was your partner brought up to
• believe OK for partners to hit 5 0 0
• Partner thinks its OK to hit 3 2 0

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Perceptions of Chuukese women

• IPV is closely linked with marital infidelity and
  the use of alcohol and drugs
• Woman are responsible for maintaining peace and
  keeping the family together even if IPV is
  present
• Communication about IPV is restricted to female
  family members, not male
• Relationships with the Partners family determine
  continuation of the relationship
• Need to integrate both cultures

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Samoan Participants

• 8 women ranging in age from 24-63 years
• 6 were married
• 2 were single.
• Children - between 3 and 10
• 7 were employed - 1 was unemployed
• income
• 8 - less than 15,000.

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Samoan Participants

• Education
• 3 with some high school education
• 3 finished high school
• 1 college graduate
• Hawaii Resident 4.2 years
• Primary language Samoan
• Partners lived in Hawaii between 0 6 years

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Perceptions of Samoan Women

• They have the right to stand up for themselves
• Protection is offered by open housing in Samoa is
  lost by nuclear family dwellings
• In Hawaii church leaders assume some roles of
  leadership in the absence of chiefs council

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Perceptions of Samoan Women

• Communication within the family has cultural
  restrictions (wife as in-law has no voice in
  family discussions)
• Alcohol contributes
• Jealousy and suspicion of fidelity
• Woman made her choice of husband, therefore for
  better or worse she remains with that partner.

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Implications of the Studies

• In indigenous populations or with migration to
  Hawaii - cultural protective practices may be
  disrupted
• Services based on findings will need to reflect
  the differences in perceptions, responses and
  needs of the specific cultural groups
• Disclosure is dependent upon the relationship
  with the provider and provider organization
• Screening for DV should occur in a variety of
  community settings

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Implications

• Cultures may have protective factors that could
  be adapted to meet the needs of women and their
  children in a new environment such as Hawaii.
• Needs identified by participants go beyond common
  organizational responses to IPV and are specific
  to each cultural group.

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Implications

• Western notions of permanently leaving a
  relationship may not be acceptable to some women.
• Identification of ways to increase safety and
  decrease harm within the family are urgently
  needed.

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The Impact of Family Violence on Children

• Violence affects the entire family
• Children who witness violent episodes are at risk.

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Children Exposed to Family Violence

• Adverse effects seen in children
• Behavioral disorders
• Developmental Delays
• Adverse effects seen in adolescents
• Depressive symptoms
• Antisocial behavior
• Drug use

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Lasting Effects from Family Violence

• Research has identified
• Chronic pain
• Depression
• Physical Symptoms
• Autoimmune diseases
• Reference ACE Study (Adverse Childhood
  Experiences) Schilling, E.A., Aseltine, R.H. Jr,
  Gore, S. (2007). Adverse childhood experiences
  and mental health in young adults a longitudinal
  survey. BMC Public Health. 7(7)30

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Cumulative Childhood Stress and Autoimmune
Diseases in Adults

• Compared with persons with no ACEs persons with
  gt/2 ACEs were at 70 increased risk for
  hospitalization with
• (Th2 Myasthenia gravis rheumatic arthritis)
• They were at 100 increased risk for rheumatic
  diseases.
• Dube, et al., (2002). Exposure to abuse,
  neglect, and household dysfunction among adults
  who witnessed IPV as children Implications for
  health and social services. Violence Vict.
  17(1), 3 17.

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Implications

• Women in our studies have talked about their
  concern for children.
• Child custody policies may cause intrusion into
  daily lives and limit flexibility to establish
  new and healthier patterns of family life.
• Strategies that promote healthy dating
  relationships are important. These strategies
  should focus on young people when they are
  learning skills for dating. This approach can
  help those at risk from becoming victims or
  offenders of IPV.
• Positive Influences in Childhood (PIC) can offset
  some of the adverse childhood experiences.

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References

• Bonomi, A, Anderson, M., Rivara, F., Thompson,
  R. , (2007) Health outcomes in women with
  physical and sexual intimate partner violence
  exposure. Journal of Womens Health 16 (7),
  987-997.
• Campbell, J.C., Webster, D., Koziol-McLain, J.,
  Block, C. R., Campbell, D. W., Curry, M. A. et
  al. (2003). Risk factors for femicide in abusive
  relationships Results from a multi-site case
  control study. Am.J.Public Health. 93 (7),
  1089-1097.
• Chung, E., Mathew, L, Elo I., Coyne, J., Culhane,
  J. (2008). Depressive symptoms in disadvantaged
  women receiving prenatal care the influence of
  adverse and positive childhood experiences. Ambul
  Pediatr. 8(2),1099-16.
• Dube, et al., (2002). Exposure to abuse,
  neglect, and household dysfunction among adults
  who witnessed IPV as children Implications for
  health and social services. Violence Vict.
  17(1), 3 17.
• Garcia-Moreno, C., Jansen, H., Ellsberg, M.,
  Heise, L., Watts, C. (2006). Prevalence of
  intimate partner violence findings from the WHO
  multi-country study on women's health and
  domestic violence. The Lancet. 368(9543),
  1260-1269.

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References (cont)

• Family Violence Prevention Fund, (2002). On
  Identifying and Responding to Domestic Violence
  Victimization in Health Care Settings. Retrieved
  January 15, 2004 from http//endabuse.org/programs
  /healthcare/files/consensus.pdf.
• Magnussen, L., Shoultz, J., Oneha, M., Hla, M.,
  Brees-Saunders, Z., Akamine, M., Talisayan, B.,
  Wong, E. (2004). Intimate partner violence A
  retrospective review of records in primary care
  settings. Journal of the American Academy of
  Nurse Practitioners. 16(11), 502-512.
• Magnussen, L., Shoultz, J., Oneha, M., Hla, M.,
  Brees-Saunders, Z. (2007). Intimate Partner
  Violence Systematic Review of Literature Focused
  on the Cultures of Hawaii. Hawaii Medical
  Journal. 66 (5), 129-133.
• Magnussen, L., Shoultz, J., Hansen, K., Sapolu,
  M., Samifua, M. (In Press- Dec 2008). Intimate
  Partner Violence Perceptions of Samoan Women.
  Journal of Community Health.
• Magnussen, L., Smith, N., Amundson, M. J.
  (2008). Through the eyes of women Cultural
  Insights into living as a battered woman.
  Journal of Nursing and Health Sciences. 10(2),
  125-130.

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References (Cont)

• Shoultz, J, Magnussen, L., Hansen, K.,
  Brees-Saunders, Z., Selifis, S., Ifenuk, M.
  (2007). Intimate Partner Violence Perceptions
  of Chuukese Women. Hawaii Medical Journal.
  66(10), 268-71.
• Shoultz, J., Oneha, M., Magnussen, L., Hla, M.,
  Brees-Saunders, Z., Dela Cruz, M., Douglas, M.
  (2006). Finding solutions to challenges faced in
  community-based participatory research. Journal
  of Interprofessional Care. 20 (1), 1-12.
• Schilling, E.A., Aseltine, R.H. Jr, Gore, S.
  (2007). Adverse childhood experiences and mental
  health in young adults a longitudinal survey.
  BMC Public Health. 7(7)30.
• Siegel, R. M., Hill, T. D. Henderson, V. A. Ernst
  H. M., Boat, B. (1999). Screening for domestic
  violence in the community pediatric setting.
  Pediatrics. 104(4), 874 877.
• Wuest, J., Merritt-Gray, M., Ford-Gilboe, M.,
  Lent, B., Varcoe, C., Campbell, J. (2008).
  Chronic pain in women survivors of intimate
  partner violence. J. Pain. 9(11), 1049-57