CommunityBased Research in Family Violence: The Challenges of Linking Policy with Evidence

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Community-Based Research in Family ViolenceThe
Challenges of Linking Policy with Evidence

• Harriet MacMillan, MD, MSc, FRCPC
• Offord Centre for Child Studies
• McMaster University

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Faculty Disclosure InformationI have no
relevant financial relationship to disclose

• Title Community-Based Research in Family
  ViolenceThe Challenges of Linking Policy with
  Evidence
• Presenter Harriet MacMillan, MD

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Objectives

• To understand the scientific evidence for
  prevention of child maltreatment and intimate
  partner violence, including prevention of
  recurrence.
• To learn about a proposed strategy to prevent
  both intimate partner violence and child
  maltreatment within a home visitation program.
• To become familiar with the challenges in linking
  policy re prevention of family violence with the
  scientific evidence.

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Public Health Approach
(Potter et al., 1998)
Implementation How do you do it?
Intervention Evaluation What works?
Risk Factor Identification Whats the cause?
Surveillance Whats the problem?
Problem
Response
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Child Maltreatment
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19th century, New York

• April 10, 1866
• the American Society for the Prevention of
  Cruelty to Animals established
• April 27, 1875
• the Society for the Prevention of Cruelty to
  Children founded
• first child protection agency in the world

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Mary Ellen
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Definition types of maltreatment

• Neglect
• Physical abuse
• Sexual abuse
• Emotional abuse (psychological abuse)
• Witnessing intimate partner violence (sometimes
  grouped with emotional abuse)

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Prevalence community studies

• OHSUP
• General population survey of Ontario residents 15
  years of age and older
• 9,953 participants
• OCHS
• Longitudinal study of Ontario sample with 3 waves
  (1983, 1987, 2001)
• 3,294 children and youths

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Physical abuse by gender
(MacMillan et al., JAMA 97)
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Sexual abuse by gender
(MacMillan et al., JAMA 97)
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Prevention points
Prevention before occurrence
Prevention of recurrence
Prevention of impairment
physical abuse sexual abuseemotional
abuse neglect
Long-term outcomes
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Prevention before occurrence

• Child maltreatment

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Primary prevention programs

• Education Programs
• Focused predominantly on prevention of sexual
  abuse and/or abduction
• Majority are universal programs
• Perinatal Early Childhood Programs
• Focused on prevention of physical abuse and
  neglect
• Majority are targeted programs

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Home visitation

• 1975 Hawaii Healthy Start Program
• Home visiting by para-professionals
• Disseminated based on uncontrolled pilot study
• Impetus for national adaptations including
  Healthy Families America
• 1986 Nurse Family Partnership
• 1992 Healthy Families America

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Healthy Start, Healthy Families

• Hawaii Healthy Start Program (Duggan et al.,
  Future of Children 99, Child Abuse Negl 04)
• improvement in a few isolated outcomes but no
  overall benefits in child maltreatment,
  hospitalizations the models efficacy has not
  been established experimentally
• Healthy Families America (Daro Harding, Future
  of Children 99)
• among 17 evaluations, 2 RCTs showed no benefits
  in child maltreatment 1 showed improvement in
  parent-child interaction

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Nurse Family Partnership Program

• First-time disadvantaged mothers received home
  visits by nurses
• Began prenatally and extended until childs 2nd
  birthday (weekly and then tapered to monthly)
• Nurses promoted 3 aspects of maternal
  functioning
• health-related behaviors
• maternal life course development
• parental care of children

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Randomized controlled trials
Elmira, NY 1977
Memphis, TN 1987
Denver, CO 1994
N 400
N 1,138
N 735

• Low-income whites
• Semi-rural

• Low-income
• blacks
• Urban

• Large portion of Hispanics
• Nurse versus paraprofessional visitors

Courtesy of David Olds, PhD
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NFP Evaluation findings

• 2 RCTs show benefit in one or more of child
  maltreatment, associated outcomes such as health
  care contact for injuries/ingestions (Elmira and
  Memphis RCTs)
• 3rd (Denver) RCT shows nurses produce a larger
  and broader range of beneficial effects (e.g.
  infant caregiving, language development) vs
  paraprofessionals

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NFP and child maltreatment

• 48 reduction in state-verified reports of child
  abuse and neglect
• Among mothers who were young, poor and unmarried,
  an 80 reduction in child maltreatment (Olds,
  2001)
• Reductions in child maltreatment not seen in
  families where there is IPV (Eckenrode, 2000)

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Program effects in IPV families
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Benefits Minus Costs

• Nurse Family Partnership 17,180
• Home Visiting for at-risk mothers/children
  6,197
• Parent-child interaction therapy 3,427
• System of care/wrap around programs -1,914
• Family Preservation Services Programs -2,531
• Healthy Families America -4,569
• Comprehensive Child Development Program -37,397
• Infant Health and Development Program -49,021

Courtesy of David Olds, PhD
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Preventing recurrence

• Child maltreatment

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Family Connections Study
163 families referred from C/CAS Child newborn to
12 Verified physical abuse or neglect no sexual
abuse Episode of abuse within last 3 months
Randomized
Standard treatment
Standard treatment Home visitation
Assessed recurrence of maltreatment and
associated outcomes
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Intervention

• Visits (1.5 hours) by PHNs occurred weekly for 6
  months, every 2 weeks for 6 months, then monthly
  for one year
• PHN home visitation focused on
• Parent support
• Linkage with health services
• Parental education regarding child development

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Recurrence by group
(MacMillan et al., Lancet 05)
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Recurrence of physical abuse
by group and length of involvement with CAS
(MacMillan et al., Lancet 05)
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Conclusions from this study

• Recurrence of child physical abuse and neglect
  was common
• Home visitation by PHNs was not effective in
  preventing recurrence of child neglect or
  physical abuse
• Effect for physical abuse may warrant further
  study in families new to CPS
• No improvement in parenting, home environment or
  child outcome measures

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Acknowledgements

• The 163 families who participated
• Special thanks to CAS and CCAS of Hamilton
• Health Canada CIHR
• The WT Grant Foundation
• Canadian Centre of Excellence in Child Welfare,
  Imperial Oil Foundation, Dr. Scholl Foundation,
  H-W Public Health

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Acknowledgements

• Helen Thomas, MSc, nurse researcher
• Michael Boyle PhD, epidemiologist
• Amiram Gafni PhD, health economist
• Ellen Jamieson, MEd, research associate
• Harry Shannon PhD, statistician
• Christine Walsh PhD, research associate

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Intimate partner violence (IPV)

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Definition and prevalence

• IPV includes physical, sexual, emotional, verbal
  and financial abuse
• Annual prevalence between 2 and 12
• Lifetime prevalence 25 to 30
• Canadian population-based 5-year rates of 8
• (Tjaden Thoennes, 2000 Statistics Canada,
  2000)

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Experienced IPV in last year
(MacMillan et al., JAMA 06)
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Framework
Identification of women experiencing abuse (who
disclose)
Health outcomes Repeat violence Physical
health Mental health
Adult women
Intermediate outcomes Social support Safety
behaviors Use of resources Others
Harms of screening
Universal screening
or
Harms of intervening
Intervention
Case- finding
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Systematic reviews of interventions

• No studies of primary care counseling met review
  inclusion criteria
• Only 1 study evaluated shelter stay judged
  poor quality
• Personal/Vocational counseling studies poor
• Prenatal counseling studies rated poor
• Batterer intervention programs have no to a small
  effect in reducing violence (0 to 7)
• Good quality couple intervention showed no effect
  
• (Wathen MacMillan, 2003 Babcock et al., 2004
  Feder Wilson, 2005)

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Insufficient evidence for

• Woman abuse shelters as a means of decreasing the
  incidence of violence (Wathen
  MacMillan, 2003)
• Personal and vocational counseling, and prenatal
  counseling
• (McFarlane et al., 2006 Tiwari et al., 2005)
• Educational, community and policy-oriented
  interventions, although recent study suggests
  that permanent civil protection orders may be
  effective
• (Holt et al., 2002)

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Post-Shelter Advocacy RCT

• Post-shelter women receiving counseling reported
• Less physical re-abuse (76 vs. 89) up to, but
  not including 3 yr fu
• Improved quality of life
• Increased use of social support
• Increased effectiveness in obtaining resources
• (Sullivan Bybee, 1999, 2005)

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Guidelines vs evidence

• Non-evidence-based guidelines generally favor
  screening, based on the prevalence and
  consequences of abuse
• Evidence-based assessments find insufficient
  evidence to determine whether screening does more
  good than harm
• (e.g. USPSTF, CTFPHC see also Ramsay et al., BMJ
  2002 325314-327)

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VAW Research Team

• Harriet MacMillan (PI)
• Kathryn Bennett
• Charlene Beynon
• Michael Boyle
• Sandy Brooks
• Cristina Catallo
• Pearl Dodd
• Marilyn Ford-Gilboe
• Clare Freeman
• Amiram Gafni
• Andrew Gulya
• Iris Gutmanis
• Jill Hancock
• Susan Jack
• Ellen Jamieson
• Susanne King
• Barb Lent

• Joyce Lock
• Daina Mueller
• Rosana Pellizzari
• Anna Marie Pietrantonio
• Rachelle Sender
• Helen Thomas
• Jackie Thomas
• Diana Tikasz
• Leslie Tutty
• Nadine Wathen
• Margo Wilson
• Andrew Worster
• CONSULTANTS
• Jacqueline Campbell
• Jeff Coben
• Louise-Anne McNutt

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RCT of screening for IPV
Follow up
Baseline 3m 6m 9m 12m 15m 18m
100
Universal screening
Positive
Positive
Negative
5
Negative
R
100
Positive
Positive
No Screening
Negative

• Baseline within 7 days of screen
• mini phone interview at 3, 9, 15 m

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IPV-KT Project

• Identify key messages within IPV research
  projects
• Synthesize knowledge and messages
• Directly engage key stakeholders
• Clinical
• Policy
• Advocacy
• Public/media
• Knowledge exchange events, online meeting spaces

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New prevention efforts
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Nurse Family Partnership

• NFP is program of nurse home visiting for
  disadvantaged first-time mothers
• Visits start prenatally, go to child age 2
• Proven benefits in a range of maternal and child
  outcomes
• Child maltreatment is reduced except in families
  where there is IPV
• 5 year funding from CDC to develop and evaluate
  an IPV component for NFP

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Methods

• Sequential, mixed methods design
• Project 1 qualitative interviews with nurses,
  clients and other stakeholders to design the
  intervention qualitative interviews and
  quantitative measures with nurses and clients to
  determine feasibility and acceptability
• Project 2 cluster RCT in 10 NFP sites

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Project team
West Virginia University
McMaster University
University of Colorado
Project management Data analysis Data
interpretation dissemination
NFP site recruitment/retention Nurse training
supervision Data analysis, interpretation
dissemination
Data collection Project coordination Data
interpretation dissemination
Coben Co-PI, administration IPV
expertise 1 Research coordinator 4 Research
assistants Stevens (Ohio), Co-I, MI
expertise Scribano (Ohio), Consultant, IPV
community liaison
MacMillan PI, administration, IPV
child abuse expertise Jack Co-I, director of
project 1 Jamieson Co-I, data management Boyle
Co-I, data analysis Ford-Gilboe (UWO) Co-I, IPV
expertise Wathen Co-I, IPV expertise
Olds Co-PI, administration, NFP RCT
expertise Baca Director, NFP Program
Development McClatchey Co-I, data
analysis Pinto NFP Replication Project
Manager OBrien Collaborator, NFP expertise
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Research practice/policy gaps
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Contributing factors

• Strong desire to implement programs that are not
  resource-intensive lower cost, less time
  commitment
• Rarely any consideration that prevention programs
  can do harm
• Some problems have no proven-effective
  interventions
• (McLennan, MacMillan, Jamieson, CMAJ 04)

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Challenges and solutions

• Clinician-scientist in unique position to conduct
  community-based research
• Partnerships between academics and
  community-based agencies provide an important
  opportunity to evaluate interventions
• Need champion(s) within community settings to
  ensure study progress

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Challenges and solutions

• Need access to policy makers
• And help in translating messages to policy makers
  and others
• Expertise in knowledge translation (KT) is a
  separate domain from expertise in research
  methods

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Conclusions

• The NFP can prevent child maltreatment but IPV in
  the home reduces this effect
• Prevention of recurrence of child maltreatment
  still a major challenge
• We know little about how to prevent IPV or reduce
  its recurrence
• There is evidence from one specific advocacy
  program re improving quality of life
• We need to develop methods of KT to ensure
  research-practice-policy link

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www.fhs.mcmaster.ca/net
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Definition of physical abuse

• When you were growing up, how often did any adult
  do any of the things on this list to you often,
  sometimes, rarely or never?
• 1. Pushed, grabbed or shoved you Often Sometimes
• Threw something at you Often Sometimes
• Kicked, bit or punched you Often Sometimes
  Rarely
• 4. Hit you with something Often Sometimes
• 5. Choked, burned, or scalded you Often Sometimes
  Rarely
• Physically attacked you in some Often Sometimes
  Rarely
• other way

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Definition of sexual abuse

• When you were growing up, did an adult do any
• of these things to you against your will?
• Exposed themselves to you more than once
• Threatened to have sex with you
• Touched the sex parts of your body
• Tried to have sex with you or sexually
• attacked you

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Physical abuse

• How many times before age 16 did an adult slap
  you on the face, head or ears or hit or spank you
  with something like a belt, wooden spoon or
  something hard? (3-5 times )
• Before age 16 did an adult push, grab, shove or
  throw something at you to hurt you? (3-5
  times )
• Before age 16 how many times did an adult kick,
  bite, punch, choke, burn you, or physically
  attack you in some way? (1-2 times )

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Sexual abuse

• Before age 16 when you were growing up, did
  anyone ever do any of the following things when
  you didn't want them to touch the private parts
  of your body or make you touch their private
  parts, threaten or try to have sex with you or
  sexually force themselves on you? (1-2 times )