Sharing Personal Experiences of Accessibility and Knowledge of Violence: A Qualitative Study

Abstract

In North America, the most common societal response to intimate partner violence (IPV) has been the establishment of women’s shelters for temporary housing and security. Rurality further compounds the challenges women experiencing IPV face, with unique barriers from their urban counterparts. This study sought to explore the intersection of rural women’s health care experiences within the context of IPV. Eight rural women living in Southwestern Ontario, who had experienced IPV, had used women’s shelter services, and who had accessed health care services in the preceding 6 months were interviewed. Using a feminist, intersectional lens, we collected and analyzed qualitative data using an interpretive description approach. Findings demonstrated that women were able to identify strengths and opportunities from their experiences, but significant challenges also exist for rural women seeking health care who experience IPV. Our findings underscore the need for filling of policy gaps between health care and the services women use. We propose that further research is needed on alternative, integrated models of shelter services that address health care needs for women experiencing IPV.

Keywords

domestic violence cultural contexts disclosure of domestic violence perceptions of domestic violence

Introduction

Intimate partner violence (IPV) is a pattern of physical, sexual, and/or emotional violence by an intimate partner within the context of coercive control (Tjaden & Thoennes, 2000). While IPV can be experienced by anyone, it is a specific form of gender-based violence that women are more likely to experience (Sinha, 2011), and it is the most common type of violence experienced by women (Rose, 2015). IPV accounts for approximately one quarter of violent crimes reported to the police in Canada, representing more than 97,000 victims annually. Furthermore, this is considered an underestimation, as it is predicted that a large percentage of IPV goes unreported to the police (Sinha, 2011).

In North America, the most common societal response to the prevalence of IPV is the establishment of shelters as temporary housing and security (Mantler, Jackson & Ford-Gilboe, 2018). While women may seek shelters for immediate housing relief, shelters are often also an entry point for health and social services as well, referring women to service providers in various sectors (Mantler, Jackson & Ford-Gilboe, 2018). Shelter staff members often make efforts to link women with the services they need, working with women on limited-time stays to help them find adequate housing and income assistance. Recent studies have found that shelter staff members are often working to alleviate multiple layers of need, some immediate, such as food security, and some long-term, like adequate health care addressing the impact of IPV (Burnett et al., 2016). Unfortunately, as a result of these broadened mandates and underfunding, shelters are often stretched well beyond physical and fiscal capacity (Burnett et al., 2016; Mantler, Jackson & Ford-Gilboe, 2018).

It is well established that IPV can result in a number of physical injuries and mental health consequences including lacerations, concussions, broken bones, and an increased risk of miscarriages, depression, anxiety, and post-traumatic stress disorder (Graham-Bermann et al., 2011; Zweig et al., 2002). IPV is also linked indirectly to health effects related to chronic stress, including hypertension, stomach ulcers, and chronic pain (Coker et al., 2000). Even after leaving an abusive relationship, women’s mental and physical health often remain affected for months and years later (Ford-Gilboe et al., 2009). The extent to which women experience negative effects of violence after leaving an abusive relationship is often associated with economic and social resources the woman has available to her (Ford-Gilboe et al., 2009). This association demonstrates the compounding impact of marginalization through structural violence on women who do not have similar resources. Structural violence is the manner in which social structures, such as policies and sociocultural organization, impede societal equity. “The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people” (Farmer et al., 2006, p. 1). Structural violence also reinforces societal power imbalances, perpetuating further oppression of those already at the margins. Contextualizing IPV in the context of structural violence moves the conversation from that of a solely interpersonal level to that of a societal level (Montesanti & Thurston, 2015) requiring an examination of the sociocultural, historical, economic, and political factors affecting women’s ability to seek and access support. Structural violence is also manifest in the policies and procedures that make it difficult for women to access the services they require. For example, some policies require women to present documentation to prove abuse before receiving income or housing supports (Burnett et al., 2016), and others require identification and compulsory sobriety—all of which inhibit access. (Kulkarni et al., 2010). While these and similar policies are often put in place for “just cause,” the ramifications of these practices serve to further marginalize already vulnerable populations (e.g., those experiencing homelessness or substance abuse). These examples of structural violence demonstrate how women experience revictimization in the process of seeking much-needed services, as well as the critical importance of viewing IPV beyond that of an interpersonal problem.

Further compounding the challenges for women who experience IPV, women accessing shelters in a rural context face unique barriers and inhibiting social structures compared with their urban counterparts. While women in urban and rural locations seek care with similar decision-making processes, different barriers are encountered depending on the geographic context (Haggerty et al., 2014). Current research describes geographic isolation as a potential barrier to accessing health and social services of all forms (Lanier & Maume, 2009). For example, rural social networks have been described as a facilitator in accessing health care. These networks are facilitators as health providers know their patients well and are willing to provide services outside of office hours or make home visits (Haggerty et al., 2014). However, this familiarity creates challenges for women who seek services with a need for privacy, confidentiality, and anonymity. In fact, familiarity among small communities often present barriers to help-seeking for women experiencing IPV, as they delay or do not seek appropriate care for fear of a lack of confidentiality (Zorn et al., 2017). Rural women may be further challenged when of a lower socioeconomic status particularly when a lack of financial resources creates transportation barriers. Women experiencing IPV in rural communities face challenges related to rurality like reaching limited services that are geographically spread out, with no public transit systems, leaving only expensive transportation options. Furthermore, rural women with lower socioeconomic status are less likely to have the same social capital to benefit from social networks and obtain the same level of access as their wealthier counterparts (Haggerty et al., 2014). These systemic barriers create additional layers of challenges that women in urban centers may not face to the same extent.

Rural shelters are challenged with fewer resources and are often underfunded (Mantler & Wolfe, 2017), affecting the ability of shelter staff to effectively assist women in their care. For example, assistance with system navigation is an essential role shelter staff members often provide to women. However, this role requires extra time, and the availability of this extra time may be jeopardized when ever-tightening budgets call for cuts to staffing. Women in shelters often seek an array of services beyond safe shelter, such as legal assistance, income support, and mental health, and addiction services (Barner & Carney, 2015; Mantler & Wolfe, 2017). Shelter staff members often help women find appropriate and accessible service providers, with shelters being an important entry point for health and social services. Unfortunately, the health and social services that these women often receive are provided by professionals having limited understanding of IPV and/or the systemic barriers women face in seeking and accessing such services (Mason et al., 2017).

Women experiencing IPV face significant barriers in system navigation among health and social services (Mantler & Wolfe, 2017); finding ways to support these women to achieve equity in terms of health and well-being is required. Integration of health and social services is one such mechanism that has been suggested to support system navigation; however, integration is complex (Mantler, Jackson & Walsh, 2018; Mantler & Wolfe, 2017). Policies governing practice differ drastically between health and social services resulting in a multitude of issues, such as client privacy between services, the appropriate model for integration (and how to bring it to fruition), and a lack of understanding of the specific barriers to system navigation. The purpose of this study was to gain an understanding of the potential barriers (and facilitators) for system integration between health and social services in the context of IPV among rural women in Canada.

Method

The purpose of this interpretive case study was to explore the intersection of women’s experiences of rural health care within the context of IPV. After appropriate institutional ethics approval was received, women living in rural settings of Southwestern Ontario, who had experienced IPV and had used health care services within the past 6 months, were recruited to participate in in-depth qualitative interviews lasting between 60 and 90 minutes. Women were recruited using online (e.g., Kijiji) advertisements posted in rural areas (cities/towns of populations less than 30,000) and word of mouth from September through November 2018. Eligibility criteria included (a) identifying as a woman, (b) being 18 years of age or older, (c) speak/read English, (d) using primary health care services in the past 6 months, (e) using rural women’s shelter in the past 6 months (including any program, that is, not limited to emergency housing), and (f) willing to be audio-recorded during a telephone interview.

Ten potential participants initially responded to the online advertisements: eight enrolled in the study, one did not meet the inclusion criteria, and one did not respond after the initial request for more information to determine eligibility. Interested participants were asked to provide safe contact information, and subsequently, a member of the research team telephoned the participant. Over the telephone, participants were screened for eligibility, were provided an overview of the study and a copy of the letter of information (if it was safe for them to receive the letter), consented to participating in the interview (verbally over the telephone), and arranged a time for the interview. Demographic data were collected, including age, education level, marital status, geographic location, employment status, and income. Next, a semi-structured interview guide with three sections was used, exploring the following: (a) ease of accessing services, barriers to services use, and service use in the past 6 months; (b) barriers and facilitators to health care (e.g., tell me about any facilitators to health care use?; Can you tell me about any barriers to health care use?; and How important is that [barrier/facilitator]?); and (c) suggestions for improvement to health care (e.g., What could health care do for you moving forward?; What barrier do you think needs to be changed first?). After the interviews, a debriefing protocol was used, which included a discussion about common signs of a stress reaction (as participating in interviews can be a trigger to some women) as well as a discussion on how to stay in contact with the study should participants want a copy of the results. No participants had further contact with the research team following the interviews.

A single researcher conducted the interviews and kept field. Field notes included documenting overall impression of the interview, major themes, and participant’s mood/behavior throughout the interview. After eight participants were interviewed, no new themes emerged, saturation was reached, and recruitment was ceased. Interviews were audio-recorded and digitally uploaded to a professional transcription service. Once interviews were transcribed, a team of five researchers conducted the analysis (Hsieh & Shannon, 2005). The analysis was positioned within a critical feminist intersectional lens, which allowed for exploration of larger social structures and their potentially oppressive influence on women’s experiences, as well as the complexity of lived experiences as women hold multiple roles in society (Crenshaw, 1994; England, 1994). This analytic approach afforded a close examination of gender-based violence in the context of the interaction and intersection of identity and social location. Each of the researchers became immersed in the data (all sources) and then identified emerging themes based on both internal and external coding. Internal coding is coding undertaken within a participant’s interview, and external coding is coding undertaken across participants. Subsequently, each researcher determined if themes should be further delineated or amalgamated—ending the process with a list of themes, operational definitions of those themes, and quotes to support each theme. Next, the researchers met to discuss findings and determine if there was consensus regarding emerging themes. Researchers took turns describing emergent themes and identified if these were congruent with the other’s findings. In the case where consensus could not be reached among the team, one of the five researchers remained as an observer to resolve issues related to nonconsensus; however, consensus was ultimately attained without intervention by the 5th researcher.

Results

Participant Description

Participants were an average of 32 years old (ranging from 21 to 64 years of age). All women were born in Canada, with two participants identifying as being Indigenous. Five of the eight participants were divorced or separated, with the remaining participants having returned to their abusive partner. The average number of years with the abusive partner was 7.5, ranging from 6 months to more than 30 years. The majority of participants had dependent children (n = 6), with five women having children who currently lived with them full- or part-time. Five women had completed either community college or a university degree, two participants had completed high school, and one participant had completed less than high school. Four participants were employed full-time, two participants were employed part-time, and two participants were on social assistance. Half of the participants made between US$50,000 and US$99,999 per year after taxes with the remaining participants making less. All participants came from rural areas with populations of less than 30,000, and six participants came from areas with a population of less than 10,000.

Service Use Description

Participants were asked, in the past year, how difficult it was to get the support they needed from systems (i.e., health care, housing, legal, social assistance), and they identified that it was somewhat difficult (n = 6) to very difficult (n = 2) on a 4-point Likert-type scale ranging from not at all difficult (1) to very difficult (4). When asked about difficulties participants had experienced in accessing services in their areas, the most common reasons included the following: no service in the area (n = 7), on a waiting list for service (n = 5), employer difficulties (n = 4), no child care (n = 3), and self-imposed limitations (e.g., not wanting to disclose violence, procrastination, and other; [n = 3]). When asked about accessing services in relation to health care, the most common issues were a lack of primary health care provider in the area (n = 5), lack of mental health care provider in the area (n = 5), and lack of transportation to health care services (n = 4). In the past 6 months, 4 participants had used a walk-in clinic and two had used an emergency room in lieu of a primary health care provider. Within the last 6 months, only two participants had used emergency housing at their local rural women’s shelter; however, all participants had used individual counseling and some participants had used group counseling (n = 4) or the 24-hour crisis line (n = 3). Participants in this study had used shelter services from four different rural women’s shelters.

Qualitative Findings

The following three themes were uncovered: (a) strengths (what I have), (b) challenges related to structural violence through policy (what I need), and (c) policy gaps (what does not exist). Participant excerpts included below have been assigned a pseudonym for anonymity.

Strengths (what I have)

Women in this study acknowledged that despite challenges, there are people providing positive health and social services experiences.

Priya spoke positively about her experience interacting with women’s shelter staff:

Someone stayed there all hours of the night, so there was someone to talk to at all times. It was really a mental health aspect, but they also could get you connected to the hospital. They had all the phone numbers. They would walk you through it with you . . . If they could tell that you didn’t seem motivated, they would try and interact and just get some ideas. Financially, they were helpful in that way. They were able to help try and find jobs for all the girls in there, and also get connected with different counsellors in areas, and provide housing and phone numbers to get connected with people for rent and things like that.

There were also positive experiences for women who had the opportunity to interact with health care providers who were sensitive to their situation and needs. Margaret spoke about her current primary health care provider in a very positive way:

She’s actually really great. My first appointment with her, there’s obviously—doctors are busy they schedule – but my first appointment with her was almost two hours. She actually asked me questions like, “What kind of traumatic things have happened in your life? How do you think this impacts your life?” I was able to tell her I’m having nightmares and she’s asking, “Is it the same nightmare? Are they recurring? Is it something that actually happened? Are they more like a memory?” She’s been really great, but it took me a long time to get there . . . My doctor now wrote me letters. She’s like trying to get me into a trauma treatment program . . . She is the first person who’s ever like recommended that.

Challenges related to structural violence through policy (what I need)

Although policies are most often well intentioned, they sometimes have negative unintended consequences. This is true at the system, or government level, as well as at the organizational level, both for hospitals and women’s shelters.

Vanessa felt that governmental policy was insensitive to her situation as a woman who had experienced violence and prevented her from receiving the help she needed. She stated:

And then, trying to find a home for myself and my daughter and subsidy won’t even look at you unless you can prove cohabitation. When you’re leaving an abusive environment, you don’t really think of taking a paper or something to show that you were living at that address. You just leave. So that was really difficult.

Karen commented on an organizational policy that she felt limited her ability to obtain the health care services she required. She stated the following:

When you should go to a walk-in clinic, they can only deal with one issue now. Before it used to be two issues now they’ve narrowed it down to one issue . . . If you need a referral and you also have a throat infection they can only deal with one thing at a time . . . The biggest barrier with walk-in clinics is basically you can’t get all your issues done at one appointment.

Margaret shared the reality of the situation in the context of the health care system was incongruent with a well-intentioned women’s shelter policy. Due to her reality of having to go to the hospital to seek care and experiencing long wait times, she was challenged to stay compliant with a women’s shelter policy regarding curfew:

If you’re not going to be on time you have to call. But it’s [inaudible] [09:56] late past the time when you’re not allowed in, more than twice a week, they’ll kick you out . . . the same thing works you can only be out one night a week. Like for me sometimes, my mom or dad would tell me to just come home for a couple nights for that mental health break away from being around everybody all the time and not being able to process anything. But you can’t, because you can only be out one night. So, I was there from September to February so during the holiday time. I wanted to go stay for Christmas. I went on Christmas Eve and Christmas Day and then I was supposed to be back on Christmas Day.

Margaret also spoke about another well-intentioned shelter policy regarding medications that had the unintended consequence of taking away control from women. Margaret stated that

And, in the shelter you’re not allowed to keep medication. So, in the office they’ve got buckets where you can put your—if you have Tylenol or anything like that. The thing is you never know that it’s coming. So, when you’re actually not well, you have to wait it out . . . [Shelter workers] can’t give Tylenol or Advil.

Systems and Stigma

Some women noted that they felt a lack of acceptance related to a variety of factors, including socioeconomic status, gender, and disability.

For instance, Karen reported that

I find as a person of low income, sometimes you’re treated differently. There could be a stigma towards people with disabilities, I believe. That could be one thing. I’m not sure it has anything to do with that, but sometimes there’s a stigma towards people on low- income . . . Dismissing my other physical problems and just looking at one area.

Women in this study spoke about feeling a lack of inclusion and acceptance, that is, stigma.

Margaret stated that she felt stigmatized by a previous physician:

I had a family doctor when I was coming out of the shelter. When I was in the shelter, I was going to be off work. It was hard because my doctor at the time, she didn’t want to write me a doctor’s note. It was really weird. She wrote me for just two weeks and then when I went back to see her she was like, “Oh yeah, I think you’re good to go back.” I felt like I wasn’t really being heard. I guess that makes you not feel as comfortable moving forward. You want to give [that person?] [17:11] the benefit of the doubt but I felt like I fought to get out of the relationship, I had to fight when I was in the shelter, [inaudible] [17:21] try to get out of the shelter, and now I’m having to fight for my doctor to support me.

Meanwhile, Vanessa noted that she felt stigmatized by the community where she stayed in a shelter. She said that

There’s just a stigma when it comes to shelters and things like that. In the neighborhood that the shelter was in, a lot of people didn’t want us being there or didn’t like that we were in the community. That was really hard . . . women are there to escape abuse, and we’re not there to cause issues or bring violence into the area. We’re just looking to live a normal life like everyone else.

Vanessa later added the following: “I feel like a lot of people think that when women are in shelter and they’re asking for help from the community it’s because they’re lazy and they don’t really want to do it on their own.”

Discussion

The findings from this qualitative study underscore the impacts—both positive and negative—of policies and policy gaps in the context of rural health care and IPV. Among this sample of rural women, more than half (n = 5) lacked a primary health care provider in their area and more than half had difficulty accessing mental health services in their area (n = 5). The findings from this study highlight that for most of these rural women, there were challenges associated with accessing health care services, and when accessed, often failed to adequately meet their health-related needs. Owing to challenges related to traveling to a physician (e.g., transportation and child care issues), some women had to rely on the use of walk-in clinics. In Ontario, Canada, use of walk-in clinics has become an increasingly common piece of the health care system, with debatable quality of care (Hutchison et al., 2003). While patients generally report greater satisfaction with walk-in clinics versus emergency departments, satisfaction with using walk-in clinics was lower than attending a family practice (Hutchison et al., 2003). Walk-in clinics, defined as “a facility that is physically separate from a hospital, has extended hours of service, and which accepts patients without an appointment or referral” (Miller & Nantes, 1989, p. 2019), either have links with family physicians, but many function independently of family practices (Miller & Nantes, 1989). Despite the convenience of walk-in clinics in terms of hours of operation and location, there have been concerns with the quality of care offered by this model of care, such as issues with continuity of care (Alemagno et al., 1986). However, the primary reason for using walk-in clinics in the urban and rural Canadian contexts was a perceived lack of access to family physicians (Szafran, 2000). In response to increasing patient workloads and the need for more time, many physicians and walk-in clinics have adopted policies related to “one problem per visit” (Canadian Medical Protective Agency, 2019), and indeed, this challenge was identified by participants in this study. However, such policies are potentially problematic, particularly when women access these services due to a lack of access to primary care physicians. For many of these women, it may not be feasible for to attend medical care when each unique condition arises, but will “save” their concerns for one visit. An extreme example of how problematic these policies can be was exemplified by a 2012 report by the Manitoba College of Physicians and Surgeons, who urged caution of these “one issue per visit” policies after a physician allegedly did not hear a woman’s concern with chest pain (because of this policy) and succumbed to a myocardial infarction a week later (Adhopia, 2019).

Health care policies, or lack thereof, can serve as particularly problematic for rural women experiencing IPV. As one of the participants in this study spoke about, her experience with the health care system was particularly challenging due to additional feelings of stigmatization and trying to overcome policy-related challenges when she required a note to be off work due to illness. To highlight, a recent critical discourse analysis evaluating how provincial, hospital and women’s shelter policies intersect and affect women in rural communities (Mantler, Jackson & Walsh, 2018) found that an absence of hospital policy around caring for women experiencing violence leads to significant problems for the women seeking health care. Absence of policy in these areas may result in health care providers not having adequate knowledge and training on how to best respond to the needs of women who experience IPV. As a result, women who have experienced IPV will have highly variable health care experiences dependent on the individual health care professional providing care. Furthermore, with the siloed approach to care that is often experienced (Mantler, Jackson & Walsh, 2018), there is a lack of consistency and continuity among the interactions of health care professionals. Calling for the establishment of formalized and unified policies among primary health care providers, health care organizations (e.g., hospitals and walk-in clinics), and other services frequently used by women who experience IPV (such as shelters and legal services) that extend beyond “screening” is urgently needed. For example, a recent online safety planning protocol (titled iSAFE in New Zealand, iCAN in Canada, IRIS in the United States, and I-Decide in Australia) has been launched internationally, which offers an interconnected series of programs which helps women to identify health consequences of violence when leaving or involved in an abusive relationship (Ford-Gilboe et al., 2017; Hegarty et al., 2015; Koziol-McLain et al., 2018). These programs are underpinned by a trauma- and violence-informed approach, referred to as trauma- and violence-informed care (TVIC; Ponic et al., 2016). A TVIC approach integrates the impacts of interpersonal and the systemic and structural inequities on health (Ponic et al., 2016; Strand et al., 2016). TVIC approaches have gained some momentum in uptake among some rural women’s shelters, but without similar uptake among health care providers and health care institutions, women experiencing IPV will continue to experience disjointed, and often, care that subjects them to further trauma.

While integration of TVIC approaches in mainstream health care offers an intermediary solution for rural women who experience violence, currently this option is not occurring within rural health care systems in Canada. Currently, women’s shelters globally expand their mandate (either explicitly or implicitly) to provide women with some of the health and social services in an attempt to meet their needs (Tschirch et al., 2006). A recent Canadian study of rural women’s shelters demonstrated how some shelters integrate one or more health/social services under one local access point to improve services for women experiencing violence (Mantler, Jackson & Walsh, 2018). A review of integrated services by women’s shelters (Mantler, Jackson & Walsh, 2018) found that shelters are trying to incorporate a variety of health-related services under one roof, such as primary care by a nurse practitioner, dental services, HIV testing, and psychiatric services. Providing such integrated services has shown beneficial outcomes for women, including improved access and acceptability and decreasing future health care needs (Mantler, Jackson & Walsh, 2018).

Limitations

This study is not without limitations including a small sample size and diverse communities. This study reflects the lived experience of eight participants. While the in-depth interviews enabled insight into the breadth of experiences and saturation was achieved in terms of emerging findings, the results still only reflect the experiences of eight women. Also, the participants were recruited from a range of rural communities, with varying population sizes, health and social services, and community values. We cannot assume that there is homogeneity in the rural experience; nonetheless, there are several similarities that emerged that stemmed from geographic location. Given both the sample size and the diversity in rural setting, it is important the results are interpreted within these contexts.

Conclusion

This study highlights that for most rural women, there were challenges associated with accessing health care services including primary health care and mental health services. These gaps in services were associated with time inequity (women traveling for great lengths of time to see a primary health care provider for a short period of time, child care issues, and the reliance on walk-in clinics as there was a lack of access to primary health care providers). Furthermore, when services were accessed, they often failed to adequately meet the health-related needs of the women. Integration of services is one system-level change that offers promise in terms of meeting the health care needs of rural women who have experienced violence. A model of integrated health and social service within women’s shelters when overseen by advanced practice nurses, such as nurse practitioners, holds promise as a potential solution to the policy gaps that currently exist between health and other required services. Further research exploring and evaluating the potential of such models is urgently needed.

Footnotes

Acknowledgements

We would like to thank the participants who shared their lived experiences with us.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by an internal grant from the University of Western Ontario.

ORCID iDs

Tara Mantler

Edmund J. Walsh

Author Biographies

Tara Mantler, PhD, is an assistant professor in the School of Health Studies at Western University, Ontario, Canada.

Kimberley T. Jackson, PhD, RN, is an assistant professor at the Arthur Labatt Family School of Nursing at Western University, Ontario, Canada. Dr. Jackson’s program of research spans issues pertaining to women’s health, with particular focus on the perinatal period.

Edmund J. Walsh, MScN, RN, is a PhD student and graduate research assistant at the Arthur Labatt Family School of Nursing at Western University in London, Ontario, Canada. Mr. Walsh is keenly interested in leadership and management, work environments, and the delivery of health care services.

Selma Tobah, PhD(c), is a research coordinator in the area of intimate partner violence at the School of Health Studies, Western University. Her research interests include health service utilization of marginalized populations, with a focus on health policy and structural violence.

Katie Shillington, BHSc, is a master’s student and graduate research assistant in Health and Rehabilitation Sciences at the School of Health Studies at Western University. She is interested in kindness as a mental health promotion approach, women’s health, and general health promotion practices.

Brianna Jackson, MScN, RN, is a doctoral student and graduate research assistant at Yale University’s School of Nursing. Her research interests span the intersection of relational trauma, structural violence, and mental health outcomes among child, adolescent, and emerging adult populations.

Emily Soares, RN, is a Masters of Science student at the University of Western Ontario with interests in intimate partner violence and rurality.

References

Adhopia

(2019, March 22). Canadian health care’s “one issue per visit” problem. CBC News. https://medium.com/@jamesalexandermichie/canadian-health-cares-one-issue-per-visit-problem-c52d31e9beb5

Alemagno

Zyzanski

Silko

(1986). Urgent care centers: What does “urgent” really mean? Family Practice Research Journal, 6(1), 12–21.

Barner

Carney

(2015). Intimate partner violence, gender and lethality: A case analysis of two facilities. Journal of Forensic Social Work, 5, 1–3.

Burnett

Ford-Gilboe

Berman

Wathen

Ward-Giriffin

(2016). The day-to-day reality of delivering shelter services to women exposed to intimate partner violence in the context of system and policy demands. Journal of Social Service Research, 42(4), 516–532. https://doi.org/10.1080/01488376.2016.1153562

Canadian Medical Protective Agency. (2019). Limiting discussion to one medical issue per visit: Know the risks. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/limiting-discussion-to-one-medical-issue-per-visit-know-the-risks

Coker

Smith

Bethea

King

McKeown

(2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9(5), 451–457.

Crenshaw

K. W.

(1994). Mapping the margins: Intersectionality, identity politics, and violence against women of color. In Fineman

M. A.

Mykitiuk

(Eds.), The public nature of private violence (pp. 93–118). Routledge.

England

K. V.

(1994). Getting personal: Reflexivity, positionality, and feminist research. The Professional Geographer, 46(1), 80–89.

Farmer

Nizeye

Stulac

Keshavjee

(2006). Structural violence and clinical medicine. PLoS Medicine, 3(10), Article e449.

10.

Ford-Gilboe

Varcoe

Scott-Storey

Wuest

Case

Currie

L. M.

Wathen

(2017). A tailored online safety and health intervention for women experiencing intimate partner violence: The iCAN Plan 4 Safety randomized controlled trial protocol. BMC Public Health, 17, Article 273. https://doi.org/10.1186/s12889-017-4143-9

11.

Ford-Gilboe

Wuest

Varcoe

Davies

Merritt-Gray

Campbell

Wilk

(2009). Modelling the effects of intimate partner violence and access to resources on women’s health in the early years after leaving an abusive partner. Social Science & Medicine, 68(6), 1021–1029.

12.

Graham-Bermann

Zularz

A. R.

Howell

K. H.

(2011). Additional adverse events among women exposed to intimate partner violence: Frequency and impact. Psychology of Violence, 1(2), 136–149.

13.

Haggerty

Roberge

Levesque

Gauthier

Loignon

(2014). An exploration of rural-urban differences in healthcare-seeking trajectories: Implications for measures of accessibility. Health & Place, 28, 92–98.

14.

Hegarty

Tarzia

Murray

Valpied

Humphreys

Taft

Glass

(2015). Protocol for a randomised controlled trial of a web-based healthy relationship tool and safety decision aid for women experiencing domestic violence (I-DECIDE). BMC Public Health, 15, Article 736. https://doi.org/10.1186/s12889-015-2072-z

15.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.

16.

Hutchison

Østbye

Barnsley

Stewart

Mathews

Campbell

Tyrrell

(2003). Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: The Ontario Walk-In Clinic Study. Canadian Medical Association Journal, 168(8), 977–983.

17.

Koziol-McLain

Vandal

A. C.

Wilson

Nada-Raja

Dobbs

McLean

Glass

N. E.

(2018). Efficacy of a web-based safety decision aid for women experiencing intimate partner violence: Randomized controlled trial. Journal of Medical Internet Research, 19(12), Article e426. https://doi.org/10.2196/jmir.8617

18.

Kulkarni

Bell

Wylie

(2010). Why don’t they follow through? Intimate partner survivors’ challenges in accessing health and social services. Family Community Health, 33(2), 94–105.

19.

Lanier

Maume

M. O.

(2009). Intimate partner violence and social isolation across the rural/urban divide. Violence Against Women, 15, 1311–1330. https://doi.org/10.1177/1077801209346711

20.

Mantler

Jackson

K. T.

Ford-Gilboe

(2018). The CENTRAL Hub Model: Strategies and innovations used by rural women’s shelters in Canada to strengthen service delivery and support women. Journal of Rural and Community Development, 13(3), 115–132. https://doi.org/10.1080/03639040500214688

21.

Mantler

Jackson

K. T.

Walsh

(2018). Integration of primary health-care services in women’s shelters: A scoping review. Trauma, Violence, & Abuse. Advance online publication. https://doi.org/10.1177/1524838018781105

22.

Mantler

Wolfe

(2017). A rural shelter in Ontario adapting to address the changing needs of women who have experienced intimate partner violence: A qualitative case study. Rural & Remote Health, 17, 3987.

23.

Mason

Wolf

O’Rinn

Ene

(2017). Making connections across silos: Intimate partner violence, mental health, and substance use. BMC Women’s Health, 17(29), 1–7.

24.

Miller

Nantes

(1989). Walk-in Clinics and Primary Care: Review of the Literature. Canadian Family Physician, 35, 2019–2022.

25.

Montesanti

Thurston

(2015). Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women’s Health, 15(1), Article 100.

26.

Ponic

Varcoe

Smutylo

(2016). Trauma-(and violence-) informed approaches to supporting victims of violence: Policy and practice considerations. Victims of Crime Research, 9, 3–15.

27.

Rose

(2015). A feminist reconceptualisation of intimate partner violence against women: A crime against humanity and a state crime. Women’s Studies International Forum, 53, 31–42.

28.

Sinha

(2011). Section 3: Intimate partner violence. https://www150.statcan.gc.ca/n1/pub/85-002-x/2013001/article/11805/11805-3-eng.htm

29.

Strand

Popescu

Abramovitz

Richards

(2016). Building agency capacity for trauma-informed evidence-based practice and field instruction. Journal of Evidence-Informed Social Work, 13(2), 179–197.

30.

Szafran

O. N. B.

(2000). Use of walk-in clinics by rural and urban patients. Canadian Family Physician, 46(1), 114–119.

31.

Tjaden

Thoennes

(2000). Extent, nature and consequences of intimate partner violence: Findings from the National Violence Against Women Survey. National Institute of Justice and the Center for Disease Control and Prevention, U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. https://doi.org/10.1037/e300342003-001

32.

Tschirch

Walker

Calvacca

(2006). Nursing in tele-mental health. Journal of Psychosocial Nursing, 44(5), 20–27. https://doi.org/10.1016/B978-0-12-416048-4.00002-6

33.

Zorn

Wuerch

Faller

Hampton

(2017). Perspectives on regional differences and intimate partner violence in Canada: A qualitative examination. Journal of Family Violence, 32(6), 633–644.

34.

Zweig

Schlichter

Burt

(2002). Assisting women victims of violence who experience multiple barriers to services. Violence Against Women, 8(2), 162–180.