Organizational Readiness for Intimate Partner Violence Response among Supportive Housing Providers: A Capacity Assessment in Maryland

Abstract

Intimate partner violence (IPV) frequently leads to housing instability and homelessness among survivors. While the client populations of many housing support programs are likely to include IPV survivors who have unique safety needs, the organizational readiness of these housing providers to identify and support IPV survivors is not clear. This study assessed organizational readiness for IPV response among Rapid Re-Housing (RRH) and Transitional Housing (TH) providers in Maryland, whose client populations include women (n = 32). We adapted the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) to create the Housing provider Readiness to Manage IPV Survey (H-REMIS), inclusive of IPV-related perceptions, policies, staff training and capability, and resources. The 12-point H-REMIS demonstrated acceptable internal consistency reliability (Cronbach’s α = 0.748). Descriptive and comparative analyses domains by IPV-specific (n = 4) and general (n = 28) housing providers assessed readiness and identified areas for improvement. IPV-specific providers had higher mean organizational readiness for IPV response scores relative to non-IPV specific providers (11.3 and 7.5, respectively). High readiness areas included perceiving the importance of IPV and staff having adequate time, space, and comfort level to address IPV. Areas of low readiness included development and use of IPV response policies as well as staff training on IPV. This assessment documents concerning gaps in organizational readiness for IPV response among supportive housing providers, and pinpoints areas where training and capacity building can be most valuable. The process of improving readiness in the supportive housing sector must involve capacity building and a systems-level approach in order to ensure that all supportive housing providers are prepared to meet the needs of IPV survivors among their client population.

Keywords

domestic violence intervention/treatment < domestic violence anything related to domestic violence < domestic violence.

Background

Over one in three women in the United States experience intimate partner violence (IPV) in their lifetimes (Smith et al., 2018). Housing instability features prominently among the many health and social consequences of IPV, and IPV is one of the most common causes of homelessness among women, while men are more likely than women to report homelessness due to job loss and mental health issues (Lehmann et al., 2007; Tessler et al., 2001). The Department of Housing and Urban Development (HUD)’s Point-in-Time count recorded nearly 45,000 homeless IPV survivors in 2019 (HUD, 2019a), which is considered an underestimate (National Law Center on Homelessness and Poverty, 2017). The odds of housing instability are almost four times greater among survivors relative to their non-abused counterparts (Pavao et al., 2007). Housing instability includes experiences of frequently moving, struggling to pay rent or mortgage, and being at risk of eviction, and can lead to homelessness (Frederick et al., 2014; Kushel et al., 2006; Suglia et al., 2011). Past research with IPV survivors has identified frequent moves (Adams et al., 2018) as well as high levels of housing instability (up to 36% in the past 2 years) and homelessness (11%) (Gilroy et al., 2016) in this population. Among IPV survivors, periods of homelessness and housing instability can be frequent, and many women return to abusive partners when faced with insufficient housing options (Tutty et al., 2013). Abuse can undermine survivors’ financial stability (O’Campo et al., 2016; Osuji & Hirst, 2015), as well as increase their need for secure housing to avoid further violence. The abuse itself can also be economic in nature, including economic control and employment sabotage (Postmus et al., 2012). The evidence linking homelessness and IPV for women, coupled with IPV survivors’ greater use of housing assistance programs (Lipsky et al., 2006), confirms the vital role of supportive housing providers in meeting the needs of IPV survivors.

The compounded instability of both homelessness and IPV are increasingly recognized at the federal level. HUD provides tools and guidance on supporting IPV survivors to local housing Continuums of Care (CoCs), and in 2018, offered a $50 million funding opportunity for CoCs to create new supportive housing for survivors (HUD, 2018). Designated financial supports for survivors are also provided through the Violence Against Women Act, HEARTH Act, and the Family Violence Prevention and Services Act (HUD, 2009, 2016; Family & Youth Services Bureau, 2018). Despite these inputs, housing needs outpace supply among IPV survivors: The 2019 census of domestic violence shelters reported that almost 43,000 survivors received housing, with nearly 8,000 requests for housing going unmet (National Network to End Domestic Violence, 2020).

Despite the close links between IPV and housing instability/homelessness, and the likely presence of IPV survivors among housing programs for the general population, little is known about the IPV response readiness of housing providers. Multiple definitions of organizational readiness have been put forward, for both general and public health-specific contexts (Department of Health and Human Services Health Resources and Services Administration, n.d.; Gagnon et al., 2018; Weiner, 2009). Drawing from this work, key concepts for the current capacity assessment of IPV response readiness include having the commitment, infrastructure, and resources to anticipate and meet IPV survivors’ needs.

Organizational readiness for IPV response has been valuable in preparing health-care settings to respond to IPV and monitoring progress toward that goal. The Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) Tool (Short et al., 2006) provides a framework for organizational readiness for IPV response that can be adapted to other settings likely to encounter survivors. Building from the PREMIS, we present a Housing provider Readiness to Manage IPV Survey (H-REMIS), and describe organizational readiness for IPV response among providers of TH and RRH whose client populations include women. TH and RRH represent leading service approaches for housing support; TH typically provides onsite housing and support for up to 2 years and RRH provides graduated financial assistance for rental housing to build stability in place and reduce the total number of housing transitions (HUD, n.d.).

Methods

Sample and Data Collection

A cross-sectional survey of supportive housing providers in Maryland was conducted between August and December 2019. Eligible programs were those providing RRH and/or TH with a client population that included women. The initial sampling frame was generated from lists of federally funded housing programs obtained from the websites of HUD and the U.S. Department of Justice Office on Violence Against Women. The 16 CoCs in Maryland provided lists of RRH and TH providers in their regions. These methods identified a total of 80 housing providers. Providers were contacted via email and/or phone to verify eligibility criteria. Twenty-seven providers were either no longer operational or utilized other housing models such as Permanent Supportive Housing (PSH) or emergency shelter. One additional provider was excluded due to only serving male clients, and five providers could not be reached to determine eligibility. Of the 47 providers with confirmed eligibility, a total of 32 completed the survey for a response rate of 68% (32/47). Of the 15 eligible providers who did not participate, 8 were RRH-only and 7 were TH-only or TH/RRH combination.

Semi-structured interviews with an organizational representative were conducted largely via phone, with four interviews (12.5% of the total) occurring in-person. The majority of informants were program coordinators or program managers, and several were organizational leaders. This study received a non-human subjects research determination from the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health.

Measures

Informants provided information on basic characteristics of their housing programs. The 12-item H-REMIS (Box 1) consists of 9 items adapted from the PREMIS (Short et al., 2006), supplemented by 3 additional items drawn from Consolidated Framework for Implementation Research (CFIR) constructs: implementation climate and readiness for implementation (Damschroder et al., 2009). These CFIR constructs were selected to address organizational culture around IPV response, while the PREMIS items focused on the training and resources available to providers. The 9 items from PREMIS had a Cronbach’s α = 0.707, which was enhanced with the inclusion of the 3 CFIR items for a final Cronbach’s α = 0.748 for the 12-point H-REMIS, indicating adequate psychometric properties. Four subscales are contained in the H-REMIS: IPV Perceptions (Cronbach’s α = 0.623), IPV Policies (Cronbach’s α = 0.555), Staff Training (Cronbach’s α = 0.784), and Staff Response Capability and Resources (Cronbach’s α = 0.555).

Analysis

Descriptive analysis summarized organizational characteristics and readiness factors and score both overall and by provider type (RRH-only or TH-only/combination). Levels of IPV readiness in each domain were mapped according to provider type, and organizational IPV readiness scores were calculated for IPV-specific and general providers. All analyses were conducted using Stata 15 (StataCorp, 2017).

Results

Organizational characteristics of housing providers are displayed in Table 1. Only 4 of the 32 providers (12.5%) served IPV survivors exclusively. For the remaining 28 providers, perceived IPV prevalence among the women in their client population was 45%.

Table 1.

Organizational Characteristics by Housing Provider Type (n = 32).^a

	All Provider Types (n = 32)	RRH Only (n = 15)	TH Only & TH/RRH Combinations (n = 17)
Annual caseload mean (SD)	75 (89)	72 (69)	78 (106)
Number of women in caseload mean (SD)	44 (49)	33 (32)	53 (59)
IPV is part of program eligibility criteria % (n)	12 (4)	7 (1)	18 (3)
Perceived IPV prevalence among women in caseload mean (SD)
All providers	45% (35%)	32% (33%)	54% (34%)
Providers for whom IPV is not part of eligibility criteria	36% (28%)	26% (27%)	44% (28%)

Notes. ^aSample size fluctuates to accommodate small amounts of missing data.

TH = Transitional Housing; RRH = Rapid Rehousing.

Table 2 displays organizational readiness for IPV response by domain. In the IPV Perceptions domain, the vast majority of providers stated that IPV was a somewhat high priority or very high priority for them, and that they understood the needs of IPV survivors well or very well (84% and 90%, respectively). There was no significant difference in the overall IPV Perceptions score between IPV-specific and general housing providers. In the IPV Policies domain, just over half of providers (59%) had an IPV screening policy that is used widely, and half had an IPV response policy that is used widely. Only a quarter of providers either had a memorandum of understanding (MoU) with an IPV service provider or were an IPV service provider themselves. For the IPV Policies section overall, IPV-specific providers scored significantly higher than general providers (p < 0.01). Within the Staff Training domain, approximately half of providers had general IPV training (53%), trauma-informed training (56%), and mandatory reporting/legal training (47%) for all staff. The IPV-specific providers had significantly higher scores on training (p < 0.05). In the Staff Response Capability and Resources domain, almost all providers stated that staff had adequate time and space to respond to IPV among clients (94%) and that staff were somewhat comfortable or very comfortable discussing IPV with clients (88%). Approximately half of providers (53%) had resource materials onsite that were well-displayed and accessed by clients. Providers serving only IPV clients scored significantly higher than general providers in this section as well (p < 0.05).

Table 2.

Organizational Readiness of IPV Response by Housing Provider Type (n = 32).

	All Provider Types (n = 32) % (n)	RRH Only (n = 15) % (n)	TH Only & TH/RRH Combinations (n = 17) % (n)
IPV perceptions
Importance of IPV for provider
Somewhat high priority or very high priority	84 (27)	74 (11)	94 (16)
Provider’s understanding of IPV survivors’ needs
Well or very well	90 (29)	87 (13)	94 (16)
IPV policies
Written policy on IPV screening
Yes, used widely	59 (19)	60 (9)	59 (10)
Written policy on IPV response
Yes, used widely	50 (16)	47 (7)	53 (9)
MOU w/ IPV provider (or is an IPV provider)	25 (8)	20 (3)	29 (5)
Staff training
IPV training
All staff	53 (17)	47 (7)	59 (10)
Trauma-informed training
All staff	56 (18)	53 (8)	59 (10)
IPV legal/ mandatory reporting training
All staff	47 (15)	47 (7)	47 (8)
Staff response capability and resources
Adequate time to respond to clients’ IPV needs	94 (30)	93 (14)	94 (16)
Adequate private space to respond to clients’ IPV needs	94 (30)	87 (13)	100 (17)
Staff comfort level discussing IPV with clients
Somewhat comfortable or very comfortable	88 (28)	87 (13)	88 (15)
Availability of IPV resource materials onsite
Yes, well-displayed and accessed	53 (17)	53 (8)	53 (9)
Housing provider readiness for IPV response score mean (SD)
All providers	7.9 (2.6)	7.5 (2.8)	8.3 (2.4)
Providers for whom IPV is part of eligibility criteria	11.3 (0.5)	*	*
Providers for whom IPV is not part of eligibility criteria	7.5 (2.4)	7.3 (2.8)	7.6 (2.1)

Notes. *Suppressed due to small cell size.

TH = Transitional Housing; RRH = Rapid Rehousing.

Box 1.

Housing Provider Readiness to Manage IPV Survey (H-REMIS) Questionnaire.

Notes. ^aAdapted from the CFIR.

^bAdapted from the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS).

⁺Response constituted a point on the H-REMIS for this survey item.

The mean organizational readiness for IPV response score was 7.9 overall, 7.5 among RRH-only providers, and 8.3 among TH-only and TH/RRH combination providers. Mean scores for IPV-specific providers and non-IPV specific providers were 11.3 and 7.5, respectively (p < 0.01).

Discussion

This study identified gaps in organizational readiness for IPV response among supportive housing providers. Gaps were particularly notable for providers who do not specialize in IPV support (mean readiness score 7.5 relative to 11.3 for IPV-specific providers). The importance of IPV was widely recognized and staff generally have the time, space, and comfort level to support survivors. Identified actionable areas for improvement include IPV-related institutional policy and training. IPV response training programs in healthcare settings have been shown to improve healthcare providers’ attitudes and self-efficacy for IPV screening and response (O’Campo et al., 2011; Zaher et al., 2014). Lessons from the process of building institutional capacity in the healthcare sector, particularly the integration of IPV interventions into existing systems and the scale-up of those interventions (Decker et al., 2012), can be highly relevant to the housing sector.

Critically, non-IPV specific housing providers may be underestimating IPV-related needs among their client population. Survivors who initially enter IPV emergency shelters or IPV-specific supportive housing programs may later require support from non-IPV specific housing providers, who must be able to address their unique circumstances. The impact of IPV on survivors includes damaged financial history (O’Campo et al., 2016; Osuji & Hirst, 2015), landlord discrimination (Barata & Stewart, 2010; Gezinski & Gonzales-Pons, 2021), a variety of mental health conditions (Lagdon et al., 2014), and the threat of escalating violence, all of which can act as barriers to housing stability.

There are both policy-level and provider-level steps to improving readiness and strengthening supportive housing systems. HUD has begun incentivizing CoCs to address the needs of IPV survivors (HUD, 2019b); strategies such as this can provide concrete financial motivations for housing providers to build IPV response capacity. Capacity building efforts may also benefit from local IPV service provider partnerships, as well as resources such as the Domestic Violence and Housing Technical Assistance Consortium, whose team includes several IPV-focused nonprofits that respond to requests for technical assistance from supportive housing providers and advocates (Domestic Violence and Housing Technical Assistance Consortium, n.d.). It is worth noting that by participating, some non-IPV specific providers became more aware of aspects of their IPV response that could be improved.

Limitations include the small sample size which precluded analysis of readiness predictors, the risk for response bias, and reliance on a single organizational representative per organization. In addition, this study does not include data on PSH, which is another leading model for supportive housing. Although PSH was outside the scope of this assessment, it is important for future work to explore PSH providers’ organizational readiness for IPV response. Results from this study may not generalize beyond the single state in which the assessment was conducted, though the framework provides a starting point for wider assessment. The definition of organizational readiness may be expanded to include concepts such as leadership support and efficacy, which were not included in this assessment but are part of other frameworks for organizational readiness (Department of Health and Human Services Health Resources and Services Administration, n.d.; Gagnon et al., 2018; Weiner, 2009).

This study provides important insights into the current state of organizational readiness for IPV response in the supportive housing sector, which is a topic that has rarely been explored despite the widely understood links between IPV and housing stability. Results demonstrate the need for enhancing readiness for IPV response among housing providers. A systems-level framework is needed to ensure that all survivors are met with policies, resources, and staff equipped to respond to the social and emotional needs of IPV survivors, which include psychosocial support as well as recognition of the unique safety needs for this population. Implementation research has been valuable in strengthening IPV response in the healthcare setting (Decker et al., 2017), and can similarly be valuable in strengthening systems capacity for IPV response among housing providers through training, dissemination of best practices, and partnerships with local IPV response programs. Advances should be inclusive of the needs of marginalized groups who may face greater barriers to housing, such as survivors who are women of color, immigrants, or part of the LGBTQ community. Housing instability and homelessness are chief concerns for many IPV survivors, and the supportive housing sector must be prepared to meet survivors’ needs.

Footnotes

Acknowledgements

This study was conducted with support from the National Institute of Justice (2018-ZD-CX-0002; PI Decker).

Drs. Grace and Holliday were supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (Number: T76MC00003 Title: Training Program in Maternal and Child Health).

We wish to thank the housing providers who participated in the study and shared their insights.

Declaration of Conflicting Interests

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

ORCID iDs

Arshdeep Kaur

Karen Trister Grace

Michele R. Decker

Authors Biographies

Arshdeep Kaur, MSPH, is a recent graduate of the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, and a current medical student at California University of Science and Medicine.

Karen Trister Grace, PhD, MSN, CNM, is a postdoctoral fellow in Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD; an adjunct instructor at Georgetown University School of Nursing & Health Studies in Washington, D.C.; and in clinical practice at Mary’s Center for Maternal Child Health in the Washington, D.C., metro area.

Charvonne N. Holliday, PhD, MPH, is an assistant professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. Her research focuses on understanding racial/ethnic disparities that persist in intimate partner violence and women’s sexual/reproductive health.

Langan Denhard, MPH, is a recent graduate of Johns Hopkins Bloomberg School of Public Health. She is currently a research assistant within the Center for Injury Research and Policy and Department of Population, Family and Reproductive Health at the Johns Hopkins School of Public Health in Baltimore, MD.

Janice Miller, LCSW-C, is the Director of Programs and Clinical Services at House of Ruth Maryland, a comprehensive domestic violence prevention and support center in operation since 1977. She has three decades of experience in direct services for survivors and is a Bloomberg American Health Initiative Fellow at the Johns Hopkins Bloomberg School of Public Health.

Michele R. Decker, ScD, MPH, is a Bloomberg Associate Professor of American Health in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. She leads the Women’s Health and Rights program of the Center for Public Health and Human Rights.

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