Integrating Reproductive Health Services Into Intimate Partner and Sexual Violence Victim Service Programs

Abstract

This study assessed the feasibility of integrating reproductive health services into intimate partner violence/sexual violence (IPV/SV) programs. After a training for victim service agencies on integration of health services, we conducted semistructured interviews with IPV/SV program leadership. Leadership reported advocates were more likely to recognize the need to refer clients to health services, and revealed challenges operationalizing partnerships with health care centers. Training to integrate basic health assessment into victim services may be one way to address women’s urgent health needs. Formal partnership agreements, protocols to facilitate referrals, and opportunities to cross-train are needed to nurture these cross-sector collaborations.

Keywords

advocates violence prevention reproductive health victim services domestic violence sexual violence

Background

Advocates working in intimate partner violence (IPV) and sexual violence (SV) agencies are in a unique position to affect women’s immediate health needs. Reproductive and sexual health concerns such as unintended pregnancy, sexually transmitted infections (STI), and HIV are often time-sensitive. Women entering shelter are especially vulnerable to poor sexual and reproductive health outcomes, as they are more likely to be experiencing severe abuse, in great physical danger, in a state of crisis with less access to health care, and at greater risk for having experienced reproductive coercion (RC; partner coercion to get pregnant, contraceptive and condom sabotage, unprotected or forced sex by a partner, partner pressure to have an abortion, partner abuse to cause miscarriage; E. Miller & Silverman, 2010; Grossman & Lundy, 2011; Lyon, Lane, & Menard, 2008; Thiel de Bocanegra, Rostovtseva, Khera, & Godhwani, 2010; Tutty, 2015). One study found over 75% of the women in shelter were in extreme or severe danger, with 49% having experienced rape by a partner, 50% being choked by their partner, and 55% having had their partners threaten to kill them (Tutty, 2015). Given the myriad challenges that women entering shelter or seeking help are facing, connecting women to timely health services to prevent STIs, HIV, unwanted pregnancy, and related sequelae may not be a high priority, either for the IPV/SV advocacy agency or the women seeking victim support services. This includes access to emergency contraception as well as treatment for STIs and HIV prophylaxis.

Although much of the literature on health consequences of IPV/SV has focused on longer term effects, the co-occurrence of IPV with RC and the high likelihood of exposure to forced sexual intercourse prior to seeking shelter (in the context of severe abuse) point to the need to attend to immediate reproductive health needs. The likelihood of RC occurring is significantly increased when a woman is already experiencing IPV (Gee, Mitra, Wan, Chavkin, & Long, 2009; E. Miller, Decker, Raj et al., 2010). Women experiencing IPV have a greater need for sexual and reproductive health services such as STI/HIV testing, contraception, emergency contraception, pregnancy testing, and abortions than women who are not experiencing IPV (American College of Obstetricians and Gynecologists [ACOG], 2013; Clark, Allen, Goyal, Raker, & Gottlieb, 2014; Gee et al., 2009; Jones & Finer, 2011; E. Miller, Decker, et al. 2010; E. Miller, McCauley et al., 2014), likely related to experiences of forced sex, partner condom nonuse, and RC in the context of IPV.

In 2013, the American College of Obstetricians and Gynecologists (ACOG) recommended reproductive health providers assess for RC in addition to IPV. Although studies have evaluated clinic-based interventions for health providers to address RC (E. Miller et al., 2011; E. Miller et al., 2016), only limited research has been conducted on how to integrate health services and assessments into IPV/SV programs. Integrating reproductive health services and health assessments into IPV/SV programs may facilitate addressing time-sensitive health needs for women who are at elevated risk for poor health outcomes.

Title X National Family Planning Program

Since 1970, the Title X Family Planning program (Title X) has provided federal funding exclusively for comprehensive family planning services, prioritizing individuals with lower income. In 2015, grants were provided to more than 90 private nonprofit agencies providing community health and family planning and public health departments nationally (Fowler, Gable, Wang, & Lasater, 2016). Notably, the characteristics of those utilizing the majority of services provided by Title X are similar to those at highest risk for experiencing IPV/RC, specifically women ages 18-24 (Breiding, Chen, & Black, 2014; Fowler et al., 2016; Hasstedt & Rowan, 2016). The Centers for Disease Control and Office of Population Affairs of the U.S. Department of Health and Human Services, which provides Family X funding, jointly provide clinical recommendations for quality family planning services including those receiving Title X funding. In 2014, these recommendations included screening women for IPV and referring where appropriate, and continued emphasis on confidentiality of services (Gavin et al., 2014). Although the family planning clinical guidelines focus on the health care sector, provision of family planning services to harder-to-reach populations is encouraged.

Futures Without Violence—Project Connect

In 2009, the U.S. Department of Health and Human Services Office on Women’s Health (OWH) funded Futures Without Violence (Futures), a national nonprofit organization dedicated to ending violence against women and children, to oversee Project Connect: A Coordinated Public Health Initiative to Prevent Violence Against Women. This national effort aimed to increase collaboration between IPV/SV agencies and public health and family planning agencies, many receiving Title X funding, with an end goal to create sustainable changes in policy and a coordinated response for victims. State teams received funding to bring together public health agencies with IPV/SV agencies to implement a brochure-based intervention across clinical sites. With the help of local IPV/SV agencies, health care providers were trained on the intersection of reproductive health, physical health, and IPV before implementing the intervention. Simultaneously, Project Connect grantees also considered parallel and complementary strategies to partner with advocates to integrate on-site health services into IPV/SV programs. This initiative required one local IPV/SV program per state team to receive training on basic health assessment and to initiate planning for on-site health services.

We focus here on the implementation of health assessment and access to reproductive health services within IPV/SV programs. Interviews with clinical and IPV/SV site leads provide insights on the feasibility and acceptability of training victim service advocates to integrate rapid access to health services (sexual and reproductive health in particular) into their work flow.

Method

Description of Training

In each of the six states participating in Project Connect, Futures led a half day, in-person training for IPV/SV advocates on integrating health services. The learning objectives for this training were to (a) explain the impact of IPV on reproductive health, (b) define RC, (c) create specific partnerships with local reproductive health programs in addition to health services more generally, (d) assess the readiness of advocates within IPV/SV programs to integrate health services, (e) demonstrate how to integrate assessment for RC as part of IPV/SV advocacy services and connect clients to reproductive health care expeditiously, and (f) identify tools and resources to integrate health services into IPV/SV programs. Futures Without Violence (2014) also provided written materials to help reinforce training content and offered additional tools for IPV/SV programs such as an organizational assessment tool to identify potential gaps in policies and protocols to facilitate connecting clients to health services.

Procedures

Two research team members conducted semistructured phone interviews with 27 Project Connect site leads (11 from the health sector, 10 from IPV/SV programs, and six other providers): 19 with state site leads in January 2014, and then a follow-up round with eight interviews in November-December 2014 to discuss progress with the project in greater detail. Although these follow-up interviews were intended to collect feedback on the Project Connect initiative overall, participants were also asked specifically about the processes of partnership building between IPV/SV agencies and health services following the initial trainings. The interviews also probed on barriers and facilitators specific to connecting clients to reproductive and sexual health services. Interviews were transcribed verbatim and de-identified to maintain privacy. This study was reviewed and approved by the University of Pittsburgh institutional review board as part of the Project Connect evaluation.

Data Analysis

Interviews from Project Connect site leads were analyzed for barriers and challenges that advocates may face integrating health services into services for survivors or providing on-site health care within their agency. All interviews were independently coded by two coders using a consensus approach. Differing opinions were resolved through meeting and examining the interviews, with any discrepancies resolved by the lead investigator. Thematic analysis was used to identify commonly expressed thoughts (Patton, 1990; Ryan & Bernard, 2000) and responses using ATLAS.ti 7.5.10 (Scientific Software Development GmbH, Berlin). The research team created an initial code book from reviewing the first three interviews and identifying advocate challenges, challenges in implementing health care into IPV/SV agencies, and Project Connect successes. The code list expanded based on reoccurring themes emerging from additional interviews, with no new codes added after one quarter of the interviews were coded, suggesting content saturation was reached.

Results

Interviews With Site Leads

Interviews with site leads from Project Connect were analyzed for system- and advocate-level barriers and challenges to collaborating with family planning and public health clinics, as well as barriers to integrating health services into IPV/SV agencies. Themes that emerged from these interviews were (a) added value of formal partnerships, (b) logistical challenges, (c) advocate discomfort around sexual health topics, (d) family planning providers who lack comfort with IPV/SV, and (e) a difference in institutional cultures.

Added Value of Formal Partnerships

In most interviews, establishing the “warm referral,” or ability to call and make a personal referral to a partnering agency, was identified as the most sustainable and valuable part of setting up formal partnerships. As one advocate site lead described, “[Making warm referrals] helped move the conversation and make connections that we were not able to make in the past 10 years of reaching out to public health.”

Consequently, the creation of these formal partnerships through Project Connect led to women receiving higher quality and more expeditious health services. Agencies providing IPV/SV services could share specific names, locations, and services provided by local health centers. In discussing partnerships with a local clinic, one advocate shared, “When talking to women about things that are so private, we can . . . say . . . here is where the building is and this is the bus you take to it.”

Formal partnerships also led to creative and sustainable solutions to get women needed health services even if agencies were not able to integrate health services on-site at the IPV/SV agency:

So what [the local health clinic] decided instead is absolute same day front of the line walk-in services for domestic and sexual violence survivors, the [IPV advocates] screen people for health issues and [advocates] drive [survivors] to the public health district. They get put at the front of the line; all [the advocates] have to do is call and say we’ve got a survivor that would like to talk to somebody.

Ultimately, the funding and guidance from Project Connect were successful in creating positive agency collaborations for most public health/clinicians and advocates. Knowing who was on the other end of the phone call increased referrals and knowledge of services, which in turn created access to expeditious care and immediate solutions for women seeking services.

Logistical Challenges

Site leads working in IPV/SV agencies shared logistical challenges to getting all staff trained which included lack of time, financial constraints, and getting all staff to one physical location. One advocacy site lead described,

It’s not realistic to just send your one advocate and expect organizational change and so you can’t just bring in one advocate from each place . . . it’s incredibly expensive to bring all of those people and pay for all their lodging and we just couldn’t find a way in the budget.

Barriers specific to integrating on-site health services into IPV/SV programs included not enough client traffic (low patient volume), lack of space, and insufficient funding on the public health side to provide staffing. In addition, agencies did not have a structure in place for integrating on-site services which created unexpected obstacles. One site lead described,

We actually thought that this would be the easiest part of Project Connect, was putting reproductive health into the domestic violence program . . . it’s been even harder for them to order contraception because we are a very very small program . . . we still haven’t been able to do it yet. It’s stuff like that you think it will be easy but it’s difficult.

Other site leads also noted similar challenges with stocking any medications at the IPV/SV program, much less emergency contraception.

Advocate Discomfort Around Sexual Health Topics

One common response when advocates were asked the most helpful aspect of Project Connect was gaining knowledge about RC and the impact on health. This often led to advocates sharing their initial discomfort and lack of knowledge around topics of reproductive health for themselves or their staff, especially prior to Project Connect. As one advocate noted, “I learned a lot about how emergency contraception works and don’t think I had a really good sense [prior to Project Connect].” Harm reduction specific to sex and pregnancy (e.g., offering emergency contraception, talking to women about the need for STI testing and treatment) seemed to provide the most discomfort. One advocate shared that the most helpful aspect of Project Connect was “understanding . . . how you can approach [reproductive coercion] and then being realistic about the feelings that you have about harm reduction when you have someone that you don’t want to put at greater risk.” This same individual also stated how important and helpful it was to speak with other advocates who have the same concerns about harm reduction. It was common for advocates to report relief in knowing others felt the same discomfort and hesitation.

As a result of increased knowledge from Project Connect involvement and the training, advocates shared in the interviews that they were more likely to have discussions of harm reduction with women in shelters, to refer to local family planning clinics, and to talk to clients about their health, including immediate need for reproductive health care. Site leads of advocacy agencies also described adding specific reproductive health questions to agency intake forms or questionnaires. One site lead shared, “One of the wins that I have seen has really been training the direct line staff and it’s been really neat. To see some of [the staff’s] personal attitudes shift about termination, about sexually transmitted infections, about women who have multiple sexual partners.” This agency continued the conversation on reproductive health by bringing in local family planning clinic staff to train on “how to talk about sexuality, what are the names of body parts that young people use, and how comfortable [advocates] are having these talks.”

Family Planning Clinic Staff and Providers’ Lack of Comfort Around IPV/SV

A few advocates reported unsuccessful collaboration attempts prior to Project Connect, some attempts that have spanned over a decade, which they attributed to lack of understanding among health care providers about the intersections of IPV and health. In part, due to this history and overall lack of communication, some IPV/SV site leads brought up the importance of going back to IPV basics with public health agencies and medical providers. Advocates indicated that health care providers would benefit from an overall IPV and RC training in addition to how to connect family planning patients to IPV/SV services as part of implementing more collaborative partnerships. One advocate described, “With the health care providers, I didn’t know there was so much concern about a woman disclosing domestic violence. And that’s because their lack of knowledge on domestic violence and who they could refer to.”

Different Institutional Cultures

Many site leads noted that funding for IPV/SV was not a priority at a national level and therefore also not a priority in the health care system, which leads to the limited resources and lack of knowledge needed to integrate health systems and IPV/SV programs. As one site lead from an advocacy agency described, “ . . . the medical community still by and large focuses this as an injury issue and let’s just screen, let’s use a validated screening tool that asks the minimum amount of questions.”

These differences often led site leads from all backgrounds to label this as an “institutional culture barrier” between the two sectors. As one IPV/SV site lead described, “The department of health and the health providers have a very different culture and perspective than the victim services providers and that’s a reflection of different educational backgrounds and different choices about where to put resources.” Site leads coming from a more clinical background also label this as a difference in culture and priorities:

There’s kind of a counter culture clash between the health care system and the DV advocate system and there’s been a lot of work trying to get each other to trust and understand and listen to each other.

Difficulties that multiple sites encountered initially with implementing on-site health services within IPV/SV programs and creating protocols for referring clients of these programs to health services were explained in this context of cultural differences between sectors.

Notably, despite these initial differences, almost every site lead interviewed reported positive communication occurring through Project Connect as seen in their reflections on collaboration success. After sharing some initial frustrations while reflecting on the differences between institutions, one site lead simply acknowledged, “We both need to learn and change a bit.” Site leads noted that having the common goals and funding through Project Connect helped to mitigate this barrier and encouraged communication between health care and IPV/SV programs.

Discussion

Integration of reproductive health services into IPV/SV victim service agencies is feasible. Successful implementation requires attention not only to training advocates but also formalizing partnerships with health services and ensuring clear policies and protocols are in place for asking survivors about their reproductive health care needs.

Although site leads reported that their staff advocates were more likely to assess for health needs after the training, they also reported ongoing discomfort asking about pregnancy intention and sex and then providing harm reduction options accordingly. Advocates shared that training around these topics was one of the most impactful aspects of Project Connect, and some sites sought out additional training to increase comfort with talking about sexual health. This suggests that additional training aimed at increasing comfort around discussing pregnancy intention and sex with clients, which can often be provided by local family planning clinics, may be an important component of preparing advocates to integrate health services into their work and to provide needed, time-sensitive harm reduction options.

Interviews indicated that clinical providers and advocates value the ability to make warm referrals to each other’s services, and formal partnerships between service providers can facilitate these connections and result in more timely provision of urgent health services. The interviews with site leads highlighted two potential implementation barriers to providing health assessment and services to women at IPV/SV agencies when no formal partnership exists. First, logistical challenges may be more difficult to navigate due to lack of structure and revenue streams for integrating health services into IPV/SV agencies. One example noted was training that was more costly and time-consuming than originally thought, especially in larger states requiring travel, a common barrier in health integration (Butler et al., 2008; Hall et al., 2015; B.F. Miller, Petterson et al., 2014). Moving forward, additional consideration for funding support may be needed for training, particularly at the state or national level. Technology solutions such as webinars or video-conferencing also may be a sustainable approach to reduce this barrier.

Second, responses suggest that IPV/SV agencies found themselves initially confronting significant resistance to collaboration with the health care sector, similar to what they had experienced prior to formalizing partnerships through Project Connect. Both advocates and health providers admitted frustrations due to significant cultural differences and expectations between sectors, such as financial priorities, differing personal and professional backgrounds, and approaches to providing care and safety to women who have experienced violence. These frustrations parallel funding and policy differences and highlight the historical lack of cross-training between the two sectors. The lack of consistent training on IPV and women’s health for both health providers and IPV advocates contributes to poor assessment in both sectors. Health providers, despite Title X guidelines that encourage assessing for IPV/SV with all women of reproductive age (Gavin et al., 2014), may feel significant stress around how to handle IPV/RC disclosures and make referrals to victim service agencies while protecting patient confidentiality. Advocate site leads noted how health care providers are not implementing universal assessment and offering information about the IPV/SV services available to all women. IPV screening alone is not effective in reducing violence reexposure or quality of life (Klevens et al., 2012; MacMillan et al., 2009; O’Doherty et al., 2015). The interviews highlighted the need for training not only for the IPV/SV staff on assessing for health needs, but also for health center staff and providers to understand how they can best support survivors of IPV/SV. Formal partnerships through Project Connect allow for training and conversation on concrete policy and practice differences and may help to mitigate some of the logistical and cultural barriers associated with integrating health services into IPV/SV victim services. These findings are consistent with prior research on cross-sector collaborations to support the needs of IPV/SV survivors (Jacobs & Jewkes, 2002; Wilson, Silberberg, Brown, & Yaggy, 2007). Wilson et al. (2007) found that staff reported a perceived disconnect with the health care system, and concluded that many logistical issues to health care access could be addressed with additional training for health care providers and advocate staff to promote greater collaboration. More implementation and systems-level research is needed on optimal strategies to initiate and sustain these cross-sector partnerships.

In interviews with site leads, Project Connect as a federally funded multistate initiative served as a catalyst to reduce initial frustration, overcome mistrust, and create partnerships, which resulted in more “warm referrals” occurring from IPV agencies to health services and vice versa. Policy changes on the agency, state, and federal levels are an integral next step for sustainability of these partnerships. Previous cycles of Project Connect funding have seen these formal partnerships lead to change in statewide policy through nursing guidelines, additional training requirements, and IPV/RC questions added to statewide surveillance (Dutton, James, Langhorne, & Kelley, 2015). Although smaller scale studies have also shown that IPV outreach workers and health professionals (e.g., nurses) can collaborate with mutual increases in knowledge about IPV and health (Wuest et al., 2015), this is the first larger scale, multistate attempt to bridge the gaps between these two sectors with a focus on increasing access to health care for survivors seeking IPV/SV services.

Limitations

Findings should be interpreted in light of several limitations. The sample was a small convenience sample, using sites already affiliated with the larger Project Connect grant, and therefore results are not generalizable to other IPV/SV agencies. Interviews were completed with site leads only, not the front-line IPV/SV advocates who completed the half-day training, thus the perspectives from the interviews cannot be generalized to advocates as a whole. However, these interviews provide rich perspectives available from those leaders who have worked to implement these partnerships, navigated implementation of health services, and understand the systems-level changes that are needed to support sustained changes in how to connect IPV/SV survivors to health services.

Conclusion

Trainings that aim to integrate basic health assessments into advocates’ routines may be one way to support women experiencing violence to receive time-sensitive health services, especially expeditious connection to reproductive health services. Feasibility of implementing these services increases when IPV/SV agencies have a formal partnership with local health care or public health services. Nurturing such collaboration requires training and full participation from both health care/public health organizations and IPV/SV agencies. Concerns about cost, staffing, and different institutional priorities remain substantial barriers to collaboration. Further research on the effectiveness of integrating health care into IPV/SV services is needed, with an emphasis on elucidating best practices and core components to create sustainable health and IPV/SV victim service sector partnerships.

Footnotes

Acknowledgements

The authors thank the advocates and leadership team members who participated in Project Connect for sharing their insights. They also thank Dr. Todd Bear and Lisa James for their critical review of earlier versions of this article.

Authors’ Note

The viewpoints expressed are the sole responsibility of the authors and do not represent the views of the Office on Women’s Health.

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: Funding support was provided by Federal Grant ASTWH110025 to Futures Without Violence from the U.S. Department of Health and Human Services, Office on Women’s Health, titled “Project Connect: A Coordinated Public Health Initiative to Prevent Violence Against Women.”

Author Biographies

Theresa Gmelin, MPH, MSW, is currently a doctoral candidate at the University of Pittsburgh through the Graduate School of Public Health. She earned her master’s degree in social work (MSW) from the University of Buffalo, the State University of New York, and her master’s in public health (MPH) from the University of Pittsburgh. She has experience as an advocate and counselor working with women experiencing intimate partner violence (IPV) and sexual violence (SV). She currently coordinates a National Institutes of Health (NIH)-funded cluster-randomized controlled trial to test a trauma-informed intervention to prevent SV on college campuses (PI: Miller).

Claire A. Raible, BS, is a clinical research coordinator in adolescent and young adult medicine at Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine. She is also a graduate student in the Graduate School of Public Health at the University of Pittsburgh. She has worked on several gender violence intervention projects in family planning and adolescent health. She is responsible for collecting and analyzing data from several national evaluation projects, including Project Connect.

Rebecca Dick, MS, is a clinical research coordinator with the Division of Adolescent and Young Adult Medicine, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine. She earned her bachelor’s degree in environmental science and geography from George Washington University and her master’s degree in health promotion from Montana State University. During her graduate work, she had the privilege of working with several American Indian tribes on sexual and reproductive health studies. She now works as a research coordinator on several of Dr. Elizabeth Miller’s violence prevention and intervention studies.

Surabhi Kukke, MPH, has worked in the field of women’s health and human rights for 15 years. Currently, she serves as a health programs consultant to Futures Without Violence, focusing on capacity building and resource development for health care workers on assessment and response to IPV and the intersections between IPV and HIV. She is based in Austin, Texas, where she was formerly with the Texas Council on Family Violence and facilitated statewide efforts to improve the public health response to IPV and strengthen violence prevention efforts. Prior to arriving in Texas, she worked in the international development sector providing operational and evaluation support to community-based HIV/AIDS and reproductive health programs in Southern Africa and South Asia. She has a master’s degree in public health from Harvard University.

Elizabeth Miller, MD, PhD, FSAHM, is chief of Adolescent and Young Adult Medicine at Children’s Hospital of Pittsburgh of UPMC, and professor of pediatrics, University of Pittsburgh School of Medicine. Trained in medical anthropology as well as internal medicine and pediatrics, her research spans community- and clinic-based prevention and intervention studies to address IPV and SV.

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