October 12, 2017

Community and Provider Resources to Address Violence and Abuse in Rural America

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Although violence and abuse are disproportionately represented in rural America, resources are available to help providers help victims.

Every day, mental, physical, and emotional bruises and scars are inflicted on victims throughout the United States. Violence in rural America happens all too frequently across the age and socioeconomic spectrums, without enough voices, resources, and solutions being presented. For that reason, every second Wednesday of October is now marked by Health Cares About Domestic Violence (HCADV) Day. 

This year’s HCADV fell on Wednesday, Oct. 11, but the resources shared and opportunities presented can be used 365 days a year. Sponsored by Futures Without Violence, the awareness-raising event aims to reach various members of the healthcare industry, including rural providers and advocacy communities, in order to offer universal education about the vital importance of education to promote healthy relationships and address the health impact of abuse, which can be classified accordingly:

  • Domestic violence, also known as intimate partner violence (IPV)
  • Sex crimes, including rape, assault, and abuse
  • Abuse of vulnerable populations, such as the elderly and people with disabilities
  • Bullying, harassment, and stalking
  • Neglect
  • Child abuse
  • Assault
  • Homicide

Abuse and Violence in Rural Life

The effects of abuse and violence in rural America are even more dangerous due to the stigma of abuse in communities. Moreover, rural life is generally characterized by limited access to healthcare services, as well as barriers to these services such as proximity and transportation. And there are other issues as well that impede healthcare delivery, including a general lack of cultural acceptance for alternative lifestyles, housing security, and socioeconomic issues such as poverty, unemployment, or lack of available shelters.

Additionally, in rural communities, there is often overlap among rural healthcare providers, law enforcement, and abuse victims. As a result, some people may be hesitant to report abuse, fearing that their actions will not be followed up on or that their reputations may be damaged in a small community.

Is Poverty the Driver to Violence and Abuse in Rural Areas?

Rural America has a greater level of poverty than the rest of America. According to a U.S. Department of Justice (DOJ) study, rates of violent victimization are impacted by poverty level, with 40 victims per 1,000 citizens categorized as “poor” (household income below $15,000) versus 18 per 1,000 citizens categorized as high-income (household income above $75,000).

As cited by 2014 federal crime statistics, violent crime rates in rural cities and towns were similar to the national average, and rates in unincorporated rural areas were significantly lower than the national average. Additionally, homicide rates were lower overall for both men and women, with an average of six deaths per 100,000 among males and two per 100,000 for females in non-core (rural) counties.

Yet the following reasons were cited in a study examining why some of these crimes go unreported:

  • Police would not or could not help: 16 percent
  • Fear of reprisal or getting offender in trouble: 15 percent
  • Other reason or not one important reason: 15 person
  • Dealt with in another way/personal matter: 36 percent
  • Not important enough to victim to report: 18 percent

Health Impacts

Many medical studies link the long-term effects of domestic violence and abuse with several health problems such as diabetes, eating disorders, obesity, substance abuse, and smoking. And while there is more focus on reimbursement, fee-for-value, and the application of chronic care management (CCM), providers and nurses routinely only ask questions applicable to the services; very few assess for domestic violence and its impact on an individual’s health and well-being.

Also, in rural areas, healthcare providers often play many roles, with little specific training to support victims of violence. There is a need for integration of screening and counseling for victims and survivors of violence and abuse in primary care practices. 

National Advisory Committee on Rural Health Policy Brief Support

In March 2015, a National Advisory Committee on Rural Health and Human Services policy brief supported routine screening for signs of violence or abuse, suggesting that this should become standard practice for primary care providers and nurses. The brief reported that professionals should be trained to provide the resources available to victims and survivors in their communities, including non-traditional sources such as churches or community clubs.

Intimate Partner Violence (IPV)

Recommended by the U.S. Preventive Services Task Force (USPSTF) for all women of childbearing age, routine healthcare is where screening for intimate partner violence should take place.

The October 2016 American Family Physician article Intimate Partner Violence provides recommendations for routine screening for domestic violence and includes examples of screening tools, as well as tips for discussing this issue with patients. Additionally, www.IPV.org is a resource healthcare providers can use to learn more about the health impact of violence and abuse. The site offers tools and resources for establishing a partnership between domestic violence agencies and health settings. Additionally available is the IPVHealthPartners.org, which offers a toolkit: Prevent, Assess, and Respond: A Domestic Violence Toolkit for Health Centers & Domestic Violence Programs. This resource highlights successful community health center-domestic violence agency partnerships.

Provider Screening Support for Elders Abuse

According to the National Center on Elder Abuse (NCEA), elder abuse is often underreported. Screening of elders for violence, neglect, and abuse is important since elders may be reluctant or unable to report being victimized.

The NCEA offers a summary of available screening tools to health providers. Additionally, a brief elder abuse screening protocol and tool that has been tested and implemented in rural primary care practices by the University of Maine Center on Aging is also available.

Resources and Options: Universal Education

The application of “Universal Education via Futures Without Violence” provides the opportunity for individuals to make the connection between health problems, risk behaviors, and the connection to violence. Through this, using a brochure-based universal education approach, individuals seeking services in healthcare facilities or domestic violence programs can receive information about healthy relationships and where to get help for abuse.

Futures Without Violence offers many ideas that healthcare organizations, including rural providers, can use to mark HCADV, such as:

  • Writing a newsletter article or an op-ed for a local paper
  • Committing to try routine screening for one week
  • Inviting a speaker to conduct a lunchtime presentation for staff
    Hanging posters in waiting rooms that advertise local resource hotlines

Futures also provides resources to help organize events and activities on and beyond HCADV, including webinars and an action kit with social media tools, blogs, outreach ideas, and other examples of what participants have highlighted. They also provide HCADV and health-related updates via a sign-up newsletter. 

Preventing Violence and Abuse in Rural Communities

Rural communities can also come together and join forces to prevent and respond to violence and abuse through an approach called a Coordinated Community Response (CCR). This collaborative approach to rural healthcare allows community groups, faith-based organizations, public health entities, social services, schools, community organizations, and other agencies focus on stopping violence before it starts.

Ending Violence and Abuse

There are all kinds of statistics illustrating trends across the diverse fabric of rural America – citizens are of different ages, cultures, genders, and circumstances, but all share the common thread of a beating heart. There are so many examples to share highlighting the need to stamp out violence and abuse.  Here are three final thoughts:

  1. Over 25 percent of women in small rural and isolated areas living in excess of 40 miles from the closest IPV program, compared with less than 1 percent of women living in urban areas.
  2. A Journal of Women's Health 2011 study revealed that 22.5 percent of women in small rural areas and 17.9 percent in isolated areas reported being victims of intimate partner violence, compared to a national average of 16.1 percent. 
  3. Domestic violence often escalates into repeated and more violent abuse, with a national average of three women killed each day by an intimate partner or spouse.

It is time to abandon the reporting stigma and replace it with safety, security, and support. 

Janelle Ali-Dinar, PhD

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx and is a member of the RACmonitor editorial board.  

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