Home Visitation as “Pretervention” of family violence

Background

Historically, perinatal home visitation (HV) programs have been used to reduce risks for poor pregnancy outcomes, improve parenting skills and enhance infant development. The core content of most perinatal HV programs includes: (1) anticipatory guidance (2) curriculum-based tips for enhancement of parenting and/or child development (3) social support and practical assistance to mothers (4) referrals to community resources. Prior education and training of home visitors varies; some home visitors are paraprofessionals, while others are nurses, social workers or health educators.

In recent times, there is a growing recognition that appropriate training also positions HVs to help mothers coping with the effects of violence to

  • recognize that infants and children are affected by violence and consider appropriate action
  • regulate their emotions and frustrations while being responsive and caring towards their child’s needs
  • understand that children can be disciplined without hostility, aggression, or coercion
  • re-evaluate hostile expectations they have about relationships with their children, parents, and other social relationships
  • recognize the effects of their own childhood trauma
  • nurture hope in their ability to change the cycle of violence for their children and themselves.

Gender based Violence (GBV, including Family violence, FV) affects the health and well-being of both women and children. Pregnant women are at significant risk of FV. Around 3% – 19% of women report being abused during the childbearing year – that is in the year before, during or after a pregnancy.   These figures are possibly much higher in some settings, given that gender violence (including family violence) is underreported. Failure to provide sufficient focus, time and resources on FV may limit the effectiveness of perinatal HV programs in promoting positive child development. If FV is left unaddressed, the associated risks can significantly impact the greater family environment. Screening should be done sensitively and privately, with protocols like that planned by CASA detailing best-practice responses to help women disclosing abuse. All home visitors need to be trained in the dynamics of FV, how to assess and how to intervene.

On the one hand, there is some evidence that visitation can bridge service-survivor gaps and holds promise as early-stage ‘pretervention’ or later-stage intervention against escalation of harms from violence (Wells & Claussen, 2012). On the other, home visitation is often seen as culturally unsafe, invasive, and a threat to family unity owing to mandated reporting duties. These negative perceptions attenuate enrollment in home visitation and also cause program attrition.

Acting at the intersections of violence against women and against children

HV’s relevance as pretervention against GBV and FV is significant as it targets two intersecting forms of violence, against women (VAW) and against children (VAC) (Guedes et al, 2016). Violence against women (VAW) is strongly linked with violence against children (VAC) and both have intergenerational effects. There are six points of intersection (1) VAC and VAW have many shared risk factors (2) Social norms often support both VAW and VAC and discourage help-seeking (3) Child maltreatment and partner violence often occur in the same household (4) Both produce intergenerational harms as parents exposed to violence as children develop unhealthy tolerance for aggression and unhealthy concepts of relationships and are more likely to be victims as well as perpetrators of violence (5) VAC and VAW have common mutually compounding consequences across the lifespan (6) VAC and VAW intersect during adolescence, a time of physical and emotional transition and heightened vulnerability.

Worldwide, women whose mothers were abused are significantly more likely to report partner violence than other women. Similarly, studies have found that men abused or neglected as children were significantly more likely than other men to perpetrate VAW. Women who experience partner violence are at heightened risk of negative mental and physical health outcomes if they also have a history of childhood violence. Consequences of child maltreatment often last into adulthood, including long-term changes in brain structure, mental and physical health problems, risk behaviours, problems with social functioning, and reduced life expectancy.

Evidence of intersections between VAW and VAC has powerful implications for programmes, policies, and research. Interventions that consolidate efforts to address shared risk factors may help prevent both forms of violence. Home visiting (HV) is a promising opportunity to consolidate efforts to address shared risk factors that contribute to both VAW and VAC. The context of home visitation is a unique opportunity to deliver services to women and children exposed to FV.  The development of a solid provider-client relationship, built on acceptance, trust and strong rapport is at the core of most long-term home visiting programs with vulnerable populations. This relationship, aided by the worker’s adoption of cultural safety and a trauma lens, may facilitate home visitors’ abilities to ask about FV and increase clients’ comfort levels in disclosing FV exposure. Working with families in their home creates opportunities to assess the quality of interpersonal relationships and the potential to identify FV before it begins or escalates.

A new Alberta-based Project to develop home visitation as a pretervention against FV (2019-2023)

In 2019, ICWA and select partners will start a 2019-2023 project to develop home visitation as a pretervention against FV in Alberta. The project is named “Culturally appropriate and safe assistance through home visitation for survivors of violence” (CASA). The Funder is Women’s Program and Regional Operations Directorate, Department for Women and Gender Equality (formerly Status of Women Canada). The aim is to create and pilot a home visitation protocol combining cultural safety and a trauma-informed approach in screening for violence and connecting survivors with supports. The protocol is to enable home visitors to understand patterns and signs of violence and connect survivors with supports. The project involves training home visitors in protocol use, monitoring how useful the protocol is in the real world in practice. Slide9.JPGThe field tested and refined protocol and training curriculum will be made available as a Blueprint for future use, testing and improvement to the service community.

The project has a provincial scope, targeting both urban and rural locations, in recognition of the diverse needs and characteristics of populations in urban and rural settings.

  • URBAN: Edmonton, Calgary, Grande Prairie/Red Deer
  • RURAL: High Level (remote, low resource, rural Indigenous population) Lloydminster/Camrose or Medicine Hat/Lethbridge.

We will orient home visitors and assessors in protocol use. Home visitors will be guided on

  • cultural safety, enabling them to check their biases, understand how discrimination shapes service uptake and address power imbalances in provider-client exchanges.
  • providing violence and trauma-informed support (including referrals), and prioritizing safety, choice, and nonviolence to mitigate impacts of violence.

Early intervention by home visitors that reduces FV may improve parenting attitudes and stabilize the home environment thereby preventing abuse and neglect and promoting positive childhood development. Failure to provide sufficient focus, time and resources on FV may limit the effectiveness of perinatal HV programs in promoting positive child development. If FV is left unaddressed, the associated risks can significantly impact the greater family environment. Screening should be done sensitively and privately, with protocols like that planned by CASA detailing best-practice responses to help women disclosing abuse. All home visitors need to be trained in the dynamics of FV, how to assess and how to intervene, as is now being done in. At the least, home visitors should routinely assess women for FV at entry into the HV program, one other time during the prenatal period (when trust has been established) and at post partum, when abuse is known to restart. These basic procedures with appropriate training should be part of all home visitation programs. Additionally, it is important for providers to serve as advocates for abused women, supporting them in their decision making and providing necessary resources and referrals.

Survivors are often isolated and unable to access supports at agency desks. Indigenous women and girls are disproportionately vulnerable to violence and poverty ‘… The over-representation of Aboriginal women among homicide victims … was most notable in the territories and the provinces of Manitoba, Alberta and Saskatchewan.’   Violence in immigrant families in Canada remains statistically under-reported but is extensively documented in reliable narrative reports, many cited in ICWA’s 2016 in-depth report on immigrant family violence in Edmonton (https://tinyurl.com/ycbfxbdh). Immigrant women are an underserved population, with fewer social connections and less access to resources than their mainstream counterparts.

Support gaps to be addressed through CASA include access to information about services, supports with cultural appropriateness, health and healing, language/interpretation and cultural and physical safety. Early brainstorming with partner agencies illustrates that there are significant gaps in practice on all these fronts, with the cumulative result that home visitation is often seen as culturally unsafe, invasive, and a threat to family unity owing to mandated reporting duties (see pp 93-94 in the 2016 Needs Assessment of ICWA’s SWC funded project AB 15072).  These negative perceptions attenuate enrollment in home visitation and also cause program attrition. Conversely, if home visitors have a well-trained practice of greater cultural safety, appropriateness and a trauma lens, their perceived trustworthiness may increase, thereby enhancing their capacity and reach to provide supports for women in the very space where violence begins.

References

Guedes, et al (2016). Bridging the gaps: a global review of intersections of violence against women and violence against children. Global health action, 9(1), 31516. (Link)

Wells, L., & Claussen, C. (2012). Home visitation as a domestic violence prevention
strategy: A discussion paper for the Government of Alberta. Calgary, AB: The University
of Calgary, Shift: The Project to End Domestic Violence. (Link)

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