Galvanizing an Agency-wide Approach: The HRSA Strategy to Address Intimate Partner Violence

Intimate partner violence (IPV) is a serious yet preventable public health concern in the United States and globally. According to the Centers for Disease Control and Prevention (CDC), IPV includes physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner.¹ Data from 2015 indicate that the prevalence of IPV is high: 1 in 4 women and 1 in 10 men in the United States have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime.² Several studies have demonstrated both direct effects and mediating effects of IPV on individual health outcomes, including but not limited to depression and suicide, HIV/AIDS, cardiovascular disease, asthma, and substance use.^3,4 In addition, IPV affects the US health care system. According to a 2017 analysis, the lifetime medical costs for IPV-related care, based on 2014 US dollars, totaled $2.1 trillion.⁵

Federal agencies in the US Department of Health and Human Services approach IPV through several legislatively mandated programs and activities. For example, the Administration for Children and Families (ACF) Family and Youth Services Bureau oversees grants to states, territories, tribes, state domestic violence coalitions, and national resource centers to support emergency shelters and associated help for IPV survivors and their children.⁶ In addition, since 2010, CDC’s Division of Violence Prevention has supported the National Intimate Partner and Sexual Violence Survey, which gathers data at national and state levels on IPV, sexual violence, and stalking.⁷ CDC also develops topical evidence-based technical packages⁸ focused on violence prevention for states and communities as well as online vetted sources of information, tools, and trainings, such as VetoViolence.⁹

The Health Resources and Services Administration (HRSA) leads efforts to improve access to high-quality primary health care for persons who are geographically isolated or economically or medically vulnerable through more than 90 programs. In addition, HRSA directly supports the training of health professionals and places health care providers in areas of the country with the greatest need (eg, health professional shortage areas). Given HRSA’s mission and increasing evidence that by integrating social determinants of health, programs are better able to achieve improved outcomes,^10-12 the agency is well positioned to lead a new strategic effort focused on addressing IPV.

In this commentary, we discuss the development of The HRSA Strategy to Address IPV, 2017-2020 (hereinafter, IPV Strategy), an agency-wide initiative led by the HRSA Office of Women’s Health (OWH) to promote partnerships between federal stakeholders and nonfederal stakeholders, strengthen existing programs, and create new activities to address IPV. We highlight the use of an integrated approach to address IPV across HRSA’s programs; this approach has features that are similar to other whole systems approaches.^13-15 To the best of our knowledge, this approach has not been implemented by other US Department of Health and Human Services agencies in regard to IPV. Finally, we discuss the challenges we faced and offer recommendations for using this unique approach.

Foundational Efforts

In 2014, OWH initiated a pilot project with HRSA’s Bureau of Primary Health Care and ACF’s Family and Youth Services Bureau. The project provided funding to ACF’s National Health Resource Center on Domestic Violence to develop active partnerships between community health centers and domestic violence organizations. Ten HRSA-supported community health centers from across the United States took part in the pilot. Participating community health centers partnered with a local domestic violence organization to identify needed systems changes and best practices so that each organization could better support the health and social needs of IPV survivors. The results of these collaborations informed the development of a virtual toolkit, ipvhealthpartners.org. The toolkit provides resources and training materials for providers in community health centers and domestic violence/sexual assault programs to address patient needs related to IPV and health.

Developing the Strategy

Encouraged by the results of this pilot project and because IPV screening had already been implemented in 2 HRSA programs (Maternal, Infant, and Early Childhood Home Visiting and Healthy Start), OWH began working on an agency-wide strategic plan to address IPV (Table). OWH saw an opportunity to prioritize IPV across programs at HRSA that were already addressing similar social determinants (eg, adverse childhood events, housing insecurity) through technical assistance and training efforts.

Table.

The Health Resources and Services Administration (HRSA) Strategy to Address Intimate Partner Violence (IPV): key actions, 2015-2018

Time Frame	Key Actions
Winter 2015– Spring 2016	Consulted with leaders from 5 bureaus and offices to assess interest in contributing to a strategic plan for IPV; their feedback expanded the scope of the initiative.
Summer–Fall 2016	Presented high-level framework to obtain buy-in from HRSA’s leadership; identified teams of IPV champions and ambassadors from each bureau and office to develop the strategic plan.
November 2016–August 2017	Convened 5 summits to develop and refine activities.
September 2017	Published strategy, convened final summit, and launched the implementation phase.
October 2017–March 2018	Convened meetings with each team to develop timeline and plan implementation.
January–December 2018	Conducted implementation monitoring and reported progress to HRSA leadership.

Generating Buy-in

To generate buy-in for a strategic plan centered on supporting IPV-related training for health care providers, OWH convened a series of consultations in late 2015 with leaders from 5 HRSA bureaus and offices. The goals of the consultations were to assess leaders’ interest in contributing to the plan and to solicit feedback on the concept and scope. Feedback from these consultations helped OWH determine that an agency-wide effort focused on IPV was feasible, given that many health conditions associated with exposure to IPV (eg, cardiovascular disease, substance use disorder, HIV) are the same conditions addressed by HRSA programs. The leaders also encouraged OWH to expand the scope beyond provider training.

In 2016, OWH used feedback from the consultations to pursue additional buy-in from the leadership of 11 of HRSA’s 16 bureaus and offices with the largest programmatic reach. During a senior staff meeting, OWH presented a framework and call to action for an agency-wide strategy to address IPV. Leaders responded enthusiastically, and an accompanying letter of support from the acting HRSA administrator resulted in 14 bureaus and offices signing on to the effort. Each bureau and office agreed to designate 2 staff members to fill the roles of IPV champion and IPV ambassador. These staff members would serve as change agents and active participants in the development of the IPV strategy. IPV champions would advocate for IPV as a bureau or office priority, foster enthusiasm among staff members, help identify appropriate activities, and make the final decision about activities. IPV ambassadors would carry out the champion’s vision, meet with colleagues to generate ideas for activities, and maintain communications with OWH.

Strategy Summits

To develop and launch the IPV Strategy, OWH convened six 2-hour strategy summits between November 2016 and September 2017. Thirty-three IPV champions and ambassadors from the 14 bureau and office teams met during each summit to learn about the intersection of IPV and health, brainstorm activities to address IPV, refine their ideas, and finalize decisions about their bureau or office contributions.

During the first summit, experts oriented the 14 teams to the complexities of IPV as a health issue through presentations on current research and best practices. The teams learned that women who talked with their health care providers about abuse were 4 times more likely to use an intervention (eg, shelter, restraining order) than women who did not talk with their health care providers about abuse.¹⁶ They also learned about a practice known as universal education, or talking to all patients about healthy relationships, to reduce stigma related to experiencing abuse.¹⁷ The group was then charged with creating a vision to anchor the strategy in values aligned with HRSA’s mission and strategic goals. The resulting statement articulated a bold vision to inspire ongoing commitment to the IPV Strategy: “A world free from IPV, where engaged community and health care systems ensure access to high-quality health services and coordinated care for all.”

With a vision established, the bureau and office teams spent the next 4 summits determining how they would take action. Through facilitated discussions and small-group work, the teams examined the current work portfolios of each bureau and office and identified activities in response to questions such as:

• What existing bureau or office activities or programs can you build on to advance the vision of the IPV Strategy?

• What new activities or programs can your bureau or office create?

• What activities or programs can you collaborate on with other bureaus or offices?

The teams then refined their ideas into activities that would be the most practical and sustainable for their bureau or office. Some teams also convened meetings outside of the summits to solicit colleagues’ perspectives about ways to integrate approaches to addressing IPV into workflows. Final activity proposals were mapped to a strategic rubric to test whether they (1) created public value for HRSA stakeholders, (2) were feasible and supported within HRSA, and (3) were able to be operationalized by HRSA and any collaborating partners. This exercise helped ensure that the activities would have a sound foundation for successful implementation during the next 3 years.

Launching and Implementing the IPV Strategy

When OWH began conceptualizing the IPV Strategy, we set a goal to generate at least 5 IPV initiatives to be implemented by HRSA programs. As a result of the ingenuity and dedication of the 14 bureau and office teams, 27 collaborative activities were generated. Once each team finalized its contributions to the 27 activities, OWH examined them for common themes and aligned each activity to a strategic objective. The activities coalesced around 4 priorities and 10 strategic objectives (Figure). HRSA’s administrator officially launched The HRSA Strategy to Address IPV, 2017-2020 in a sixth and final summit in September 2017 and charged all staff members to work together to implement the activities.¹⁸

Figure.

The Health Resources and Services Administration (HRSA) Strategy to Address Intimate Partner Violence (IPV): priorities and objectives.

The priorities and strategic objectives emphasize HRSA’s strengths in training the health workforce, developing partnerships to raise awareness, increasing access to quality care, and addressing gaps in knowledge. Activities in priority 1 focus on disseminating IPV-related training and tools through HRSA-supported channels and tailoring IPV resources for special populations (eg, pregnant and parenting mothers, rural populations, and persons living with HIV). Activities in priority 2 leverage strategic partnerships across HRSA’s internal and external stakeholder groups to increase awareness of IPV’s effect on health outcomes. Priority 3 activities work to integrate IPV-related content into existing programs (eg, within the Ryan White Program and the Health Center Program) or implement new programmatic efforts to address IPV (eg, developing an IPV collaborative improvement and innovation network within the Maternal, Infant, and Early Childhood Home Visiting Program). Priority 4 activities work to address important gaps in evidence for special populations and to conduct surveillance to inform programmatic policy. Of the 27 activities, 10 will be fully implemented by a single bureau or office, 8 are collaborations in which multiple bureau and office teams share equal responsibility for implementation, and 9 identify a lead bureau or office with 1-10 collaborating partners.

From fall 2017 through winter 2018, OWH staff members met with each bureau team and office team to define implementation and monitoring plans and establish an overall timeline for implementing the IPV Strategy. The final timeline indicated that many teams were open to implementing their activities across multiple years to maximize both current and future opportunities to integrate IPV prevention into their programs. To support activity implementation, 5 teams added the role of Implementation Tracking Lead. These staff members were important liaisons to OWH in helping to track implementation and identify any challenges. OWH maintained responsibility for following up with each team about its progress and setting deadlines for data collection and reporting high-level updates to the HRSA administrator. This accountability helped sustain momentum and ensure that each activity began its implementation in 2018. Two additional phases of implementation will continue through 2020. An unexpected evolution of the strategy’s implementation is the teams’ ongoing innovation and identification of additional activity contributions. These extensions speak to the depth of the buy-in from HRSA leaders in their continued support to address IPV through 2020 and beyond.

Public Health Implications and Recommendations

The HRSA Strategy to Address IPV, 2017-2020 provides a model for public health organizations to consider in planning similar efforts to address social determinants using an agency-wide approach.¹⁸ To our knowledge, the IPV Strategy is the first of its kind to address IPV within a single federal agency through collaborating across bureaus and offices and integrating concrete actions in key priority areas. IPV is an important public health concern that warrants a comprehensive response from all public health agencies, in collaboration with community-based organizations and other partners.

As with other innovative public health initiatives, leadership support was key to building internal buy-in, which in turn led to staff member engagement across numerous programs with various mandates and stakeholders. An inspiring vision, regular communication, and staff member recognition helped maintain momentum during the strategy’s development year. Other key strengths of this work included strong collaboration and broadening efforts beyond provider training to encompass other delivery mechanisms, as well as maintaining an openness to diversity in the types of activities the teams chose to develop.

To mitigate challenges associated with prioritizing and sustaining efforts to implement the IPV Strategy across distinct bureau and office teams, OWH staff members provided coordination and logistical support throughout the development period and into implementation. The 6 strategy summits required dedicated time and offered an important forum for facilitating discussions between collaborating bureau and office partners. Tailoring the IPV Strategy’s activities to the context (eg, training capacity, stakeholders, and legislative authority) of each bureau or office while maintaining the goal of cross-collaboration was an ongoing effort. Limited funding precluded supporting a formal evaluation at the outset of this work; however, OWH is monitoring and reporting on implementation progress annually and exploring options for evaluating a subset of the activities.¹⁹

Future efforts should include evaluation studies that address the longer-term effect of agency-wide approaches, including sustainability and integration into programmatic priorities, and examine how similar strategic plans can contribute to greater efficiency and collaboration.