Domestic Violence:

The Problem

Domestic violence (DV) is a prevalent and pervasive public health issue that has enormous health, well-being, and economic impacts. Domestic violence is when one person in a relationship perpetrates a pattern of coercive or assaultive behaviors over another. The abuser uses physical violence, sexual violence, threats, emotional abuse and/or financial manipulation to harm and control their partner. Noting that domestic and sexual violence are chronically underreported, “about 1 in 4 women and nearly 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime.”¹ Domestic violence impacts individuals across all demographic lines, impacting people regardless of age, race, religion, ethnicity, culture, socioeconomic class, education level, gender, and sexuality. That said, women of color, members of the LGBTQ+ community, and those living in poverty are disproportionately impacted.

Domestic violence results in disparate health outcomes for survivors and their families in the areas of chronic disease, mental health, substance use, and reproductive health. In addition to physical injuries, domestic violence can result in chronic pain, headaches, fatigue, immune, endocrine and gastrointestinal disorders, as well increased risk of irritable bowel syndrome and diabetes.² Domestic violence survivors are three times more likely to have a mental health condition; six times more likely to become dependent on drugs or alcohol, and twice as likely to smoke, become obese, and practice sexual risk behaviors, increasing risk for STIs, including HIV.²

The health, well-being, and social impacts of domestic violence have only been exacerbated by the COVID-19 pandemic, resulting in an increase in severity and complexity of the safety, health, and social needs of survivors.

The Need

Domestic violence has long been treated as a criminal justice issue to be handled by law enforcement and the courts. This traditional approach contains systemic barriers for many survivors, and there have been increasing calls from survivors and advocates alike to “develop responses to gender violence that do not depend on a sexist, racist, classist, and homophobic criminal justice system.”³ For many victims of domestic violence, the first source of help will not be law enforcement, but rather their healthcare provider. Victims of domestic violence who may be too frightened to involve the police or the courts because of retribution by their abuser, or systemic barriers, may seek assistance and counseling through their doctor. This creates an opportunity for an additional access point for survivors to connect to domestic violence resources and support.

Whether survivors seek support from their health care team or other care provider, it is imperative that the response be trauma-informed. Trauma-informed care “is an intentional approach to understanding and interacting with people who have or may be experiencing trauma.”⁴ For domestic violence survivors, this care includes treating the survivor as the expert on their experience and supporting their decision-making, and being survivor-centered. Survivor-centered care aligns with the healthcare community’s commitment to patient-centered care.

It is also important that domestic violence response, referral, and support services are equitably accessible. Survivors from historically marginalized communities often face additional barriers in accessing care and support – barriers around the language of services, the location of services, time limitations on duration of service engagement, and documentation status requirements.

Promising Solution

The Domestic Violence – Community Health Worker Project (DV-CHW Project) is a collaborative effort among the Delaware Coalition Against Domestic Violence (DCADV), CHILD, Inc., ChristianaCare, Westside Family Healthcare, and St. Francis Hospital. DCADV serves as the project lead, guiding this public health response to domestic violence. The DV-CHW Project provides life-saving services and care coordination to victims of domestic violence and crucial training and resources to health care teams.

The unique service delivery model of the DV-CHW Project combines the trauma-informed, survivor-centered work of domestic violence advocates with the community-based, culturally competent, and accessible work of Community Health Workers (CHWs). This innovative approach creates services that address the complex safety, health, and social needs of domestic violence survivors and their families.

Project partner CHILD Inc. employs three full-time DV-CHWs who meet with survivors wherever they feel safe and comfortable. The DV-CHW team is mobile and committed to the accessibility of their services, going to survivors’ homes, libraries, health clinics, coffee shops, workplaces, stores, and an ever-expanding list of other convenient locations. Two of the three DV-CHWs are bilingual in Spanish and English. Critical to their services and survivor engagement, the DV-CHW Project utilizes flex funds—flexible financial assistance—to meet the tangible and urgent needs of survivors. Understanding that survivors cannot focus on their health or safety if their children are hungry or their lights are about to be shut off, these flex funds target survivors’ social determinants of health needs, with the top categories of spending being basic needs, housing, children’s needs, transportation, and physical health.

DCADV also provides free practice area-specific trainings to health care teams around trauma-informed, evidence-based domestic violence screening and referral, along with a wide variety of domestic violence resource materials in multiple languages. These trainings and resources seek to strengthen the frequency and efficacy of health care-based domestic violence screenings and referrals, targeting the low rates of screening among health care providers.^5,6

The Impact

The DV-CHWs have been serving survivors in New Castle County since February 2019. Through regular communication and a trauma-informed approach, the DV-CHWs build supportive connections focused on long-term safety and health. Survivors stay engaged with their DV-CHW for an average of ten months, connecting multiple times a month, often for long periods of time.⁷ The DV-CHWs complete a health and social needs screening, ensure the survivor is connected to healthcare, engage in safety planning that includes both immediate protections and a long-term plan, and assist with addressing barriers to health and safety. On average, the team currently serves almost 90 survivors a month.⁷

As the DV-CHW pilot became a critical and innovative program, it became clear that the level of engagement needed to support survivors’ safety, health, and social needs was high. Formal evaluation of the DV-CHW program by the University of Delaware (UD) revealed that, in a large part, it is the meaningful and authentic relationship between the survivor and DV-CHW itself that is paramount to the survivors’ feelings of safety and well-being.⁸ UD noted that in qualitative interviews with survivors, they described the wide variety of services the DV-CHW program provides and the impact on their overall well-being by way of increased social and emotional support, increases in their knowledge of and connection to community resources, and reduced financial stress.^8,9 Using trauma-informed relationship building and emotional support, the DV-CHWs increase the survivors’ perceptions of safety and comfort accessing services, including healthcare services.

In addition to the positive impacts on well-being, recent further evaluation by UD revealed that survivors engaged with the DV-CHWs report reduction in poor health, as measured by Healthy Days core questions of the Centers for Disease Control and Prevention (CDC) asked at intake and throughout engagement.¹⁰ Notably, the reduction in poor physical and mental health days increases the longer the survivor engages with the DV-CHWs.¹⁰

Next Steps

Meeting the complex safety, health, and social needs of survivors of domestic violence requires trauma-informed, survivor-centered services that are accessible to underserved communities. DCADV’s Domestic Violence – Community Health Worker Project is a shift from the traditional criminal justice approach to a trauma-informed public health approach. The commitment, passion, and flexibility of CHILD, Inc.’s DV-CHWs is incredible and the impact on survivors’ health and well-being is promising.

The DV-CHW Project currently serves survivors in New Castle County and, like many other innovative approaches, relies on grant funding. As DCADV looks to secure the funding needed to expand statewide, sustainable funding is critical. DCADV is one of many organizations collaborating with the newly formed Community Health Worker Association of Delaware, recognizing the importance of community-based, trauma-informed approaches, exemplified by CHWs. The CHW service model ensures that vulnerable and underserved individuals receive services that are accessible, equitable, and culturally specific. CHW certification and reimbursement is an important public health approach to reducing the health inequities Delaware’s most vulnerable communities face.

To learn more about DCADV, the DV-CHW Project, or domestic violence resources, please visit dcadv.org.