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Exploring the ethical and social aspects of using mHealth technology in urban and rural home visitation programmes for women affected by domestic violence

Final Report Summary - DOVE (Exploring the ethical and social aspects of using mHealth technology in urban and rural home visitation programmes for women affected by domestic violence)

Exploring the ethical and social aspects of an mHealth intervention in urban and rural perinatal home visitation programmes in the USA for women affected by domestic violence

1) To explore the ethical and social aspects of using mHealth to deliver the DOVE (Domestic Violence Enhanced Intervention) in perinatal home visitation programmes for women in urban and rural settings in the USA and compare this with DOVE administered by home visitors using qualitative research methods.
2) To draw on a range of inter-disciplinary perspectives from the nursing literature and from society and technology in order to explore (1) above.
3) To disseminate findings through submission of papers to peer reviewed journals; presentation of findings at international conferences; and expert and interdisciplinary meetings.
4) To establish and maintain international research partnerships with the Schools of Nursing at the University of Virginia and John Hopkins University.
5) To use the findings from the study to inform the development of a research proposal for a home visiting intervention with European collaborators.

Pregnancy and the postpartum is a time of increased risk for intimate partner violence (IPV). IPV can have a lasting impact on the health of women and the developing fetus and children. Perinatal home visitation provides an opportunity for preventive and early intervention. Little is known about the best methods for identifying and supporting abused women in home settings that maintains privacy, is sensitive, and accurately identifies those affected by IPV. For the Marie Curie Fellowship, a nested qualitative study was undertaken within the DOVE trial which tests the effectiveness of (i) standard DOVE intervention administered by nurse home visitors using paper assessment and a brochure for assessing risk and developing safety plans (ii) eMOCHA DOVE delivered by mHealth technology. In-depth the views were conducted with home visitors and their clients to explore their views and experiences of the DOVE intervention.

Work undertaken:

Nested qualitative interpretive study
A nested qualitative interpretive study was conducted to explore the views and experiences of home visitors and women enrolled in the Domestic Violence Enhanced Intervention (DOVE). DOVE is a randomized controlled trial which compares two methods for screening women for IPV and offering an intervention: (i) usual care consists of screening for IPV by a home visitor using the Abuse Assessment Screen (McFarlane et al. 1996) and the Women’s Experience of Battering Scale (Smith, Earp & DeVellis, 1995). This is followed by review of a pamphlet on IPV health consequences, assessment of the risk factors associated with increased risk of homicide using the Danger Assessment Scale (Campbell et al. 2009), individualized safety planning and information about community resources (ii) the comparison group the same materials are delivered using mHealth (i.e. a computer tablet). The study is underpinned by an interpretivist paradigm, which posits that reality is multiple and relative guided by the researcher’s worldview and understanding of this worldview (Denzin & Lincoln, 2005). From this position, the reality of screening and intervening for IPV during perinatal home visitation exists in the form of multiple socially and experientially based constructions of home visitors and women, (Guba & Lincoln, 1994).

Between November 2013 and August 2014 a total of 51 interviews were undertaken including: 26 women, 23 home visiting staff and 2 DOVE computer tablet designers. In addition, 4 non-participant observations of home visits were conducted in a rural setting. Study sites were rural (Virginia and Missouri) and urban (Baltimore). The methodological approach was underpinned by an interpretivist paradigm.

Literature searches
Bibliographic databases were searched for literature on: perinatatal home visitation programmes in the USA; the use of mobile health technology in the delivery of health care including any studies using a theoretical framework; nursing theories on interpersonal interaction; as well as relevant theories from Science Technology and Society.

Formal and informal training/interdisciplinary meetings
Informal training in randomized controlled trials of social interventions was obtained through my day-to-day involvement in the DOVE trial. Formal training included the following courses: qualitative research analysis; using mixed methods research; using theory of change to develop, implement and evaluate complex interventions; managing teams and individuals; and coaching. Over 50 inter-disciplinary meetings/conferences were attended during the first period and 20 in the second period. Findings from the research study were presented at 8 international conferences during the fellowship including the American Public Health Association, Futures Without Violence, the Nursing Network on Violence Against Women and the European Domestic Violence Conference.

Key outputs:

Bacchus LJ, Bullock L, Sharps P, Burnett C, Schminkey D, Buller AM, Campbell J. Infusing technology into a perinatal home visitation intervention for women experiencing intimate partner violence in urban and rural settings in the USA. Status: Submitted for peer review.

Bacchus LJ, Bullock, Sharps P, Burnett C, Schminkey D, Buller AM, Norling M, Campbell J. “Opening the door”: women’s experiences of being asked about intimate partner violence during perinatal home visits in rural and urban settings in the USA. Invited contribution to the Special Issue on Domestic Violence in the Journal of Research in Nursing.

Bullock L, Bacchus L, Sharps P. (2014) Why Affordable Care Act Mandated Screening Matters. Futures Without Violence, Health ebulletin, July. Featuring the Marie Curie study and available on line at:

Bacchus LJ, Kubik M, Garey C, Stewart D, Burke K, Holden R, Bullock L, Sharps P, Campbell J, Norling M, Kanu I, Hill K. (2014) “Opening the Door: An Educational Film for Care Providers About Supporting Families Dealing with Intimate Partner Violence”. Link to the film:
The educational film was based on the findings of the nested qualitative study within the DOVE trial and involved collaboration between the Schools of Nursing at the University of Virginia and John Hopkins University and the Drama and Media Departments at the University of Virginia. It addresses three common problems that the DOVE home visitors were encountering which emerged during the course of my research: (i) initiating discussion about intimate partner violence; (ii) helping women to develop a tailored safety plan in a way that was empowering; (iii) and effective communication strategies to use when women are minimizing the abuse or are reluctant to accept help. The film was used to undertake reinforcement training activities with home visitors involved in the DOVE study and was independently evaluated. The film has received international exposure and a training manual is currently being developed to accompany the film.

Main research findings:

One of the key findings was that home visitors and women supported enquiry for domestic violence during home visits and regarded it as a legitimate healthcare concern. The computer tablet was viewed as a safe and confidential way for abused women to disclose their experiences without fear of being judged. However, the meanings that the technology held for home visitors and women led to its construction as either an impersonal artefact that was an impediment to discussion of domestic violence, or a conduit through which interpersonal connection could be deepened thereby facilitating discussion about abuse. Some women and home visitors preferred in-person screening for domestic violence. Underpinning home visitors and women’s experiences of screening for domestic violence by either method was the quality and depth of their relationship. Time was needed to develop a trusting relationship in order to promote open discussion about partner abuse. We conclude that perinatal home visitors can provide opportunities for women to talk about experiences of IPV and assist them with developing safety plans and accessing community resources. However, it must occur with rigorous safety protocols and training for home visitors.

Home visitors and women suggested that tailored interventions were needed. Abused women are faced with complex decisions and there is a growing body of research indicating that how women seek safety is a gradual process involving multiple steps or strategies and this should be reflected in the types of interventions that are offered. Interventions are more likely to be effective if they are substantiated by theory and involve end user input in the development process. Further research should be dedicated to tailoring technology based interventions like DOVE or developing new applications that women find useful and that complements the care approach of health practitioners and enhances the therapeutic relationship.

Potential impact and use:

To date, this is the first study to compare an in-person and a technology based approach to asking women about domestic violence in home visitation programmes. The findings of the study are transferrable to other high income countries that deliver perinatal home visiting programmes and parenting programmes, where continuity of care provider is assured. Adaptations may be necessary to accommodate different contextual and cultural issues that may impact on either enquiry for domestic violence by health care providers and/or the use of technology based interventions for domestic violence.

The findings are highly relevant to current national and international policy recommendations. For example, the US Preventive Services Task Force recommend that clinicians screen women of childbearing age for domestic violence and provide or refer those who screen positive to intervention services (Moyer, 2013). However, the World Health Organisation does not recommend universal screening for domestic violence citing insufficient evidence of improved outcomes for women and increased referral to support services. Instead they recommend that health care providers receive training in the mental and physical indicators of intimate partner violence, how to ask questions and respond to disclosures of abuse (WHO, 2013). Studies show that women want health care providers to provide first line support including listening, sensitive and non-judgemental enquiry about their needs, validation of disclosure, respecting their wishes and facilitating access to services (Feder et al. 2006).

The findings of the research are of particular significance to President Obama’s Affordable Care Act 2010. This act establishes the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) which provides funding for evidence-based home visiting to families in “at-risk” communities. Perinatal home visitation programs that receive MIECVH funding are required to demonstrate improvement in a number of benchmark areas including reduction in crime and domestic violence. Home visitation programs that implement screening for domestic violence will benefit from findings about best practice and the possible use of mHealth technology.

Perinatal home visitation programmes aim to: improve health and development; prevent child injuries, child abuse, neglect or maltreatment; improve school readiness and achievement; reduce crime (including domestic violence); improve family economic self- sufficiency; and increase access to community resources. The DOVE intervention enabled socially deprived women and children exposed to domestic violence to access community resources and rebuild their lives. Since all women in perinatal home visitation programs were screened for domestic violence, the DOVE intervention also had a wider societal impact on women with no history of abuse. It conveyed an important message that domestic violence is unacceptable and that support for women and children is available.

Contact Details:
Dr Loraine J Bacchus, Lecturer
Marie Curie Alumni
London School of Hygiene & Tropical Medicine
Faculty of Public Health and Policy
Department of Global Health & Development
Gender Violence and Health Centre
15-17 Tavistock Square
London WC1H 9SH