Public Health/ Health Evaluation &Implementation
The group I was working with this semester selected women seeking safety as our population of interest. We learned how, as public health nurses working with women in the community, we could assess the community, identify health risks and protective factors, screen and make referrals for diagnosis, and identify interventions delivered at the community- and systems-levels of service to improve the health of the population (Minnesota Department of Health, 2019). (Minnesota Department of Health, 2019). We identified posttraumatic stress disorder (PTSD) as a potential health risk experienced by women seeking safety, with the possibility that PTSD could lead to suicide among survivors (LeBouthillier et al., 2015). (LeBouthillier et al., 2015). Based on the recommendations from the U.S. Preventive Services Task Force (2018) that all women should be screened for exposure to violence, we identified ways that public health nurses could conduct outreach, case finding, screening, referral, and follow-up as a secondary prevention strategy and incorporate a mental health screening at the same time (Minnesota Department of Health, 2019). (Minnesota Department of Health, 2019). We thought that if a woman was seeking safety, she would likely be open to services to address potential mental health problems as well.
Patient Population
As we researched the literature about intimate partner violence (IPV), I was surprised to see the many descriptions of violence against women and the numerous populations affected by violence (Montesanti & Thurston, 2015). (Montesanti & Thurston, 2015). As a veteran myself, I was shocked by the prevalence of IPV and additionally traumatic brain injury (TBI) among women veterans. Iverson et al. (2020) found that 63% of women veterans who had served in Iraq or Afghanistan and were being evaluated for a TBI self-reported a prior experience with IPV. In an online survey of veterans, 55% reported IPV experiences, and those with IPV and symptoms of PTSD were almost 6 times more likely than veterans without PTSD to have TBI (Inverson et al., 2017). (Inverson et al., 2017). I cannot imagine dealing with a return from combat, suffering from a brain injury, and also, perhaps, dealing with violence in a relationship. I decided women who are veterans experiencing PTSD and a history of IPV are the population I would focus on for this paper.
Evidence-based Program
I reviewed three studies I located through a search of PubMed. One program, called Strength at Home, was designed for veterans but was delivered in a clinic setting to male veterans and their partners (Creech et al., 2018; Taft et al., 2016). (Creech et al., 2018; Taft et al., 2016). I was concerned that this program would not assist women who wanted to leave a violent relationship; additionally, almost half the participants did not finish the program (Creech et al., 2018). (Creech et al., 2018). Another intervention that has been tested with veterans is cognitive trauma therapy (CTT) (Allard et al., 2018). (Allard et al., 2018). CTT involves social and cognitive skills training to improve stress management, relaxation, effectively expressing anger, assertiveness, self-advocacy, and empowerment with the goal of avoiding violence in relationships (Allard et al., 2018). (Allard et al., 2018). I decided against this intervention because it required trained counselors and was not based in the community. The intervention that most appealed to me was not delivered to veterans, but I think it could be. I selected a community-based advocacy program (Stevens et al., 2015; Sullivan & Bybee, 1999) and decided to call it the veteran’s advocacy program (VAP) (VAP).
Evidence-based Program Goal
The community-based advocacy program was developed by Sullivan and Bybee (1999) and delivered to women exiting a shelter in the community. The women who participated received 10 weeks of support from trained advocates and were studied for 2 years after they left the shelter. Though the women were not veterans, they were a very diverse group of women similar to the veteran population (17-61 years old with an average age of 29, 45% Black, 42% White, 7% Latina, 2% Asian, and 35% with some college) (Bybee & Sullivan, 2002). (Bybee & Sullivan, 2002). The broad goal of the program was to support women seeking safety to reduce their risk for future IPV.
Public Health Nursing Interventions
VAP would be coordinated by a public health nurse (PHN) who is also a veteran. This would ensure that the women participating in the program received support and services integrated with those available through the Veterans Health Administration (VHA) (VHA). The VHA has been making efforts to ensure veterans are screened for IPV and referred for follow-up (Ditcher et al., 2017). (Ditcher et al., 2017). The VAP PHN would receive referrals from primary care and mental health service providers in the local VHA facilities. The PHN would conduct outreach, one of the public health interventions, to enroll women in the program (Minnesota Department of Health, 2019). (Minnesota Department of Health, 2019). Recently, Dichter et al. (2018) found that women who disclosed IPV during screening in the VHA were more likely than those who did not to have increased healthcare utilization during the 6 months after disclosure. This suggests that veterans would be open to VAP after a positive screening for IPV. The PHN VAP coordinator would also provide consultation and counseling upon enrollment. Lastly, the PHN would coordinate a network of community health advocates who provide case management to the women enrolled in VAP (Minnesota Department of Health, 2019). (Minnesota Department of Health, 2019).
Process Evaluation
The goals of VAP would be to reduce PTSD symptoms, improve quality of life, increase social support, and reduce involvement with a violent partner. A process measure used to evaluate the implementation of VAP would be the monitoring and supervision of the case managers by the VAP PHN coordinator. Bybee and Sullivan (2002) provided the community-based advocates in their program to participate in an extensive training program and to work with each woman for about 4-6 hours a week. Each week there were supervision meetings with 5-7 advocates and their supervisor; the supervisor was also available by phone 24 hours/a day (Bybee & Sullivan, 2002). (Bybee & Sullivan, 2002). The VAP PHN would review notes and logs of activities to ensure each advocate was providing the intensive case management required.
Level of Evidence
Stevens et al. (2015) conducted a randomized controlled trial (RCT) of the advocacy program developed by Sullivan and Bybee (1999). (1999). They provided the program via telephone and did not have the same success that Bybee and Sullivan (2002) reported in their RCT. This was likely due to the difference in the intensity of the intervention. The two RCTs demonstrate that the advocacy program is effective but only when women receive intensive services. Women receiving telephone support in the Stevens et al. (2015) study were also more likely than those in the Bybee and Sullivan (2002) study to drop out of the program. Bybee and Sullivan (2002) reported that 95% of the women completed their program. I expect that women seeking safety need more frequent contact with an advocate case manager, especially during the beginning of the program.
Outcome Evaluation
The primary outcome that would support the effectiveness of VAP would be freedom from violence in a relationship. The VAP PHN would measure this by ensuring the case managers regularly collected information about experiencing IPV from the women veterans. They could use the 5-item Hurt/Insult/Threaten/Scream (HITS) tool, which the VHA is using to screen for IPV (Iverson et al., 2015). (Iverson et al., 2015). The sensitivity of the HITS was 0.75, and the specificity was 0.82, which means it is an accurate measure of IPV (Iverson et al., 2015). (Iverson et al., 2015). VAP would be successful if 95% of veterans completed the program and all no longer reported IPV. This program is needed in the veteran community and in Fresno. In 2018, prior to the pandemic, Fresno reported the highest number of calls to the police for IPV than any other city in the state (Sheehan, 2019). (Sheehan, 2019). The pandemic has only worsened this problem.
References
Allard, C. B., Norman, S. B., Thorp, S. R., Browne, K. C., & Stein, M. B. (2018). Mid-treatment reduction in trauma-related guilt predicts PTSD and functioning following cognitive trauma therapy for survivors of intimate partner violence. Journal of Interpersonal Violence, 33(23), 3610–3629. https://doi.org/10.1177/0886260516636068
Bybee, D. I., & Sullivan, C. M. (2002). The process through which an advocacy intervention resulted in positive change for battered women over time. American Journal of Community Psychology, 30(1), 103–132. https://doi.org/10.1023/A:1014376202459
Creech, S. K., Benzer, J. K., Ebalu, T., Murphy, C. M., & Taft, C. T. (2018). National implementation of a trauma-informed intervention for intimate partner violence in the Department of Veterans Affairs: First-year outcomes. BMC Health Services Research, 18(1), 582. https://doi.org/10.1186/s12913-018- 3401-6
Dichter, M. E., Haywood, T. N., Butler, A. E., Bellamy, S. L., & Iverson, K. M. (2017). Intimate partner violence screening in the Veterans Health Administration: Demographic and military service characteristics. American Journal of Preventive Medicine, 52(6), 761–768. https://doi.org/10.1016/j.amepre.2017.01.003
Iverson, K. M., King, M. W., Gerber, M. R., Resick, P. A., Kimerling, R., Street, A. E., & Vogt, D. (2015). Accuracy of an intimate partner violence screening tool for female VHA patients: A replication and extension. Journal of Traumatic Stress, 28(1), 79–82. https://doi.org/10.1002/jts.21985
Iverson, K. M., Dardis, C. M., & Pogoda, T. K. (2017). Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Comprehensive Psychiatry, 74, 80–87. https://doi.org/10.1016/j.comppsych.2017.01.007
Iverson, K. M., Sayer, N. A., Meterko, M., Stolzmann, K., Suri, P., Gormley, K., Nealon Seibert, M., Yan, K., & Pogoda, T. K. (2020). Intimate partner violence among female OEF/OIF/OND veterans who were evaluated for traumatic brain injury in the Veterans Health Administration: A preliminary investigation. Journal of Interpersonal Violence, 35(13-14), 2422–2445. https://doi.org/10.1177/0886260517702491
LeBouthillier, D. M., McMillan, K. A., Thibodeau, M. A., & Asmundson, G. J. (2015). Types and a number of traumas associated with suicidal ideation and suicide attempts in PTSD: Findings from a U.S. nationally representative sample. Journal of Traumatic Stress, 28(3), 183–190. https://doi.org/10.1002/jts.22010
Montesanti, S. R., & Thurston, W. E. (2015). Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women’s Health, 15, 100. https://doi.org/10.1186/s12905-015-0256-4
Minnesota Department of Health. (2019). Public health interventions: Applications for public health nursing practice (2nd ed.).
Sheehan (2019, December 27). Fresno’s domestic violence rate tops California’s big cities. What’s behind the numbers? The Fresno Bee. https://www.fresnobee.com/news/local/article238114974.html
Stevens, J., Scribano, P. V., Marshall, J., Nadkarni, R., Hayes, J., & Kelleher, K. J. (2015). A trial of telephone support services to prevent further intimate partner violence. Violence against Women, 21(12), 1528–1547. https://doi.org/10.1177/1077801215596849
Sullivan, C. M., & Bybee, D. I. (1999). Reducing violence using community-based advocacy for women with abusive partners. Journal of Consulting and Clinical Psychology, 67(1), 43–53. https://doi.org/10.1037//0022- 006x.67.1.43
Taft, C. T., Macdonald, A., Creech, S. K., Monson, C. M., & Murphy, C. M. (2016). A randomized controlled clinical trial of the strength at home men’s program for partner violence in military veterans. The Journal of Clinical Psychiatry, 77(9), 1168–1175. https://doi.org/10.4088/JCP.15m10020
U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Jr, Grossman, C., Kemper, A. R., Kubik, M., Kurth, A., Landefeld, C. S., Mangione, C. M., Silverstein, M., Simon, M. A., Tseng, C. W., & Wong, J. B. (2018). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: U.S. Preventive Services Task Force final recommendation statement. JAMA, 320(16), 1678–1687. https://doi.org/10.1001/jama.2018.14741
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Question 
This is Master level, please read. I have a Public Health Program FINAL PROJ. Proposal (15 pages) On High Blood Pressure (HTN) to fill in. The outlines are already created ( TOPIC is HTN, Objectives are determined, and Community is chosen). I need someone with Health care experience who has done previous Assignments on HTN and is an expert on how to address the problem on different levels: INTRApersonal, INTERpersonal, COMMUNITY level, SOCIETY levels.
Public Health Evaluation &Implementation
1)TOPIC: High blood pressure (hypertension)
2)OBJECTIVES: My health promotion program proposal will focus on the optimization of hypertension management in rural communities; a 50% reduction in cases of HTN in West Virginia rural community
3)This project focuses on PROGRAM PLANNING MODELS: planning model I have selected for my proposal is the Intervention Mapping Model.
My Health promotion program proposal will focus on the optimization of the delivery of rural health care through the development of an INTERVENTION PROGRAM that increases hypertension awareness and self-management by using community volunteers as health coaches. YOU will fill in more details here.
THE INTERVENTION STRATEGIES are to be filled in, I have already chosen a Behavioral theory to be applied.
I have uploaded a FINAL PROJ.EXAMPLE in an adobe, from a colleague, for you to use it as INSPIRATION, please do not COPY PASTE anything from that!