Health and Social Development, Faculty of (Okanagan)
Nursing, School of
DSpace
UBCO
Davila Lara, G. Yazmin
Doctor of Philosophy - PhD
University of British Columbia
In 2015, the WHO released a call to action to stop violence against women. This call to action has been translated into initiatives to improve health and social policies and services. Health system integration, defined as the process to improve healthcare performance, can better organize and integrate the care of people, especially those experiencing inequities. For women who experience marginalization and intimate partner violence (IPV), health system integration has the potential to address inequities. This dissertation involved three phases to illuminate how health system integration and equity-based services can support women who experience marginalization and IPV. Phase 1 (Scoping Review), involved a comprehensive review of Canadian literature on health system integration and equity-based services to meet women’s needs. Phase 2 (Policy Analysis), involved the analysis of publicly available documents for the design and delivery of services related to the care for women in British Columbia (BC). Phase 3 (Discussion Session), involved a virtual session with women and relevant contributors to gather their insights, and develop recommendations for action in the Southern Interior of BC. Results demonstrated: a) services based on health equity limited social exclusion by supporting women’s healing processes; b) understanding the diversity of the needs of multiple groups of women is essential for women-centred care; c) providers often did not recognize the complexity of women’s experiences and reproduced systemic violence; d) a cross-sectoral approach facilitated the approval of policy actions related to care for women in BC. Key recommendations included: implementing a formal process of integrating women’s voices and direction in the design of policies and services locally, provincially, and nationally; and reinforcing trauma- and violence-informed care across sectors and levels of care. To limit further inequities, community-based approaches that consider preventive actions are fundamental to challenge violence, and enhancements in housing, justice, and financial supports are needed.
HEALTH SYSTEM INTEGRATION AND EQUITY-BASED SERVICES TO SUPPORT WOMEN WHO EXPERIENCE MARGINALIZATION AND IPV by G. Yazmin Davila Lara PhD. Student A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE COLLEGE OF GRADUATE STUDIES (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2022 © Guadalupe Yazmin Davila Lara, 2022 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: HEALTH SYSTEM INTEGRATION AND EQUITY-BASED SERVICES TO SUPPORT WOMEN WHO EXPERIENCE MARGINALIZATION AND IPV submitted by G. Yazmin Davila Lara in partial fulfillment of the requirements of the degree of Doctor of Philosophy . Dr. Nelly D. Oelke, School of Nursing Supervisor Dr. Silvina Mema, School of Population and Public Health Supervisory Committee Member Dr. Colleen Varcoe, School of Nursing Supervisory Committee Member Dr. Jan Cioe, Irving K. Barber Faculty of Arts and Social Sciences University Examiner Dr. Jane Koziol-Mclain. University of Auckland, New Zealand External Examiner iii Abstract In 2015, the WHO released a call to action to stop violence against women. This call to action has been translated into initiatives to improve health and social policies and services. Health system integration, defined as the process to improve healthcare performance, can better organize and integrate the care of people, especially those experiencing inequities. For women who experience marginalization and intimate partner violence (IPV), health system integration has the potential to address inequities. This dissertation involved three phases to illuminate how health system integration and equity-based services can support women who experience marginalization and IPV. Phase 1 (Scoping Review), involved a comprehensive review of Canadian literature on health system integration and equity-based services to meet women’s needs. Phase 2 (Policy Analysis), involved the analysis of publicly available documents for the design and delivery of services related to the care for women in British Columbia (BC). Phase 3 (Discussion Session), involved a virtual session with women and relevant contributors to gather their insights, and develop recommendations for action in the Southern Interior of BC. Results demonstrated: a) services based on health equity limited social exclusion by supporting women’s healing processes; b) understanding the diversity of the needs of multiple groups of women is essential for women-centred care; c) providers often did not recognize the complexity of women’s experiences and reproduced systemic violence; d) a cross-sectoral approach facilitated the approval of policy actions related to care for women in BC. Key recommendations included: implementing a formal process of integrating women’s voices and direction in the design of policies and services locally, provincially, and nationally; and reinforcing trauma- and violence-informed care across sectors and levels of care. To limit further inequities, community-based approaches that consider preventive actions are fundamental to challenge violence, and enhancements in housing, justice, and financial supports are needed. iv Lay Summary The experience of domestic violence negatively impacts women’s lives and society as a whole. Women who experience domestic violence also experience more health inequities than women who do not experience such violence. Health inequities are unfair differences in health (e.g., poorer health) caused by the way societies organize and distribute resources. For example, the way services assist women, such as the lack of integrated and appropriate care, is a health inequity. Because these differences are avoidable, addressing them will help women improve their lives. This dissertation studied how to deliver appropriate and integrated supports to address the needs of women who experience domestic violence. Key results demonstrated that the participation of women in service planning and delivery can help organizations tailor services appropriately, and that improving the understanding of the diversity of women’s needs is essential for appropriate integrated and women-centred care. This study contributes to the ongoing discussion about health equity and the integration of health services, and how they affect women’s health. v Preface The three phases comprising this study were designed and conducted by the doctoral student, YDL, with supervision from committee members, NDO, SM, and CV through meetings and written feedback. Conceptual development of the study design was influenced by discussions in these meetings. Data collection and analyses, including interpretation of results, were carried out by YDL and guided by the committee members. Research results, discussions, and conclusions were completed by YDL with feedback and consultation with the supervisor and committee members. Writing this dissertation was completed by YDL, assisted by written comments and verbal consultation with the committee members. YDL integrated all components of this study, including conceptual and methodological development, ethics applications, and overall results. Publications: A version of the scoping review (Phase 1) that appears in Chapter 3 has been submitted for publication: Davila-Lara, Y., Varcoe, C., Mema, M., & Oelke, N. (Under review). Intimate partner violence and marginalization in women: A scoping review of health system integration and health equity in Canada. Trauma and Violence Journal. Authorship contributions: YDL conceptualized and conducted the work for this study with guidance from NDO, SM, and CV., who provided specific feedback and recommendations through several revisions. Ethical Approval: The research protocol for the study reported in this dissertation was approved through a harmonized review between the Interior Health Research Ethics Board (IH REB file number #2021-22-055-H) and the UBC Behavioural Research Ethics Board (Certificate # H21-00169) on November 22nd, 2021. vi Table of Contents Abstract ....................................................................................................................................................... iii Lay Summary .............................................................................................................................................. iv Preface ......................................................................................................................................................... v List of Tables .............................................................................................................................................. xi List of Figures ........................................................................................................................................... xii Acknowledgements ................................................................................................................................. xiii Dedication ................................................................................................................................................. xiv Chapter 1: Introduction .............................................................................................................................. 1 1.1 Health Equity ..................................................................................................................................... 2 1.2 Marginalization and its Impact on Women’s Healthcare ............................................................... 4 1.3 Sex- and Gender-Based Violence and Intimate Partner Violence ................................................ 4 1.3.1 Social Dimensions of Intimate Partner Violence and Sex- and Gender-Based Violence ........... 5 1.4 Health System Integration ................................................................................................................ 7 1.4.1 Health System Integration for Women’s Health and Social Care ............................................... 8 1.5 Theoretical Frameworks Supporting the Research ....................................................................... 9 1.5.1 Feminist Research ...................................................................................................................... 9 1.5.2 Approaches to Researching Health Experiences and Outcomes ............................................. 10 1.5.3 Approaches Towards Knowledge Translation, Dissemination, and Exchange ......................... 14 1.6 Problem Statement ......................................................................................................................... 15 1.6.1 Research Project Question ....................................................................................................... 16 1.6.2 Research Project Objectives ..................................................................................................... 16 1.7 Research Study Design .................................................................................................................. 16 1.7.1 Evaluation Strategy ................................................................................................................... 18 1.8 Quality and Rigour .......................................................................................................................... 18 1.9 Positionality and Reflexivity .......................................................................................................... 18 vii Chapter 2: Literature Review ................................................................................................................... 23 2.1 Methods ........................................................................................................................................... 23 2.1.1 Define the Research Question for the Rapid Review and Synthesis ........................................ 23 2.1.2 Search for Evidence .................................................................................................................. 24 2.1.3 Appraisal of the Evidence .......................................................................................................... 25 2.1.4 Synthesis of the Evidence ......................................................................................................... 26 2.2 Results ............................................................................................................................................. 28 2.2.1 Types of Health and Social Interventions for Women who Experience IPV ............................. 29 2.2.2 Women’s Health Needs and Perceptions of Services .............................................................. 30 2.2.3 Providers’ Perspectives on Services ......................................................................................... 32 2.2.4 Understanding IPV to Develop Integrated and Equity-Based Services .................................... 33 2.2.5 Facilitators and Barriers ............................................................................................................ 37 2.2.6 Gaps in Integrated and Equity-Based Services ........................................................................ 38 2.3 Summary .......................................................................................................................................... 38 2.4 Remarks and Moving Forward ....................................................................................................... 42 Chapter 3. Scoping Review ...................................................................................................................... 44 3.1 Background ..................................................................................................................................... 44 3.2 Methods ........................................................................................................................................... 46 3.2.1 Identifying the Research Question ............................................................................................ 46 3.2.2 Identifying Relevant Studies ...................................................................................................... 46 3.2.3 Selecting Study Inclusion-Exclusion Criteria ............................................................................. 46 3.2.4 Charting the Data ...................................................................................................................... 47 3.2.5 Collating, Summarizing, and Reporting Results ........................................................................ 47 3.3 Results ............................................................................................................................................. 48 3.3.1 Descriptive Analysis .................................................................................................................. 48 3.3.2 Thematic and Content Analysis................................................................................................. 52 3.4 Discussion ....................................................................................................................................... 59 viii 3.4.1 Implications for Practice and Research ..................................................................................... 63 3.5 Remarks ........................................................................................................................................... 64 Chapter 4. Policy Analysis ....................................................................................................................... 66 4.1 Background ..................................................................................................................................... 66 4.2 Methods ........................................................................................................................................... 68 4.2.1 Analytical Foundation ................................................................................................................ 68 4.2.2 Methodological Framework ....................................................................................................... 68 4.2.3 Methodological Procedures ....................................................................................................... 71 4.3 Results ............................................................................................................................................. 72 4.3.1 Effects of the Policies Being Studied ........................................................................................ 75 4.3.2 Implementation Concerns ......................................................................................................... 81 4.4 Discussion ....................................................................................................................................... 86 4.4.1 Towards More Integrated and Equity-Based Services for Women ........................................... 87 4.4.2 Strengths and Limitations for Health System Integration and Health Equity ............................ 93 4.5 Recommendations .......................................................................................................................... 94 4.5.1 For British Columbia .................................................................................................................. 94 4.5.2 For IPV Policy ............................................................................................................................ 95 4.5.3 For Policy Analysis Research .................................................................................................... 96 4.6 Strengths and Limitations of the Policy Analysis ....................................................................... 96 4.7 Remarks ........................................................................................................................................... 97 Chapter 5. Knowledge Translation Discussion Session ....................................................................... 99 5.1 Background ..................................................................................................................................... 99 5.2 Methods ......................................................................................................................................... 100 5.2.1 Analytical Foundation .............................................................................................................. 100 5.2.2 Methodological Procedures ..................................................................................................... 100 5.2.3 Ethical Considerations ............................................................................................................. 103 ix 5.2.4 Specifications About Confidentiality and Inclusiveness .......................................................... 104 5.3 Results ........................................................................................................................................... 104 5.3.1 Women’s Experiences Should Drive Service Planning and Delivery...................................... 104 5.3.2 Gaps in Policy, Service Planning, and Delivery for Women who Experience IPV .................. 112 5.4 Discussion ..................................................................................................................................... 115 5.4.1 Strengthen Integration and Equity-Based Services for Women who Experience IPV ............ 115 5.5 Recommendations ........................................................................................................................ 121 5.6 Strengths and Limitations ............................................................................................................ 123 5.6.1 Strengths ................................................................................................................................. 123 5.6.2 Limitations ............................................................................................................................... 123 5.7 Remarks ......................................................................................................................................... 124 Chapter 6. Synthesis and Conclusion .................................................................................................. 126 6.1 Recap.............................................................................................................................................. 126 6.2 Overview of the Three Phases of This Study ............................................................................. 127 6.3 Towards More Integrated and Equity-Based Services for Women Experiencing IPV in BC . 128 6.3.1 IPV as a Complex Health and Social Issue ............................................................................. 128 6.3.2 Engaging Women with Lived Experiences .............................................................................. 131 6.3.3 Addressing the Diverse Needs of Women .............................................................................. 132 6.3.4 Partnership and Collaboration ................................................................................................. 133 6.3.5 Designing Services and Supports ........................................................................................... 135 6.4 Strengths and Limitations ............................................................................................................ 136 6.4.1 Strengths ................................................................................................................................. 136 6.4.2 Limitations ............................................................................................................................... 137 6.5 Implications ................................................................................................................................... 138 6.6 Conclusion ..................................................................................................................................... 138 References ............................................................................................................................................... 141 x Appendix A .............................................................................................................................................. 171 Appendix B .............................................................................................................................................. 172 Appendix C .............................................................................................................................................. 173 Appendix D .............................................................................................................................................. 177 Appendix E............................................................................................................................................... 182 Appendix F ............................................................................................................................................... 184 Appendix G .............................................................................................................................................. 186 Appendix H .............................................................................................................................................. 187 Appendix I ................................................................................................................................................ 188 Appendix J ............................................................................................................................................... 191 Appendix K .............................................................................................................................................. 192 Appendix L ............................................................................................................................................... 195 Appendix M .............................................................................................................................................. 197 Appendix N .............................................................................................................................................. 198 Appendix O .............................................................................................................................................. 201 Appendix P............................................................................................................................................... 202 Appendix Q .............................................................................................................................................. 205 xi List of Tables Table 1 Data Sets by Phase ...................................................................................................................... 18 Table 2 Strategies to Satisfy Quality and Rigour ........................................................................................ 19 Table 3 Overview of Selected Records ...................................................................................................... 28 Table 4 Key Outcomes and Impact of Interventions from Systematic Reviews ........................................ 31 Table 5 Comprehensive and System-Level Approaches to IPV ................................................................. 33 Table 6 Key Highlights per Study (Systematic Reviews and Primary Studies) .......................................... 34 Table 7 Facilitators and Barriers to Build Services for Women who Experience IPV ................................ 37 Table 8 Gaps to Addressing the Needs of Women who Experience IPV .................................................. 39 Table 9 Overview of Selected Records ...................................................................................................... 49 Table 10 Summary of Research Studies ................................................................................................... 50 Table 11 Summary of Critical Results ........................................................................................................ 53 Table 12 Summary of Implications ............................................................................................................. 64 Table 13 Dimensions for Analyzing Public Policies ................................................................................... 70 Table 14 Overview of the Policies Studied ................................................................................................ 73 Table 15 Analytical Dimension: Effectiveness ........................................................................................... 76 Table 16 Analytical Dimension: Equity ....................................................................................................... 80 Table 17 Analytical Dimension: Cost ......................................................................................................... 82 Table 18 Analytical Dimension: Feasibility ................................................................................................. 83 Table 19 Analytical Dimension: Acceptability ............................................................................................ 85 Table 20 Gaps in Policy and Service Planning and Delivery ................................................................... 113 Table 21 Key Results per Phase ............................................................................................................. 129 Table 22 Summary of Implications of the Study ...................................................................................... 139 xii List of Figures Figure 1 Research Question, Phases, and Objectives .............................................................................. 17 Figure 2 Decision Tree (PRISMA) ............................................................................................................. 27 Figure 3 Flow Diagram of Studies (PRISMA) ............................................................................................ 48 Figure 4 Health (Healthy) Public Policy and Public Health Policy ............................................................. 69 Figure 5 Map of the Policies Studied and Policy Instruments Identified (2010–2021) .............................. 74 xiii Acknowledgements I want to thank everyone who supported me and offered kind words, cheered me along, and listened to me during the whole process. My family, friends, cats, and plants have been with me all the way. Several circumstances—personal, professional, labour, and academic—brought me here. All of these pieces were aligned towards making the decision to come to Canada to pursue my PhD. After all this time and work, it seems this process is coming to an end. I came to Canada to obtain a PhD; four years later, I have a husband, three cat babies, multiple plants, and, soon, a human baby. And my Doctoral degree, certainly. I am grateful for the support of my supervisory committee members. All of these women guided my learning process in such important ways. They also challenged me to keep growing professionally. Through their encouragement and freedom, I explored my capabilities. I received financial support to develop this program from the Consejo Nacional de Ciencia y Tecnologia (National Council for Science and Technology) in Mexico. I sincerely acknowledge their support to start and finish my doctorate. Funding support was also provided by the University of British Columbia (UBC) Okanagan through University Graduate Fellowships. Finally, I thank the women with lived experiences of IPV who have been part of my professional and personal development. It is because of you that I find the motivation to improve your lives, to improve our lives. xiv Dedication To the women who came before me. “I stand on the shoulders of women who marched before me.” – Maria Shriver xv Glossary Equity-based services or health and social services based on equity “Where different populations are served by a variety of service providers” (Lavoie et al., 2018, p. 6) to meet their needs, and there are also appropriate resources for those who need them the most (EQUIP Health Care, 2020). Health equity The absence of systematic and avoidable obstacles in health between individuals and groups that impact the possibility of being as healthy as possible. Examples of barriers and obstacles include poverty or discrimination (Braveman et al., 2017). Note: Although there is some consensus and overlap among health equity definitions, there is not the same consensus on the best ways to achieve it; hence, the definition proposed for this dissertation attempts to guide action and research beyond offering the best ways to achieve it. Health inequities Differences in health experiences and outcomes created through preventable and modifiable social elements such as policies, practices, decisions, and actions. These differences are unfair, unnecessary, and remedial (World Health Organization [WHO], 2015, n.d., n.d.-a). Health equality The absence of differences in health or in the distribution of health determinants among individuals, groups, or populations (Northwestern Health Unit, 2020; Arcaya et al., 2015). Health inequalities or health disparities Differences in health status, outcomes or in the distribution of health determinants between different population groups (WHO, 2015, n.d., n.d.-a). Health system integration A process (instead of only a destination) to improve healthcare performance that benefits systems, programs, practices, communities, patients, and providers (Armitage et al., 2009). Marginalization or social exclusion Marginalization refers to structural social, economic, and historical processes and circumstances that contribute to relegation, disadvantage, or exclusion of people from the benefits of society – to the margins – in diverse aspects, including health status (Dwivedi et al., 2007; Prodan-Bhalla & Browne, 2019). Social exclusion refers to the result of constant marginalization or disadvantageous processes in society, directly or indirectly related to a location of privilege (Dwivedi et al., 2007). These disadvantages are associated with a wide range of intersecting elements such as wealth distribution or the impacts of social discriminations (e.g., racism, ableism, sexism). Social exclusion “places the emphasis on dynamic processes that prevent many from being fully included in society” (Piachaud et al., 2009, p. 4). Note: For this dissertation, marginalization and social exclusion are used interchangeably since they have overlapping pieces. Social determinants of health (SDH) Social and economic conditions that shape people’s lives and health, including life experiences, workplace environments, and other elements (e.g., social network, disabilities) (Canadian Public Health Association, 2020, para 1). System integration The “tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care” (Valentijn et al., 2013, p. 4). Women who experience marginalization Women or self-identified women who are at the intersections of multiple forms of marginalization, including but not limited to women who experience homelessness, substance use, mental health concerns, disabilities, HIV, living in poverty, rural communities and/or women who are single mothers, older women, xvi members of the Lesbian Gay Bisexual Queer Transgender (LGBQT) community, Indigenous women, refugees, migrants, asylum seekers, sex workers, travelers, and unemployed women (O’Donnell et al., 2018). Intimate partner violence “A pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks, as well as economic coercion, that adults or adolescents use against their intimate partners” (Sievers & Greifinger, 2016, p. 4). Considering that marginalization determines women’s vulnerability to experiencing segregation in society and to receiving or participating in benefits (Di Cesare, 2014), this study focused on intimate partner violence as a reflection and intersection of social exclusion and other elements. 1 Chapter 1: Introduction The World Health Organization (WHO) states that the interaction of the social determinants of health (SDH) plays a significant role in determining individual and population health (WHO, n.d.). Across the SDH, there are specific social (e.g., experiences of discrimination) and economic (e.g., poverty) determinants that are associated with a person’s place in society (Canadian Public Health Association, 2020). Social and health inequities are the expression of intentional or unintentional power imbalances rooted in the SDH, including structures (e.g., policies, practices) (Gkiouleka et al., 2018) and categories of difference such as positions (e.g., income) and identities (e.g., gender) (Braveman et al., 2017). For example, gender-based inequities are the expression of these elements interacting. The experience of sex- and gender-based violence (SGBV) and intimate partner violence (IPV) reflect an interaction among factors shaping women’s vulnerability that results from gender-based inequities, social inequities, and the SDH. According to the Canadian Femicide Observatory for Justice and Accountability (2018), 106 women and girls were killed in Canada during the first eight months of 2018. Of these, 31% were classified as intimate femicide. This aligns with international statistics showing that in 2017 “as many as 38% of murders of women are committed by a male intimate partner” (WHO, 2021b); and almost 30% of women in a past or present relationship reported experiencing physical and/or sexual violence from their partner (Unicef, 2021; WHO, 2021b). Overall, women who experience greater inequities tend to experience higher rates of IPV regardless of race, economic status, or other social contexts (Clifford et al., 2007). IPV against women is recognized as a public health issue (Garcia-Moreno, Hegarty, et al., 2015; Garcia-Moreno, Zimmerman, et al., 2015; Hardesty & Ogolsky, 2020). The relationship among these collective and individual experiences of people and the SDH is influenced by processes of inclusion or exclusion in relation to healthcare, which include facilitating or denying health services, and shaping further inequities in relation to who accesses specific resources, and how, where, and when these resources are delivered. The study of inclusion/exclusion to health and social policies and services, and service delivery, allows researchers to identify differences in health status that can help re-design health systems. Additionally, the study of disadvantages that negatively contribute to health status (e.g., gender-based inequities) can be used to measure health differences that 2 may need tailored health and social services. The understanding of how to address health differences among populations will inform how to promote health equity. Since system integration is recognized as an approach to enhance and effectively deliver the right care at the right time in the right place, clarification of the role that this approach can play to improve health equity for specific groups is key. This dissertation focuses on health system integration and equity-based services as health and social care approaches to meet the needs of women who experience marginalization and IPV, with an overall goal of investigating how to improve health equity for women by improving health system integration. It uses a geographically narrowing study design, from national (Canada), to provincial (British Columbia [BC]), to local (Southern Interior of BC) levels. It contains six chapters: a) an introduction to present key concepts and the rationale for the research; b) a rapid review to understand the current state of the literature, including gaps in evidence for this population; c) a scoping review to identify relevant Canadian peer-reviewed literature on the topics; d) a policy analysis to study policy documents related to the care of women who experience IPV; e) a knowledge translation discussion session to integrate women’s and contributors’ insights about health and this study, and f) a synthesis and conclusion of the study. 1.1 Health Equity Health equity plays an important role in addressing the issue of health differences among individuals and populations due to preventable circumstances (e.g., poverty, discrimination) (Public Health Ontario, 2020). Research on how specific SDH (e.g., housing environment) impact physical or mental health is needed to understand people’s lives and health outcomes (Canadian Public Health Association, 2020); this study will develop a better understanding of health equity in the context of health and policy action to improve population health. An in-depth understanding of the SDH includes the assessment of the person’s position in society, including specific social structures and social categories of difference. Understanding how these elements interact to influence health status will assist in planning effective health and social services. According to Braveman (2014), social structures include: a) the socioeconomic and political circumstances and processes determining the availability, distribution, effectiveness and quality of infrastructure, services, and resources (e.g., housing, education, healthcare); and b) the sociocultural 3 conditions and processes framing the social relationships and values attributed to resources, services and goods. In the case of social categories of difference such as identities and positions, this assessment is key to understanding the impact of social structures on people’s health. Whereas social identity refers to one’s personally held identity, social position refers to one’s occupancy in social structures (Bauer, 2014). Identities are multidimensional categories of difference that include a self-recognition, acceptance, and identification in society and within groups. For example, an elderly Black woman has multiple identities including ethnicity, age, and sex/gender. On the other hand, positions can be identified either by objective measures (e.g., income) or the way a person is perceived by others (e.g., racialization). Although both interact with one another, a key difference is that “identities are context-specific and may shift with regard to place and time” (Bauer, 2014, p. 13), which is key for innovative tailored healthcare. Social positions (e.g., income or level of education) can impact health status independently of which identities are presented. The study of social structures and categories of difference provides a better understanding of how the interactions among them reinforce or limit privileges in relation to infrastructures, services, and resources, including health and social services; and who receives or who is excluded from specific resources (e.g., service delivery), even if unintentionally. A negative interaction among social structures and categories of difference over time can determine marginalization, which results in exclusionary effects characterized by differences in access to resources, capabilities, and rights. “This continuum results in health inequities” (O’Donnell et al., 2018, p. 3). Browne et al. (2012) stated that health inequities are the result of how policies, practices, institutions, and arrangements operate to produce an unbalanced distribution of individual and population health. The argument about how health and social inequities are framed offers clarity to identify actions to move towards health equity. If there are no mechanisms to enable health equity, socially avoidable circumstances will negatively impact health status and result in further health inequities. As such, there is a requirement to modify social structures and their health-equity-limiting effects in groups historically affected, such as women who experience marginalization and IPV. The next section will expand upon the impact of social structures on women’s health. 4 1.2 Marginalization and its Impact on Women’s Healthcare Marginalization shapes human experiences in diverse ways. According to Hankivsky (2014), health and social inequities result from power imbalances among the SDH. The impact of these power imbalances includes variations in accessing resources, limitations in using the resources available, and differences in having or being denied rights (O’Donnell et al., 2018). In the case of women, marginalization is experienced through power imbalances established by vulnerability or disadvantage because of specific structural exclusionary policies and practices such as maternity leave, legal aid, access to childcare, eldercare, housing opportunities, and underrepresentation in healthcare research (Prodan-Bhalla & Browne, 2019). As Di Cesare (2014) states, the “lack of economic autonomy, fair pay, an imbalance in the number of working (paid and unpaid) hours are all dimensions which affect women’s health and wellbeing” (p. 3). Although it is known that many exclusionary processes for women are related to gender-based inequalities and inequities (e.g., differences in incomes, employment rates and opportunities) (Pederson et al., 2014), we still need to illuminate how and to what extent specific structural forces and social categories of difference shape health status for diverse groups of women (Prodan-Bhalla & Browne, 2019). Since the interaction of these elements have differently shaped sociopolitical and economic agendas in health and social services for various groups of women, the following section will analyze SGBV and IPV in the context of social disadvantage. 1.3 Sex- and Gender-Based Violence and Intimate Partner Violence The Office of the United Nations High Commissioner for Refugees (United Nations High Commissioner for Refugees, 2020, para 1) defines sex- and gender-based violence as an action against a person’s will based on their biological sex or social gender norms. The WHO (2021b) and other agencies (Centers for Disease Control and Prevention, 2020; Canadian Women’s Foundation, 2020) consider SGBV to be a public health and human rights issue that can lead to severe social, economic, and cultural consequences in a society. These harmful patterns primarily affect women and girls; however, men, boys, and sexual and gender minorities also experience SGBV. SGBV includes violence and coercion; although it often can be physical, emotional, psychological, or sexual, it also can be recognized as a denial of resources or access to goods or services (United Nations High Commissioner for Refugees, 2020). SGBV also includes forms of violence such as rape and attempted rape, sexual 5 abuse, sexual exploitation, forced early marriage, domestic violence, marital rape, trafficking, and female genital mutilation (European Institute for Gender Equality, n. d.; Unicef, 2021; WHO, 2021b). Evidence shows that IPV is the most widespread form of SGBV, with approximately one in three women globally having experienced it (WHO, 2021b). IPV can be defined as “a pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks, as well as economic coercion, that adults or adolescents use against their intimate partners” (Sievers & Greifinger, 2016, p. 4). In addition to experiencing IPV, other types of violence often happen concurrently. IPV exists independently of social, economic, and cultural structures; however, evidence shows lower rates of IPV in higher-income countries (Sievers & Greifinger, 2016; WHO, 2021b). Since these forms of violence represent power imbalances because women and girls remain in unequal positions in societies, the next section will further discuss social elements of SGBV and IPV. 1.3.1 Social Dimensions of Intimate Partner Violence and Sex- and Gender-Based Violence Research has shown that in societies that follow patriarchal gender norms or beliefs, where men are considered superior and women are considered subordinate to them, violence can be acceptable and used to gain and maintain power and control (Semahegn et al., 2019). This is relevant from the macro-policy level through to meso and micro levels of service delivery where organizational and operational structures need to consider practices to limit violence, harm, and inequities. For instance, culturally sensitive and trauma- and violence-informed care approaches can broaden the understanding of the social dimensions of IPV and help policy-makers, decision-makers, and providers design and provide services that do not cause more harm and support the healing process (Ponic et al., 2016; Rollero & Tartaglia, 2019). However, understanding the systemic impact that structures of oppression such as patriarchy have had on women’s health experiences and gender inequities is complex due to the intertwining influences of other systems such as capitalism and colonialism which historically have reproduced oppression and exploitation (Fellows & Razack, 1998). Although a comprehensive discussion goes beyond the scope of this dissertation, a better understanding of gender-based inequality is necessary for research and policy action implications of IPV and SGBV. Willie and Kershaw (2019) developed an analysis of gender inequality to examine the association between the prevalence of lifetime IPV and the Gender Inequality Index which “captures the loss in human development and achievements 6 due to gender disparities” (p. 7). By analyzing the estimated prevalence rate of IPV for women and men, socio-demographics, and five indicators (maternal mortality ratio, teen birth rate, government representation, educational attainment, and labor force participation of gender inequality), they demonstrated that the occurrence of any form of IPV was associated with gender inequality in the United States (Willie & Kershaw, 2019). Results for the indicators of educational attainment (percentage of women and men 25 years and older who reported having at least a high school diploma) and labor force participation (the percentage of women and men between the ages of 20–64 years in a non-institutionalized population who participated in the labor force) showed that the lower the level of women’s education and labor participation, the higher the association with any form of IPV. As such, structural changes considering intersectoral initiatives (e.g., educative and financial supports) are needed to decrease gender inequality and the incidence of IPV. Gender stereotypes have been studied to complement the discussion of the social dimensions of IPV and SGBV. As cited in Rollero (2019), the WHO considers that “gender differences in roles and behaviors can create inequalities, and possibly encourage an environment in which one group becomes empowered and other is disadvantaged” (p. 3). To explain IPV, it is necessary to improve the understanding of power imbalances based on sex as well as other structures of oppression such as class or race, which can be enhanced by understanding the impact of patriarchy, among other systems (Hankivsky, 2012). This aligns with research about the gender stereotyping associated with IPV (Bates et al., 2019; Subirana-Malaret et al., 2019). A key argument relies on how social and cultural values approving sexist attitudes and victim blaming are more likely to reproduce and make violence acceptable. According to Rollero and Tartaglia (2019), women remain submissive or willing to please men; and tolerate infidelity or any kind and level of violence, including the perception of being responsible for the abuse. Since the internalization of social gender roles can legitimize violence and reinforce gender stereotypes, Rollero (2019) advocated for a comprehensive analysis that considers social and individual determinants or risks for victims and perpetrators. By studying male perpetrators, the author found that a male’s process of self-awareness throughout treatment can help to identify and change behaviour. When men became aware of a broader conceptualization of violence (e.g., implications of psychological harm or economic restrictions), this understanding helped them plan new roles and re-analyze behaviours. By 7 recognizing that gender inequality is a societal-level determinant impacting health status at the individual level, research can be translated into tailored service enhancements (Willie & Kershaw, 2019). These initiatives may offer insight into how to tackle gender-based inequities across sectors. The next section will discuss the relevance of health systems integration in the planning and delivery of care. 1.4 Health System Integration Previous investigation has established that initiatives based on integration of health and social systems have become efficient approaches to reduce fragmentation of systems and improve patient and population health. According to Suter, Oelke, et al. (2009), there are key principles that can be used to improve the integration of health systems (e.g., comprehensive care, organizational culture, physician integration, governance structure, financial management) with specific processes and models. The authors emphasized the importance of being cautious about specific structures needed to redesign systems based on these principles, stressing that the structures should be flexible and adaptable to the local context. Despite the emphasis on integrated health systems, Armitage et al. (2009) found diverse definitions of integration, and Suter et al. (2017) identified a gap in conceptualizing, measuring, and translating health system integration. Armitage et al. (2009) found that health system integration has been characterized as a process (instead of only a destination) to improve healthcare performance that benefits systems, programs, practices, communities, patients, and providers. To better understand health system integration, the elements proposed in the Rainbow Model of Integrated Care (RMIC) (Valentijn et al., 2013) have been used to translate integrated health models in diverse contexts. The model places the elements of person-centred care within a bio-psychosocial perspective; further, it uses a population-based approach aimed at addressing people’s needs (Valentijn et al., 2013). The RMIC proposes three levels of integration: micro (clinical), meso (organizational), and macro (system), as well as vertical and horizontal integration to understand the interaction of elements and functions across the health system. Clinical integration is grounded in person-centred care and occurs when the services are aligned to meet a person’s needs; organizational integration, including professional integration, refers to services and providers being linked to each other, including those from other social organizations (e.g., housing, legal services); and system integration encompasses full integration of the system, which improves efficiency, quality of care, quality of life, and patient satisfaction (Valentijn et al., 2013). The next section 8 will explore health systems integration, specifically in relation to health equity for women experiencing marginalization and IPV. 1.4.1 Health System Integration for Women’s Health and Social Care Suter et al. (2017) recognized the need to improve how health system integration can be translated into initiatives addressing specific people’s health needs. As presented earlier, health and social policies, practices, institutions, and actions play a fundamental role in reproducing an unbalanced distribution of healthcare throughout complex systems of power. When studying marginalization and its effect on health, considering health equity in initiatives seeking integration of systems is key, since health system integration “refers to the alignment of rules and policies within a system” (Valentijn et al., 2013, p. 3). More work is needed to explain why and how certain groups of women receive or do not receive services, to help illuminate how and to what extent specific health outcomes have been affected by sociopolitical and economic agendas. Identifying how health status and outcomes are shaped by structural forces opens the potential for integrated health systems and initiatives based on health equity to impact health experiences and outcomes by counteracting or removing oppressive social structures and their negative consequences. In recent years, research has advanced the development of innovative approaches exploring health system integration based on health equity for women experiencing marginalization and social exclusionary processes. For example, an inclusive, collaborative, and engaging approach was proposed by O’Brien et al. (2017). The authors studied the experiences of women living with HIV and their perceptions regarding how a women-centred HIV care approach should be implemented. Three central characteristics are needed for the care to be women-centred: It needs to be coordinated and integrated, address structural limitations to access, and promote peer support and peer leadership. The study identified that a women-centred HIV care approach can foster women’s engagement and empowerment by prioritizing women’s ownership over decisions that affect their lives. The results showed the extent to which system integration improved population health. Since health system integration “requires a tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care” (Valentijn et al., 2013, p. 4), O’Brien’s et al. (2017) study proposed a women-centred HIV care approach that considered multiple layers of care to address diverse needs. At 9 the bottom level, services need to focus on meeting basic care competencies grounded in ethical values (e.g., empathy, respect) and knowledge; at the mid-level, services should acknowledge person-centred care characteristics for meeting both women’s health and social needs in general and their specific HIV care needs (e.g., person-centred care or mental health services); and at the top level, it should address specific considerations for women with HIV, including structural barriers (e.g., stigma). 1.5 Theoretical Frameworks Supporting the Research 1.5.1 Feminist Research With transformative frameworks such as feminism, researchers conceptualize that knowledge is not neutral. Knowledge “reflects the power and social relationships within society, and the purpose of knowledge construction is to aid people to improve society” (Sweetman et al., 2010, p. 442). As such, issues of power imbalances such as oppression and gender inequality need to be studied. Although feminist perspectives vary, this type of research emerged as “a critique of the invisibility of women, both as objects of study and as social scientists, to the critique of the method and purpose of social science” (Gorelick, 1991, p. 459). As cited in Beck (2013), Smith (1987) points out that “society is organized by gendered processes that perform a routine, generalized, and effective repression” (p. 243). Further, as feminism has evolved, it has provided scholars with the possibility of challenging the structure and values of the dominant social order (Lorber, 2010, 2018). As such, to develop feminist research, there is a need “to challenge knowledge that excludes, while seeming to include — assuming that when we speak of the generic term men, we also mean women” (Hesse-Biber, 2012, p. 4). By asking questions that document women’s lives, experiences, concerns, and perceptions, feminist research enhances the empowerment of women and other groups in less powerful positions than others in society (Brooks & Hesse-Biber, 2007). Additionally, the production of knowledge in feminist research is based on how researchers have engaged with and contribute to women’s knowledge, which is determined by different elements. These elements are the ways that researchers try to give meaning to women’s studies, including “the researcher’s subjectivity, ontology, epistemology, methods, theory and ethics/politics” (Ramazanoglu & Holland 2002, p. 34). For feminist research, it is more important to know how the method is used, rather than the properties of the method itself. Principles of feminist research are outlined as “inclusiveness and 10 diversity, the importance of social and historical context, combating power and privilege, and social activism” (White and colleagues, 2001, as cited in Beckman, 2014, p. 166). Evidence varies regarding how to apply the principles of feminist research to develop specific feminist methodologies. According to Chernomas (1997), the main objective of feminist research is to recognize that each person in the research process is knowledgeable. It means that the production of knowledge comes from multiple social realities. Likewise, Hall and Stevens (1991) pointed out that research questions should reflect specific women’s needs; thus, there may not be an intention of generalizing or using a standard model for all participants. A feminist approach should answer women’s questions, so their health services questions and the researcher’s assumptions should be brought to the surface to play a role in the process of conceptualizing and analyzing phenomena. Since feminist research makes a unique contribution to understanding women’s health experiences, the advancement of social changes and the construction of new knowledge for health equity can be enhanced by promoting critical levels of moral action (Kitzinger, 2004; Wickramasinghe, 2010). Although there may not be a single feminist epistemology or methodology in feminist research (Hesse-Biber, 2012), the reason for calling out and developing feminist research stems from the need to not diminish or silence – even more – the voices of women or groups in less powerful positions. 1.5.2 Approaches to Researching Health Experiences and Outcomes There have been attempts to research health experiences and outcomes, including social and health inequities. Browne and Varcoe (2018) presented arguments to emphasize that culturally safe research recognizes equally important social determinants of health, beyond gender, to understand immigrant women’s decisions and health experiences. The complexity of studying health outcomes by considering cultural frameworks was also studied by Viruell-Fuentes et al. (2012), who emphasized the need for inclusive frameworks to consider the intersecting multiple dimensions of inequality that shape health outcomes. Although the authors did not highlight specific assumptions to differentiate the impact of these intersecting dimensions among all genders, they presented an analysis of the interaction of different forces of power and social categories to frame health, including race/ethnicity, gender, and class. This research showed how discrimination, racialization processes, residential segregation, and immigration policies impacted health outcomes for immigrant people. Yet according to Hankivsky (2012), 11 there has been a lack of approaches to understand and address the impact of social structures such as policies, institutions, and structures on specific groups, including diverse groups of women (e.g., Indigenous women, women with disabilities). Health and social care research have progressed in understanding the study of health experiences mainly based on sex and gender differences. A common approach used for these analyses is sex- and gender-based analysis (SGBA). SGBA emphasizes the need to incorporate sex and gender as defining variables in health research, and highlights the need to clearly understand the differences between sex and gender to recognize the interactions and explore the impact on health experiences (Johnson et al., 2009). This approach is actively critiqued by Hankivsky et al. (2010), who encourage the inclusion of social positions beyond sex and gender by referring to the ideas of Weldon, as follows: “Gender analysis must incorporate analysis of race, class, sexuality, and other axes of disadvantage, and explore interactions among them” (as cited in Hankivsky et al., 2010, p. 2). This understanding is a key piece to broaden the analysis of how systems of privilege and social structures frame healthcare for women. As an example of studying the effect of systems of privilege in particular groups, Shahram et al. (2017) studied the negative impact of social structures on Indigenous women’s health rights. The authors showed how classism, colonialism, and racism impacted women’s vulnerability and put them at a disadvantage in receiving child protection interventions, compared to non-Indigenous women. Intersectionality. According to Hankivsky (2014) and Hankivsky et al. (2010, 2014), SGBA tends to use an additive model to study health inequities; as such, SGBA may not pay attention to the mutually interdependent, interactive, and unique relationship among other social categories of difference from specific groups. These authors consider that these approaches are limited to identifying relationships of power among other intersections. In contrast, an intersectionality framework (Hankivsky et al., 2014) encourages the inclusion of those other social categories of difference to explain people’s health experiences, and multiple and complex dimensions of inequities resulting from systems of power. Since intersectionality-type analyses seek to better explain how systems of privilege, oppression, or domination at the macro social-structural level (e. g., racism, sexism, heterosexism, ableism) intersect at the micro level of personal experiences to frame health status, they offer an insightful approach to embrace health equity and, therefore, social justice (Bowleg, 2012; Bowleg & Bauer, 2016). As mentioned earlier in this 12 chapter, social structures interact with each other to determine health status or health inequities. And although the impact of those interlocking systems is difficult to measure, Green et al. (2017) pointed out that a key element of intersectionality-type analysis is that it improves the “understanding of between and within group differences” (Green et al., 2017, p. 215). Bowleg (2012) illustrated that a better understanding of the interaction of specific social categories of difference is crucial to move towards health equity. To design initiatives based on health equity, evidence shows the need for approaches based on diversity. For this dissertation, intersectionality is used as a theoretical framework more than an analytical approach for data analysis. Studying Power Imbalances and Intimate Partner Violence. Hankivsky et al. (2017) highlighted that the added value of intersectionality-type analyses can be found at every stage of the research process. Harris and Leonardo (2018) examined how intersectionality-type analyses can level up the meaning and understanding of power relationships and systems of oppression. The authors presented a wide-ranging analysis of the differences among intersectionality and other similar approaches to study race-gender subordination and education. First, intersectionality seeks to study social categories of difference that are identified as marginal or invisible. Second, intersectionality outlines the complexity of power, but “although intersectionality research attests to the interplay between social organization and power, it does not put forth a particular theory of power as such” (p. 5). Third, intersectionality embraces the gap between social categories of difference and the complexity of individual experiences. Finally, since single social categories of difference in an individual person (e. g., male, white, lesbian, rich) never end, the analysis never ends. Although intersectionality does not recognize a specific theory of power, the understanding of power and power relations for this dissertation aligns with Foucault’s (1976) theory; as well as with Roth’s (2021) research on feminism as social movement and the unmarked social categories of difference. The main point of Foucault’s theory relies on force relationships, and, as such, they are relative to an effect of difference, inequality, or unbalance. For Foucault, power is not something a person or group holds and keeps; instead, power is a complex group of forces that comes from everything and goes everywhere. As such, force and power relations are constantly changing and interacting, which may weaken, strengthen, or change one another. A difference with feminism is that it may claim a general and 13 oppressing system where one societal class or group oppresses another, whereas in Foucault’s theory, this understanding is partial and therefore it cannot describe all forms of power. Further, Foucault’s work, among others such as Jacques Lacan, Claude Lévi-Strauss set the foundations of structuralism: theory or methodology that “uncovers the structures that underlie all the things that humans do, think, perceive, and feel” (“Structuralism”, n. d., para. 1). Foucault positions structuralism (Carrabine, 2019) in relation to the concept of binary opposition (Buchanan, 2018). From an inquiry perspective, structuralism and post-structuralism helped to broadly conceptualize level structures, including structures of power, which line up with principles of feminism. By understanding how social structures have impacted multiple social categories of difference in framing health experiences, it is possible to acknowledge that a one-size-fits-all approach to health and social care is not enough to improve health equity. This understanding helps clarify the role that service delivery organizations have had in limiting or reproducing health inequities – even unintentionally – in groups who have experienced social exclusion. From a policy perspective, this understanding can lead to social change, including the changes needed to end these inequities. In the case of women who experience IPV, by studying how service delivery could limit or end IPV or the impact of social services on health outcomes, it may be possible to develop tailored approaches to bridge health equity gaps. As Kulkarni (2018) and Herrera and Agoff (2018) proposed, there is a need to re-conceptualize approaches to analyze health and social care for women who experience IPV, based on a better understanding of the intersecting systems of privilege and oppression, principally patriarchy. Policy and services may include innovative, integrated health and social justice approaches with analyses of complex relationships and solutions to prevent and end SGBV, including IPV (Crane & Easton, 2017). For example, Varcoe (2018) presented a comprehensive interpersonal violence assessment to effectively deal with violence from a provider perspective. This proposal responds to interpersonal violence by beginning with trauma- and violence-informed care. Overall, the delivery of care must be based on respectful listening, being alert to red flags for violence, using broad inquiring techniques, validating the person’s worth, and facilitating protection. 14 1.5.3 Approaches Towards Knowledge Translation, Dissemination, and Exchange There has been increasing interest in demonstrating why studying knowledge exchange, dissemination, and coproduction is central to improving health and social care. Knowledge dissemination is an “active process to communicate results to potential users by targeting, tailoring and packaging the message for a particular target audience” (Gagnon, 2010), which is highlighted as a “make it happen” perspective. Knowledge diffusion has a “let it happen” perspective, where the dissemination is a passive, unplanned, and uncontrolled process (e.g., conferences) and service users need to seek out the knowledge. To improve health and social services, approaches need to translate policy into practice, reflect the needs of those using services, and incorporate specific strategies for knowledge exchange and coproduction (Banner et al., 2019; Canadian Institutes of Health Research [CIHR], 2014). Knowledge dissemination, exchange, and coproduction can take place at the end of a project when results are ready to share (e.g., end-of-grant) or during the research processes (e.g., integrated). End-of grant approaches illustrate the power of research exchange and spreading, including the sharing of findings and recommendations of the study at specific spaces (e.g., education seminars, linkage and exchange events) where there is a target audience and an explicit intention to generate interest and further development. On the other hand, approaches emphasizing the importance of creating collaboration and partnerships are integrated approaches (Jull et al., 2017). Studying the Experiences of Women who Experience Marginalization and IPV: This study used end-of-grant and integrated knowledge translation (IKT) (CIHR, 2012) strategies to facilitate the implementation of the research and uptake of the results. The strategies facilitated knowledge exchange, dissemination, and coproduction; and improved collaboration and partnership among the researchers, knowledge holders (women with lived experiences), and knowledge users (contributors). Further, to understand the impact of oppression in the population of study and have an equity-based approach to health and social research, the phases of the spectrum of public participation (e.g., inform, consult, involve, collaborate, empower) (International Association for Public Participation, n. d.) were used. The research team involved a knowledge user from Interior Health Authority along with researchers from UBC (Okanagan and Vancouver). For Phase 3 of the study, a Knowledge Translation (KT) Discussion Session that involved knowledge holders, including women with lived experiences of IPV, and contributors from 15 both health and social services, were engaged to obtain their input, feedback, and recommendations for action. The goal of Phase 3 was to bring the researchers, women, and contributors together to share relevant research results and develop recommendations for health and social services approaches that support health systems integration and health equity. 1.6 Problem Statement The impact of IPV on societies has been such that there have been multiple international commitments to eliminate it. Despite the magnitude of the public health problem, understanding women’s experiences and health and social responses to IPV is complex and requires specific analyses and measurements. Improvements in research and practice include the study of the social factors impacting women’s health experiences along with specific and tailored health and social approaches for the delivery of care. At a macro-level perspective, literature includes impact measurements and innovative policy analyses, while at a micro-level approach, considerations encompass the analysis of interventions that jointly tailor and integrate services (Rivas et al., 2019). However, service delivery initiatives have almost exclusively focused on protecting the victims, an in-depth understanding of the root-causes and effects of diverse interacting elements is still in progress. This understanding would illuminate the role that specific actions have on the health status of women who experience marginalization and IPV. The presence of avoidable and unfair obstacles (e.g., discrimination) impacts health experiences (Public Heath Ontario, 2020), and since health equity is a complex value, policy and service improvements will need to address specific considerations for women who experience marginalization and IPV. First, current health systems focused on women’s health emphasizes reproductive health and fertility control. Second, women’s participation in health and social policy planning for their own health is a complicated process due to power imbalances. Third, since overall directives of health system integration (e.g., quality of care, efficiency, cost-effectiveness) impact people’s satisfaction, quality of life, and population health (Suter et al., 2017), these benefits need to be measured against tailored initiatives for women who experience marginalization and IPV. Fourth, IPV against women is often rooted in the SDH and the complex contexts of women’s lives. Fifth, evidence shows that the impacts of patriarchy, capitalism, and other systems of power are determinants for women’s lives. Sixth, the self-process that women experience in moving towards empowerment and ownership, and hence towards their wellbeing, 16 is significant from a health equity perspective. Seventh, there is a need to understand women’s health and social experiences to identify and intervene in the specific social factors influencing health. The implementation of health and social care approaches with implications for policy action and service delivery based on health equity requires an exploration of initiatives addressing the complexity of person and population needs. By recognizing the impact of explicit features of the health system (e.g., organizational procedures, aligned funding, change management), we have the potential to identify the effects that reorganization of health and social services towards health equity and integration could have on women’s health. Otherwise, a lack of awareness of the impact of these actions or practices will unintentionally continue to impact health status negatively. Since there is little research about the impact of health system integration to address women’s health needs and their impact on health equity, this study facilitated an understanding of health policies and service delivery for women who experience marginalization and IPV, and the barriers and enablers to implementing such policies and services. 1.6.1 Research Project Question How can health system integration enable health equity for women who experience marginalization and IPV? 1.6.2 Research Project Objectives Objective 1. Identify how system integration and health equity have been designed and implemented to address the needs of women who experience marginalization and IPV in Canada. Objective 2. Identify how policies and structures enhance or limit system integration and health equity for women who experience marginalization and IPV in BC. Objective 2.1. Identify barriers and enablers to implementing system integration and health equity for women who experience marginalization and IPV in BC. Objective 3. Develop recommendations for actions to support health equity through health system integration for women who experience marginalization and IPV in the Southern Interior of BC. 1.7 Research Study Design A study with interconnected phases (see Figure 1) was developed: a) a scoping review of relevant literature on health system integration and equity-based services related to the care of women who experience marginalization and IPV in Canada; b) a policy analysis of relevant documents related to 17 Figure 1 Research Question, Phases, and Objectives the care of women in BC; and c) a KT discussion session with women with lived experience of IPV and key contributors from health and social services organizations in the Southern Interior of BC. This geographically narrowing approach allowed me to consider three levels of service delivery (e.g., national, provincial, local) with corresponding implications. Each of the phases and their related objectives are presented in Figure 1. Different data sets were generated for each phase (see Table 1). Data to answer the research question included peer-reviewed literature and qualitative data collected via policy documents and a virtual KT discussion session. Phase 3: KT discussion session•Objective 3: Develop recommendations for actions to support health equity through system integration for women who experience marginalization and IPV in the Southern Interior of BC.Phase 2: Policy analysis •Objective 2: Identify how policies and structures enhance or limit system integration and health equity for women who experience marginalization and IPV in BC.Phase 1: Scoping review•Objective 1: Identify how system integration and health equity have been designed and implemented to address the needs of women who experience marginalization and IPV in Canada. Feminist and intersectional analyses Research Question: How can health system integration enable health equity for women who experience marginalization and IPV? 18 Table 1 Data Sets by Phase Phases Scoping Review Policy Analysis KT Discussion Session Data sources Articles Searches in interdisciplinary databases for literature focused on health system integration and equity-based services to address the needs of women who experience marginalization and IPV in Canada. Policy documents Publicly available documents designed for the implementation and delivery of services related to care for women who experience marginalization and IPV in BC. Policies and other publicly available documents delivered to me by contributors (e.g., Health Authorities). Qualitative data Qualitative data collected via a virtual KT discussion with women with lived experiences of IPV, contributors, and research team members. Transcripts of audio recordings, notes, and chat messages. 1.7.1 Evaluation Strategy The deliverables for the study were a) a synthesis summary report including results from the scoping literature review and policy analysis; b) a KT discussion session to share results of phases 1 and 2 with women with lived experience of IPV and key contributors to co-develop recommendations for action; and c) three manuscripts for publication on the results from each of the phases – scoping review (currently under review), policy analysis, and KT discussion session. 1.8 Quality and Rigour Quality and rigour criteria were guided by Tracy’s (2010) eight “big tent” criteria for excellent qualitative research, which are worthy topic, rich rigour, sincerity, credibility, resonance, significant contribution, ethical, and meaningful coherence. The criteria and an overview of the strategies used to satisfy them are described in Table 2. 1.9 Positionality and Reflexivity “By acknowledging researchers’ own embodiment and situatedness in the research project per se, the researcher’s own positionality in terms of background and potential privilege (or disadvantage) is clarified and can more easily be taken into account” (Clarke, 2015, p. 21). Sultana (2007) emphasizes the relevance of identifying power relations in research, as such, being aware of my own position in the research was central to facilitate my ethical responsibilities. Although my experience with feminist research per se has been limited, my work and research has focused on improving health services to populations in disadvantaged positions (e.g., people living with HIV, people with tuberculosis) who 19 Table 2 Strategies to Satisfy Quality and Rigour Criteria* Description* Considerations Applicable from this Study Worthy topic The topic of the research is relevant, timely, significant and interesting • Aligned with initiatives focused on bridging health inequity gaps by tackling root causes: The Sustainable Development Goals Report (United Nations, 2017); Integrating Equity, Gender, Human Rights and Social Determinants into the Work of WHO: Roadmap for Action, 2014–2019 (WHO, 2015) • Built on national research to advance health equity work such as Key Health Inequalities in Canada, A National Portrait (Public Health Agency of Canada, 2018), What are Social Determinants of Health? (Canadian Public Health Association, 2020), and work of the National Collaborating Centre for Determinants of Health (National Collaborating Centre for Determinants of Health, 2022) • Supported initiatives towards eliminating any type of violence against women: RESPECT Women: Preventing Violence Against Women (WHO, 2019), Health Equity (WHO, 2019a), Caring for Women Subjected to Violence: A WHO Curriculum for Training Health-care Providers (WHO, 2021a) • Helped to address SGBV in Canada and locally: It’s Time, Canada’s Strategy to Prevent and Address Gender-Based Violence (2018–2019) (Women and Gender Equality Canada, 2020). Rich rigour The study uses enough, abundant, appropriate, and complex theoretical constructs, data, sample, context, collection and analysis processes • Based on diverse theoretical, methodological, and analytical foundations • Explored international and national evidence from broad and rich body of literature to obtain detailed information • Used the theoretical frameworks that underpinned and complemented each for each of the phases • Had methodological approaches offering solid foundations to data collection and analysis, including specific methods for data gathering • Considered collaborative strategies to facilitate involvement and enhance respect, ethics, understanding, and empowerment among the research population Sincerity The study is characterized by self-reflexivity about values, biases, and inclinations of the researcher and transparency about the methods and challenges • Had an iterative design that facilitated a continuous process of critical analysis and reflection on the practice of health system integration and equity-based services • Approached each phase with specific methodologies and procedures, which built upon rigour • Presented overall limitations in the discussion section (see Chapter 6 of this dissertation) • Emphasized self-reflexive procedures as part of the process of inquiry • Stressed the relevance of using self-position to recognize, understand, and embrace inclinations towards the phenomenon 20 Criteria* Description* Considerations Applicable from this Study Credibility The research is marked by solid description, concrete detail, explication of tacit knowledge, and showing rather than telling; triangulation, multivocality and member reflections • Managed and processed results through exhaustive readings and descriptions, drawing on direct quotes, and agreeing upon interpretations • Paid attention to a critical and analytical thinking process, including in-depth reflection • Conducted the development of literature reviews, including a detailed selection of databases and a comprehensive search strategy • Explored member reflection through questioning the doubts and certainties encountered Resonance The research influences either particular readers or a variety of audiences through aesthetic, evocative representation, naturalistic generalizations, transferable findings • Managed critical analysis towards interpretation and exploration of alternative solutions and conclusions • Considered attention to a clear message with presentation of ideas in ways that call to action, interest, and encouragement • Used academic prose for the presentation of results; however, the use of diagrams complemented the presentation of key results (Chapters 3 to 6) Significant contribution The research provides a significant contribution conceptually, practically, morally, methodologically, heuristically • Focused on understanding the relationships between root causes of health inequities and marginalization and IPV • Conducted each phase to evolve separately but an iterative design strengthened the analytical processes and presentation of results • Included implications for research and practice, as well as policy action and education • Supported evidence and practices for researchers and front-line providers interested in advancing health equity • Used specific concepts and strategies for engagement and collaboration with participants towards social change Ethical The research considers procedural ethics, situational and culturally specific ethics, relational ethics, exiting ethics • Reviewed by two research ethics boards (Interior Health and UBC Behavioural Research Ethics Board) • Kept discussions of results and limitations among the research team members to address ethical reflections such as trustworthiness and credibility • Used relational ethics (Doane & Varcoe, 2007) throughout the study (Chapter 5) Meaningful coherence The study achieves what it purports to be about using methods and procedures that fit its stated goals, meaningfully interconnects literature, research questions, findings, and interpretations with each other • Used theoretical frameworks, methodological approaches, data gathering procedures, and analytical processes characterized by harmonization and congruence • Combined the processes of understanding, engaging, analyzing, and synthesizing results throughout the study *Adapted from Tracy (2010, p. 840) 21 experience health inequities. By using feminist approaches and collaborative engagement strategies, health and social research, including this study, will facilitate skills to speak up and out against structural and systemic inequities (Banner et al., 2019; England, 1994). Feminist and intersectional analyses share foundations related to social science applications, enabling me to explore in-depth my understanding of structural and power dynamics impacting health inequities for women who experience marginalization and IPV. Since I am a woman who experienced child-abuse, witnessed IPV against my mother and my stepmother, was raised within patriarchal roles, and experienced SGBV, the processes of self-construction/deconstruction and gradual ownership of my voice and agency have been challenging but enriching. Although the journey started before the beginning of my doctoral program, I positioned myself as engaging in social justice throughout my academic experience. The use of critical and equity-based lenses (e.g., intersectionality) increased my interest in health and social issues related to power imbalances and my commitment to limiting health and social inequities as a health and social researcher. The study of power structures, relationships, and their impact on hindering or facilitating health inequities (Hankivsky et al., 2010) facilitated my understanding of how the participants’ experiences resonated with my own experiences as a key process in analyzing data (Liong, 2015). According to Doane (2014), reflexivity encompasses attention to the reflection between both one’s thoughts, ideas, beliefs, and knowledge in relation to what we do (or do not do), and one’s responses in relationship to others. As such, I recognized that the data analysis was incomplete and required participation from others who also position themselves differently. My standpoint in relation to inequities, and in terms of my viewpoint as the insider-outsider, were recognized from the beginning of the study design and were also part of my committee members’ viewpoints. Since my professional development was carried out through historical, political, and social processes that now are part of my life as a researcher in another country, and as a racialized woman, the possible power relations that I found in this study may have stood out over the analysis of results and conclusions, including the visual representations (e.g., maps, images) (Sultana, 2007). Hoskins (2015) examined the complexity of research and the consequences of identifying ourselves as a researcher and a research participant at the same time, referring to the ideas of Maher 22 and Tetreault: “gender, race, class, and other aspects of our identities [as] markers of relational positions rather than essential qualities” (Hoskins, 2015, p. 400). I elaborated the analyses of this study based on power relationship, social injustice and inequities, and service improvement considerations. My lens and identity come from being a feminist woman, a health researcher, a migrant international student coming from a working middle class family, and a partner of a White Canadian man. As such, codes, concepts, and themes related to specific intersections (e.g., gender, ethnicity, economic status, patriarchal attitudes, power positions) were brought to the surface as I went through the transcripts. Through ongoing critical and analytical processes, including reflecting on my own positionality, I dove into interactive processes in keeping my identity, and managing my outlook as the insider-outsider. Data analysis and conclusions included processes of discomfort to work on the results due to limitations (e.g., post-traumatic stress disorder) and an encouraging piece to develop better understandings of the phenomenon (Koch & Harrington, 1998). Chapter 2 presents the results of a modified rapid review conducted to examine trends in evidence about health system integration and health equity for the delivery of services for women who experience IPV. The review provides evidence to set the stage for the scoping review (Phase 1) and policy analysis (Phase 2) of this dissertation. The review positions health system integration and equity-based services as important approaches that are relevant to improving the health experiences and outcomes of women who experience marginalization and IPV. 23 Chapter 2: Literature Review As discussed in Chapter 1, health and social service improvements based on health system integration and equity-based services have the potential to address women’s unmet health needs (O’Brien et al., 2017). However, there was a need to explore the international literature on women’s health and social care, particularly, policies and service delivery, and barriers and enablers to implementing integrated and equity-based services for women. A modified rapid review and synthesis pertaining to women experiencing marginalization and IPV, and health and social approaches to meet their needs was developed. The review was conducted as a foundation for this dissertation which sets the study nationally, provincially, and locally. In this chapter, results for the modified rapid review and synthesis are presented. 2.1 Methods The modified rapid review and synthesis were guided by the Rapid Review Guidebook: Steps for Conducting a Rapid Review (Dobbins, 2017) and the approach to conducting rapid syntheses by the McMaster Health Forum’s Rapid Response program (Wilson et al., 2014). Efforts were made to identify relevant evidence drawn from these steps and specific tools. 2.1.1 Define the Research Question for the Rapid Review and Synthesis The goal of the overall research for this dissertation was to investigate how to improve health equity for women who experience marginalization and IPV by improving health system integration. The specific research question for this rapid review was identified through readings and discussion on system integration, health equity, health inequities, women’s health needs, and the interest of the principal author. The research question guiding this review and synthesis was the following: What is the evidence of health system integration and health equity on health experiences and outcomes among women who experience IPV? A decision was made not to use “marginalization” in the research question, since health and social services may not operationalize specific approaches for social exclusion; yet, the search strategy conceptualized and operationalized marginalization in terms of groups of women historically socially excluded. To refine the research question, I used components from the PICO framework (Richardson et al., 1995) to clearly explore how system integration and health equity were designed and 24 implemented to meet the needs of women who experience IPV. The following components were identified: • Population of interest: women who experience IPV; • Intervention: health system integration and health equity; • Comparator: services not based on system integration nor health equity; and • Outcomes: impact on health experiences and health related outcomes. Since this dissertation used qualitative methodology to answer the overall research question (see Chapter 1), the Situation component was also considered: • Situation: IPV in the context of structures, policies, and practices in health and social services. 2.1.2 Search for Evidence The next step in the process involved a search for published literature. I used available evidence indexed in a specific search database (Medline), online resources for evidence-based practices, and grey literature. The Rapid Review Guidebook: Steps for Conducting a Rapid Review (Dobbins, 2017) was used to develop a comprehensive and systematic review of the literature, and multiple search strategies covering a combination of vocabulary and keywords based on the specifications for explicit electronic databases/sources were conducted. I followed the “6S Pyramid of Evidence” (Dobbins, 2017) tool to identify relevant and high-quality public health evidence (see Appendix A). The pyramid uses a hierarchical search approach, which puts the most synthesized evidence at the top of the pyramid (systems) and the least synthesized evidence (single studies) at the bottom. The pyramid starts with systems (the ideal source of evidence for clinical decision-making), then moves down to summaries (guidelines that integrate information about specific clinical problems), synopses of syntheses (summarize the information found in systematic reviews), syntheses (usually a systematic review that is a comprehensive summary of all the evidence surrounding specific issue), synopses of single studies (summarize evidence from high-quality studies), and single studies (single research conducted to answer specific questions). This approach to searching for evidence aligns with the Rapid Synthesis approach (McMaster University, 2018) where, when applicable, a rapid synthesis “summarizes research evidence drawn from 25 systematic reviews of the research literature and occasionally from single research studies” (p. 7). Since each level of the 6S Pyramid has specific tools, including specific databases (e.g., Best Practice Guidelines) and online libraries (e.g., Cochrane Centre) to search for evidence, this step included multiple searches where language used covered a combination of vocabulary and keywords to match the specific search engine for each source covering the key concepts of the study. Specific search terms covered both the subjects or main concepts (e.g., system integration, health equity), and the applicable Medical Subjects Headings (MeSH). Appendix B shows the main concepts used for the overall search strategy. Other filters such as year of publication (2015 – 2020) and language (e.g., English) were applied to further refine the searches. The tracking sheet for these searches appears in Appendix C. For the purpose of this review, system integration referred to the “tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care” (Valentijn et al., 2013, p. 4). Health system integration was identified as a process to improve healthcare performance that benefits systems, programs, practices, communities, patients, and providers (Armitage et al., 2009). Also, health equality was considered as the absence of differences in health or in the distribution of health determinants among individuals, groups, or populations (Arcaya et al., 2015; Northwestern Health Unit, 2020). 2.1.3 Appraisal of the Evidence Inclusion/Exclusion Criteria: To be included in the review and synthesis, documents had to be a) systematic reviews and documents in higher levels of the pyramid (e.g., synopses of synthesis), documents (e.g., summaries, synopses of synthesis, synthesis, synopsis of single studies) that rigorously synthesized findings about the effectiveness of specific health and social interventions, or single studies that presented tailored and detailed health and social approaches for IPV; b) published in English; c) published from 2015 to 2020; d) focused on the delivery of services for IPV; e) considered the impact of services on health outcomes and experiences; and f) applicable only to women. Exclusion criteria were a) focus children/youth and b) Canadian literature. The last exclusion criterion was considered to avoid potential duplication with Phase 1 of this study (Scoping Review) which focused on Canadian literature only. 26 Retrieving and Assessing Evidence: The literature search was performed between August and November 2020. Records were considered following the process outlined below. Identification: The “Search for Evidence” (section 2.1.2 above) outlines this information. Appendix C shows the specific search strategy for each database, as well as the links for the records. Appendix D presents the sources considered and the number of results. Since www.health-evidence.ca is an online free searchable database populated through seven electronic databases (Medline, EMBASE, CINAHL, PsycINFO, Sociological Abstracts, BIOSIS, SportDiscus) and collections containing quality-appraised literature, it was primarily used to ensure a comprehensive search of the literature where specific libraries (e.g., https://rnao.ca/bpg/guidelines) were searched. After a search of evidence, 69 documents were found. Two records were duplicates (determined manually) and were eliminated. Screening and Assessment: Records were screened using the title and abstract, and excluded if they were not relevant or did not meet the selection criteria. All records were screened by myself using an ExcelTM table to classify records as: Yes (Y) and No (N). Only records identified as “Yes” were evaluated for relevance. Relevance was identified as per whether items met the inclusion criteria, answered the research question, and were pertinent to support this rapid review and synthesis. Selection: Documents retained through all steps were included. Given that rapid reviews are used to “synthesize findings and assess the validity of research evidence using ‘abbreviated’ systematic review methods, modifying these methods to generate evidence in a short time” (Tricco et al., 2017, p. 6), these types of reviews tend to favour highly appraised documents (e.g., documents in higher levels of the pyramid) and evaluations of the effectiveness of specific interventions. As such, a purposive and intentional selection of documents was used to include studies using the pyramid as a quality assessment process. Figure 2 shows the research strategy decision tree (PRISMA) flowchart. 2.1.4 Synthesis of the Evidence Data were extracted into an ExcelTM spreadsheet using the Rapid Synthesis approach (McMaster University, 2018). This approach summarizes relevant and high-quality research and public health evidence from higher levels and occasionally from single research studies. Given the goal of this rapid review and synthesis to set the rationale for this study, an iterative combined process to synthesizing and presenting the evidence was used. For systematic reviews and documents in higher levels of the pyramid, data such 27 Figure 2 Decision Tree (PRISMA) Adapted from Dobbins, 2017 as the effectiveness of specific interventions were prioritized, thoroughly reviewed, and extracted. For primary studies, key findings in relation to the research question were obtained. Since single studies provided detailed evidence but they are not appraised for rigour and quality, tailored information was extracted to support the rationale for the dissertation. Gaps, barriers, or facilitators were extracted when applicable. A synthesis of the results is presented in the next section. Overview of Search Process ( November, 2021) Potentially relevant articles (21) Relevance assessment of full document versions (20) Weak articles (0) Total relevant articles (11) Non - relevant articles (9) Systems (0) Exclusion criteria #3 (Canadian, 6) Exclusion criteria #1 (Not in English, 2) Exclusion criteria #2 (Not from 2015 onwards, 1) Quality assessment of relevant articles (11) Strong articles (3) Moderate articles (8) Primary relevance assessment (67) Removal of duplicates Non - relevant (based on title and abstract screening) (46) Duplicates (2) Summaries (guidelines) (2) Synopses of syntheses (1) Synopses of single studies (0) Syntheses (systematic reviews) (3) Single studies ( 63) MEDLINE Total identified articles ( 69) Identifi cation Screening Eligibilit y Included 28 2.2 Results This rapid review and synthesis explored international literature on health and social approaches, and barriers and enablers to implementing integrated and equity-based services for women experiencing marginalization and IPV. The results from this review supported the rationale for this dissertation. Eleven studies met the inclusion criteria. An overview of the studies included is presented in Table 3. There were three systematic reviews: Hameed et al. (2020), Rivas et al. (2015), and Prosmanet al. (2015); and eight primary studies: Briones-Vozmediano et al. (2018), Danitz et al. (2019), Decker et al. (2018), Iverson et al. (2016), Miller et al. (2015), Phares et al. (2019), Poleshuck et al. (2018), and Pongthippat et al. (2018). Measures Studied: Primary and secondary health outcomes were measured in the studies reviewed. Mental health issues such as depression or anxiety, self-efficacy score, and dropouts from treatment were studied as primary outcomes. Secondary outcomes evaluated included general mental health symptoms; anxiety; posttraumatic stress disorder (PTSD); quality of life; re-exposure to IPV (including safety planning, self-care activities, or both); use of healthcare and IPV services; and social support. The form of abuse, quality of life, depression, and anxiety or psychological distress were also Table 3 Overview of Selected Records Characteristic Primary studies Systematic reviews Country of origin • Spain (n=1) (Briones-Vozmediano et al., 2018) • Sweden (n=1) (Pongthippat et al., 2018) • USA (n=6) (Danitz et al., 2019; Decker et al., 2018; Iverson et al., 2016; Miller et al., 2015; Phares et al., 2019; Poleshuck et al., 2018) • Not applicable Year of publication • 2019 (n=2) (Danitz et al., 2019; Phares et al., 2019) • 2018 (n=4) (Briones-Vozmediano et al., 2018; Decker et al., 2018; Poleshuck et al., 2018; Pongthippat et al., 2018) • 2016 (n=1) (Iverson et al., 2016) • 2015 (n=1) (Miller et al., 2015) • 2020 (n=1) (Hameed et al. (2020 • 2015 (n=2) (Rivas et al., 2015; Prosman et al., 2015) Study design • Qualitative (n=5) o Interview (n=3) (Briones-Vozmediano et al., 2018; Danitz et al., 2019; Pongthippat et al., 2018) o Focus groups (n=1) (Poleshuck et al., 2018) o Retrospective review of medical records (n=1) (Iverson et al., 2016) • Theoretical (n=3) (Decker et al., 2018; Miller et al., 2015; Phares et al., 2019) • Systematic review 29 studied. Physical, sexual, emotional abuse, and other types of abuse such as risk of homicide were measured as well. An in-depth analysis of the studies allowed me to identify key components to provide a foundation for this dissertation and answer the research question. Types of health and social interventions for women who experience IPV, women’s health needs and perceptions of services, providers’ perspectives on services, and understanding IPV are key components in developing integrated and equity-based services. Also, barriers, facilitators, and gaps to meeting the needs of women who experience IPV are presented. 2.2.1 Types of Health and Social Interventions for Women who Experience IPV Three types of health and social care interventions to meet the needs of women who experience IPV were identified: psychological, advocacy, and home visiting interventions. Hameed et al. (2020) assessed the effectiveness of psychological therapies for women who experience IPV in 33 trials, including randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, and cross-over trials of psychological therapies. Psychological therapies were defined as “a wide range of interventions that target cognition, motivation and behaviour aimed at alleviating distress or impairment” (p. 9). Rivas et al. (2015) identified and evaluated advocacy interventions to reduce or eliminate IPV in 13 trials. The authors included RCTs or quasi-RCTs comparing advocacy interventions for women who experience IPV versus no intervention or usual care. Usual care was defined as “[…] such care only includes a minimal element of advocacy […] if more substantive advocacy is offered, then less than 20% of women in the control arm received such care” (p. 12). Prosman et al. (2015) assessed six RCTs investigating home visiting interventions for women and children exposed to IPV that explicitly measured IPV as an outcome. The control groups received usual care, which was not defined. Three approaches for home visiting interventions for women and/or their children were identified: 1) support for women on how to manage IPV; 2) focus on reducing child abuse but not paying attention to reducing or eliminating IPV; and 3) support for pregnant women with an emphasis on child abuse with a secondary goal of decreasing IPV. Effectiveness of Health and Social Care Interventions: For women who experience IPV, psychological therapies may have reduced depression and anxiety symptoms; however, there was no evidence that psychological therapies improved secondary outcomes (Hameed et al., 2020). Regarding 30 advocacy interventions, while intensive and short-term advocacy may have improved women’s lives in specific settings (e.g., shelters) and reduced physical violence up to two years post intervention, there was no clear evidence that intensive advocacy impacted women’s mental health or that it would have changed diverse types of violence. Evidence is not conclusive about the effectiveness of brief advocacy interventions (mostly given in healthcare settings). They may have an impact on women experiencing less severe abuse and for pregnant women in that they provide short-term mental health benefits (Rivas et al., 2015). Home visiting interventions were reported to be effective in reducing IPV in the short term, but it was unknown if these results would be effective in the long term (Prosman et al., 2015). Table 4 presents key outcomes identified for each systematic review. 2.2.2 Women’s Health Needs and Perceptions of Services Three primary studies mainly reported on women’s health experiences and perceptions related to health and social services for women who experience IPV: Iverson et al. (2016), Poleshuck et al. (2018), and Pongthippat et al. (2018). Iverson et al. (2016) identified women’s priorities for counselling and service delivery preferences. Those priorities for counselling included learning how to handle crises (76.6%); focusing on steps women could take if they would like to end the relationship (74%); or dealing with overwhelming emotions (70.3%). Women’s preferences for service delivery included individual counselling (78.8%), group counselling (39.5%), or counselling as a couple (38.7%). Also, 61.3% rated web-based resources as desirable, and 75% indicated having free counselling available would increase their likelihood of seeking counselling. Poleshuck et al. (2018) identified women’s and providers’ perceptions in relation to informing and developing an IPV intervention. A community advisory board (CAB) formed by women and contributors argued for a shift in interventions aimed at addressing IPV. Women explained that “existing IPV resources tend to ignore the health concerns of survivors” (Poleshuck et al., 2018, p. 2717). Women recognized that the current medical model did not consider how IPV impacted the way they experienced their struggle. Providers need to consider women’s preferences and understand that non-traditional options are important to women. A proposed model by Poleshuck et al. (2018) highlighted the relevance of providing integrated support for psychosocial concerns in three main aspects: a) education for all, including survivors, providers, and the community in general; b) consultation services for providers or 31 Table 4 Key Outcomes and Impact of Interventions from Systematic Reviews Source Primary outcomes Secondary Outcomes Hameed et al., 2020 • Showed a probable beneficial effect of psychological therapies in reducing depression measured as a continuous outcome in four trials o Moderate-certainty or moderate-quality evidence (GRADE Scale by Guyatt et al., 2008) • Reported no evidence of a difference between groups for self-efficacy in one trial o Low-certainty evidence • Measured harm outcomes using a validated scale only in one trial • Showed psychological therapies may reduce anxiety symptoms in four trials; anxiety was measured only at short-term follow-up o Low-certainty evidence • Showed not enough evidence within medium-term follow-up interventions among groups for the following outcomes: o Post-traumatic stress disorder o Quality of life o Re-exposure to IPV Rivas et al., 2015 Physical abuse: • Showed no short-term effect of advocacy at 12 months follow-up in three studies o Moderate-quality evidence Emotional abuse: • Showed statistically significant reduction in emotional abuse at 16 to 34 weeks after a brief session of advocacy in one study o Moderate quality evidence Harassment at work: • Reported a statistically significant effect at 24 months in one study Quality of life: • Reported significant improvements in women’s physical quality of life only immediately postintervention in intensive advocacy interventions by mentor mothers Depression and anxiety/psychological distress: • Showed no evidence that intensive advocacy reduces depression in a meta-analysis of three trials Death: • Reported two deaths of participants Chronic health disorders: • Showed no evidence that women who received advocacy reported less chronic pain Post-traumatic stress: • Showed no evidence in reduction in levels of PTSD in two trials • Reported no evidence of higher levels of self-efficacy in receiving advocacy at 12-month, two-year, and three-year follow-ups Perceived social support: • Reported no evidence to suggest that intensive advocacy had a positive effect on social support in less than 12 months Independence from abuser: • Reported no evidence of statistically significant positive effect in the short-term Prosman et al., 2015 • Reported no significant reduction of physical and psychological abuse • Found that a program delivered over 2 years by nurses showed less IPV during the 6-month interval before the 4-year interview • Reported that home visits over a 3-year period showed significantly lower rates of physical abuse only after 3 years of follow-up • Reported prevalence of physical IPV significantly lower amongst women in the intervention group at 2 years after the birth of the first child women in the form of an interdisciplinary team, as well as legal, social, and mental health specialists; and c) accessible, women-centred clinics that provide trauma-informed care. 32 Pongthippat et al. (2018) presented the experiences of IPV of Thai immigrant women who had lived in Sweden for more than 5 years and who reported psychological, physical, economic and/or sexual violence. A theme identified related to how women should behave to be recognized as a reliable wife, for example, being faithful and silent. Another theme revealed women’s fears and concerns of being replaced and losing dignity. Women described their IPV experiences, including how the combination of IPV with their partner’s drugs and alcohol abuse made their life hard. Since some marriages ended in divorce or break-up, these women felt stressed and lost their connection to Swedish society and “reported feeling stripped of their human dignity with no respect for their legal rights or any clear means of protecting their human rights or individual well-being” (Pongthippat et al., 2018, p. 5). 2.2.3 Providers’ Perspectives on Services Two studies elaborated on providers’ perceptions, attitudes, and beliefs on meeting the needs of women who experience IPV. Briones-Vozmediano et al. (2018) and Danitz et al. (2019) interviewed contributors in charge of the delivery of services. Briones-Vozmediano et al. (2018) found that providers recognized a dilemma about complying, or not complying, with legal services when a woman affected by IPV may not have agreed to report the issues. Providers recognized the relevance of an integrated and multisectoral response to IPV; however, they argued that the involvement of multiple social sectors makes it hard to solve and stop violence because there are diverse sectors trying to align efforts. IPV was perceived by providers as a gender issue, as a women’s issue, where providers (mainly men) had resistance in responding to IPV. Since the same providers were usually responsible for the women’s healthcare as well as that of her relatives, including the potential perpetrator, women did not find the support they needed. Danitz et al. (2019) presented providers’ perspectives on an intervention called Recovering from IPV through Strength and Empowerment (RISE). The results were presented in three main categories: acceptability and appropriateness, relative advantage and facilitating factors, and barriers. Providers liked the modular style, and found the content was manageable and the format was flexible. Providers also pointed out that the “non-judgmental and empowering stance” (Danitz et al., 2019, p. 5) was appropriate to meet the needs of women. Providers perceived that the intervention manual would support those who have less experience addressing IPV. Recommended settings for RISE implementation included 33 integrated women’s health primary care clinics and settings where professionals who have less experience addressing IPV were typically embedded within the clinic. 2.2.4 Understanding IPV to Develop Integrated and Equity-Based Services Three primary articles (Decker et al., 2018; Miller et al., 2015; Phares et al., 2018) outlined comprehensive frameworks to understand and address IPV (see Table 5). Decker et al. (2018) presented a public health approach to analyze the impact of individual, interpersonal, community, and structural aspects of IPV. There were three main aspects for a comprehensive response: a) using primary and secondary prevention of violence, b) identifying and supporting survivors to mitigate the impact (e.g., secondary, tertiary prevention), and c) facilitating equitable and accessible justice processes to hold offenders accountable. Miller et al. (2015) presented a system-based approach to the implementation of IPV screening and counselling by using the Kaiser Permanente Model in the US. To address IPV, the involvement of women, providers, health system leaders, and policy-decision makers was required, and organizations should enhance actions to support and connect patients to services. Phares et al. (2018) presented a position statement on IPV for the US health system, including domestic violence laws, screening recommendations, and barriers. Table 6 shows an overview of key information from both types of studies included, systematic reviews and primary studies. Table 5 Comprehensive and System-Level Approaches to IPV Source Insights Decker et al., 2018 • A broader understanding of violence should consider policies and social norms affecting conditions impacting violence such as alcohol-related or firearm policies • Trauma-informed care was identified as an ideal approach to help survivors develop skills towards self-control and empowerment • An integrated public health approach to IPV should seek to impact the policy and normative levels as much as individual behaviour levels Miller et al., 2015 • An effective approach to IPV should consider the social structures of IPV • A combination of clinician training, a strong electronic health records system, and integrated care (e.g., including referrals, screening) makes an intervention feasible • Assessment for IPV should consider prompts in the health records where providers can offer women information about IPV-related services Phares et al., 2018 • Screening for IPV is not as effective as system-based interventions • Structural interventions should consider specific processes and actions. For example, IPV interventions should include “danger assessment, safety planning, prevention options; referral to violence intervention programs, social services, or behavioral health professionals; and compliance with reporting laws” (p. 864) 34 Table 6 Key Highlights per Study (Systematic Reviews and Primary Studies) Source Methodological Approach of the Intervention or Study Key Findings Briones-Vozmediano et al., 2018 • Conducted 26 interviews: o 23 interviews with providers from 17 regions o 3 interviews with national representatives • Included participants’ backgrounds: medical doctors (14), nurses (4), psychologists (2), midwives (2), anthropologist (1), social worker (1), sociologist (1), and pharmacist (1) • Identified diverse responses to IPV integration • Identified providers’ lack of training and understandings of complex nonbiomedical problems such as IPV • Identified providers’ attitudes depend on their motivations and organizational factors (e.g., cultural changes) • Identified resistance to deliver care among male providers Danitz et al., 2019 • Presented providers’ perspectives on an intervention called RISE (Recovering from IPV through Strength and Empowerment) • Conducted semi-structured telephone interviews with 23 Veterans Health Administration (VHA) providers • Included two centers in the New England region of the US (VA Boston Healthcare System and the VA Connecticut Health care System) • Found the components of the intervention appropriate to the unique needs of women experiencing IPV • Recognized what types of providers and clinical contexts would be best suited to facilitate the delivery of RISE • Identified providers with training in mental health and psychosocial health issues (e.g., psychologists, social workers, marriage and family therapists, case managers, peer specialists) suited to deliver care though RISE Hameed et al., 2020 • Assessed psychological interventions • Studied a total of 5517 women 16 years and over • Included techniques such as patient-centred care and active listening, motivational interviewing, psychoeducation, cognitive restructuring, social-skills building, problem-solving techniques for validating women’s experiences and feelings, and relaxation • Delivered by people who received training • Implemented one to 20 sessions for at least 30 minutes • Classified follow-ups as short-term (up to 6 months), medium-term (from 6 to under 12 months), and long-term (12 months or more) • Included 33 trials, including 11 integrative therapies, 9 humanistic therapies, 6 cognitive behavioural therapy, 4 third-wave cognitive behavioural therapies and 3 other psychologically orientated interventions • Recruited women from healthcare, community, shelter or refuge settings, or a combination of any or all of these • Over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past 2 years (2 trials) and 42% during their lifetime (14 trials) • Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (2 to 50 sessions) and staff delivering therapies 35 Source Methodological Approach of the Intervention or Study Key Findings Iverson et al., 2016 • Administered a web-based survey to a national sample of United States (US) women veterans • Contacted 548 women, and 411 women participated • Delivered a survey that lasted 30 minutes and was anonymous • Asked women to complete questions regarding their preferences for IPV and health service delivery • Identified priorities for the content of IPV-related counselling and service delivery • Identified that 55% women (n=226) reported lifetime IPV • Found women’s priorities for general counselling such as women’s physical safety and children and pets’ safety • Identified that women’s preferences for specific counselling focused on addressing symptoms of depression and anxiety and learning about the effects of IPV on women’s and children's emotional health • Identified women’s preferences for health service delivery such as preference for individual compared to group or couple counselling Miller et al., 2015 • Outlined a systems approach to the implementation of IPV screening and counseling • Focused on integrated health and advocacy service delivery • Used of electronic health records tools and partnerships • Identified research to improve the uptake and implementation of IPV screening and counseling procedures • Recommended to ensure training on person- centred, and confidential IPV assessment regardless of disclosure • Supported the development and implementation of electronic health records prompts (e.g., alerts, progress notes templates) for IPV to guide clinical care • Provided clinicians with best guidelines, decision support tools, and resources when IPV is disclosed • Integrated “IPV identification and intervention into quality-improvement efforts with data tracking (such as frequency of screening and brief counseling) and feedback on performance (such as patient satisfaction with the clinical encounter and connections made to victim advocacy services)” (p.97) Poleshuck et al., 2018 • Informed the content, design, and characteristics of a two-phase IPV intervention • 1st phase involved five focus groups with 31 women victims and survivors of IPV who were not experiencing current IPV or living with their former perpetrator • 2nd phase included the development of the intervention with participation of a community advisory board (CAB) formed with 5 women and other providers, directors, coordinators, and researchers • Proposed an integrated and comprehensive approach to address victim and provider needs by using one-on-one care, education, as well as interdisciplinary case management • Implemented teams comprising law enforcement, advocates, and prosecutors to create safety plans that include perpetrator detention and electronic monitoring • Highlighted that funding sources, such as “the health-oriented Patient Centred Outcomes insist patients be at the table as an equal partner sharing in the research agenda from conceptualization, to design and implementation” (p. 2718) 36 Source Methodological Approach of the Intervention or Study Key Findings Pongthippat et al., 2018 • Conducted 40 interviews with women in 3 cities close to the capital of Sweden • Results came from 18 interviews due to data saturation • Included women if they were a) born in Thailand and self-identified as Thai, b) lived in Sweden for at least 5 years, and c) were currently or previously married to a native-born Swedish man • Identified women’s response to IPV included acting loyal and silent • Recognized that immigrant women faced vulnerability that needs to be acknowledged by health and social organizations • Stated that home-based health check-ups are needed to stop violence and abuse of immigrant wives • Showed a need for education about the unrecognised negative conditions of immigrant wives Prosman et al., 2015 • Assessed home visiting interventions • Did not specify how many women were included • Lasted 12-months, two years or over, and at least three years • No specifications regarding the duration, or the type of support provided for follow-ups • Delivered by nurses or mentor mothers • Included 19 trials, including 6 different home visiting studies • Identified 3 different types of studies • Recognized that in one study the primary focus was abused mothers and the secondary focus was the children • Identified 2 studies with a primarily focus on reduction of child abuse and a secondary focus on IPV • Found that home visiting interventions supporting abused women seemed to be effective in reducing IPV in the short term Rivas et al., 2015 • Studied advocacy interventions • Studied a total of 2141 women aged 15 to 65 years • Encompassed activities that provided legal, housing, and financial assistance to facilitate access to resources, or provide ongoing support and informal counselling • Based on “the concept of empowerment and included education, advice on safety and accessing resources, and empathic support” (p. 20) • Lasted from 30 minutes to 80 hours • Classified as brief (less than 12 hours) or intensive (12 or more hours) • Delivered by advocates, nurses, social workers, psychologists, and trained students • Included 13 trials • Identified heterogeneity in terms of methodology, study processes and design, including the duration of follow-up (postintervention to 3 years) • Recognized benefits from advocacy interventions, however, most studies had low level of evidence • Identified ambiguity about the magnitude of benefit, the impact of abuse severity, and the setting where the interventions were implemented • Found that intensive advocacy interventions may improve short-term quality of life and reduced physical abuse from 1 to 2 years after the intervention • Recognized that brief advocacy may provide small short-term mental health benefits and reduce abuse 37 2.2.5 Facilitators and Barriers Table 7 shows facilitators and barriers from the eight primary studies to better deliver services for women who experience IPV. Although not all these aspects were clearly stated by the primary authors, they were appropriate as facilitators and barriers. Facilitators included having a broad understanding of Table 7 Facilitators and Barriers to Build Services for Women who Experience IPV Source Facilitators Barriers Briones-Vozmediano et al., 2018 • Approaches based on person-centred care facilitated the integration of responses to IPV • Health systems need to enable structures, processes, and procedures to facilitate providers’ response to IPV • Lack of training and time constraints • Providers’ professional autonomy to refuse to deliver services due to personal beliefs Danitz et al., 2019 • “RISE may help to facilitate provider comfort […] addressing IPV in a more comprehensive manner through delivering RISE or referring a female patient to RISE” (p. 7) • Provider discomfort related to work with IPV and trauma issues • Limited time and resources to deliver the intervention in a busy clinical setting Decker et al., 2018 • Interventions must be evaluated • Justice systems as first responders have determinant role to ensure victims receive services • The justice response has minimized violence and sustained re-traumatization • Lack of collaboration among services Miller et al., 2015 • Increase coordination and integration of services prioritizing privacy, confidentiality, and safety • Ensure collaborations with victim-service advocates • Limited implementation of procedures to conducting screening • Lack of knowledge about how to support women who disclose IPV Phares et al., 2018 • Services for women should be implemented across sectors • Standardized methodologies for screening, identification, diagnosis, intervention, and documentation of IPV • Lack of specific training for providers in charge of the delivery of care • Attitudes and perception of healthcare providers • Specific screening and management models of perpetrators of IPV Iverson et al., 2016 • Incorporate a warm- handoff approach where the provider would introduce the woman to a specific IPV-trained provider to whom she is being referred (if it is approved by the woman) • Limit women to participate in specific aspects of counselling interventions and in general in their own health decision-making process Poleshuck et al., 2018 • A woman-centred and integrated clinic for IPV survivors should meet physical and mental health concerns • Providers need to implement safety and accessibility actions • “Existing IPV services often neglect addressing health concerns” (p. 2707) • Limited evidence-based interventions for IPV sensitive care Pongthippat et al., 2018 • “Home-based health check-ups are needed to stop the exploitation of imported wives” (p.8) • Depending on cultural aspects, specific strategies are needed to support immigrant women 38 IPV that considers social implications of violence, as well as broader understandings of women’s multiple needs. A women-centred care approach can support women’s physical and mental health. A key barrier, the lack of understanding of the multiple needs and interactions of women’s realities, limited providers in addressing women’s concerns. 2.2.6 Gaps in Integrated and Equity-Based Services The final analysis of the included documents allowed me to identify key gaps in meeting the needs of women who experience IPV. Structural barriers such as fragmentation of services and stigmatization are recognized as gaps in meeting women’s needs across studies. Moreover, the lack of sensitive and appropriate care approaches (e.g., trauma- and violence-informed care) limited organizations’ understanding of the complexity of women’s lives and the impact of the complexities on their health and wellbeing (see Table 8). 2.3 Summary The rapid review and synthesis presented evidence regarding how health and social services are addressing the health and social needs of women who experience IPV through health system integration and equity-based services in the past 5 years (excluding Canadian literature). The body of the literature is diverse. There were wide-ranging approaches from system-based frameworks (e.g., Decker et al., 2018; Miller et al., 2015), to a position statement (Phares et al., 2019), to systematic reviews of specific interventions (Hameed et al., 2020; Prosman et al., 2015; Rivas et al., 2015), and health and social research related to the experiences of women and providers when delivering care (Briones-Vozmediano et al., 2018; Danitz et al., 2019; Iverson et al., 2016; Poleshuck et al., 2018; Pongthippat et al., 2018). To explain the intersections of elements in IPV, authors have built frameworks and theoretical understandings of violence from a system-based perspective (Decker et al., 2018; Miller et al., 2015; Phares et al., 2019). A system-based approach facilitated the identification of IPV and SGBV from a structural and social perspective, including actions impacting violence. Although there are multiple considerations to explain IPV across the authors’ frameworks, there are common intersecting factors. The social determinants of violence influence individual determinants of violence (e.g., trauma, mental health issues), and even perpetration of violence (Decker et al., 2018). At the individual level, there are strategies to limit IPV based on health equity. These actions consider specific care approaches (e.g., 39 Table 8 Gaps to Addressing the Needs of Women who Experience IPV Gaps • Limited allocated budget, and lack of effective referral system • Weak and inconsistent health and social structures and/or procedures make providers’ progress dependent only on certain individuals (Briones-Vozmediano et al., 2018) • Healthcare system not recognizing IPV as a public health priority (Danitz et al., 2019) • Lack of knowledge from providers about the structural forms of violence that women experience (Miller et al., 2015) • Minimized violence and sustained re-traumatization by the justice response (Decker et al., 2018) • Barriers in electronic health records such as privacy restriction and lack of standardized terminology (Miller et al., 2015) • Lack of specific and sensitive training for providers at the point of care (Phares et al., 2018) • A “one-size-fits-all” approach for counselling may not meet women's specific IPV-related health needs (Iverson et al., 2016) • Fragmented and narrow health and social care approach (Poleshuck et al., 2018) • Lack of collaboration among health and social services, including education and criminal justice (Decker et al., 2018) • Lack of trust in the justice system by IPV victims has resulted from persistent barriers such as mistrust, concerns for minimization of violence, or victim blaming (Phares et al., 2018) • More equitable justice system processes, it is essential to hold offenders accountable for IPV (Decker et al., 2018) • Need for safer spaces within the delivery of services, “the clinical space transforms into a place to build connections to supports, services, and protection” (Miller et al., 2015, p. 96) trauma- and violence-informed) and recognize the impact of structural barriers on health. Trauma-informed care is an approach to support victims of violence to eventually build on personal and social skills to support coping and problem-solving. It works to reduce re-traumatization based on principles such as empathy, inclusion, respect, diversity, and a non-judgmental perspective (Elliott et al., 2005). A system-based approach aligns with public health models to address the complexity of delivering services, including a better understanding of the role of services on health status (Dixit & Sambasivan, 2020; Garcia-Moreno, Hegarty, et al., 2015). Also, system-level approaches highlight the relevance of aligning structures such as legislation and policies with the delivery of services to limit structural barriers. These structures (e.g., laws, policies, procedures) are planned and then implemented to support specific actions at multiple levels of health and social organizations to deliver equity-oriented services (Lavoie et al., 2018). Since the system-based frameworks proposed by authors (e.g., Miller et al., 2015) share multilevel and intersectional elements to measure the impact of systems of oppression or privilege on health (Hankivsky et al., 2014, 2017), and attempt to integrate comprehensive biological and 40 social considerations to support women’s decisions (Krieger, 2011; Garcia-Moreno, Hegarty, et al., 2015), these theoretical studies should be further analyzed. The studies included showed women and providers acknowledging the need to involve and collaborate with one another on the planning and delivery of health and social services to support women’s lives. Comprehensive health and social services need a personalized, one-on-one approach to meet the multiple needs of women (Poleshuck et al., 2018) and where women feel supported to make decisions for their own health. Since women survivors of IPV stated that services must include them as contributors to planning, services need to consider specific education programs for them. As part of these actions, women proposed a peer group where they would provide outreach and treatment engagement (Poleshuck et al., 2018). In terms of an equity-based perspective for health and social services, women’s participation in their own delivery of services is relevant to build capacity and specific resources for those who need them the most (Braveman et al., 2017). Women's preferences for counselling and health service delivery are diverse (Rivas et al., 2015), so having multiple, inclusive, diverse, and integrated services, including tailored health and social approaches to meet various needs, is well aligned with health system integration and equity-based services (Farmanova et al., 2019). Improving availability and acceptability of services on weekends and evenings, as specified by women themselves in Iverson et al. (2016), would make it possible to have an impact on health inequities. Women also included other priority needs such as offering physical safety, including for children, teaching skills to handle crises, and addressing symptoms of depression and anxiety (Iverson et al., 2016). There is a consensus for health and social services to deliver first responses to limit and end violence. Nevertheless, there is mixed evidence on how to intervene effectively. Services have focused on improving health status, addressing specific social needs such as legal assistance or housing provision, or supporting victims in crisis (Niolon et al., 2017). In some of the primary studies included for this rapid review and synthesis (e.g., Danitz et al., 2019; Hameed et al., 2020), a common underlying aspect of the developed improvements relied on conceptualizing and implementing empowerment-based strategies, including their potential impact on developing skills towards self-control, self-confidence, and agency for the decision-making processes. These characteristics could align with advocacy interventions since empowerment-based strategies aim to help develop skills towards personal-social and economic 41 empowerment (WHO & Pan American Health Organization, 2012). However, as presented, advocacy interventions and empowerment-based interventions such as counselling approaches (e.g., motivational interviewing, empowerment counselling strategies) still need further assessment. Danitz et al. (2019) presented examples of empowerment-based strategies, including providers’ perspectives of the RISE IPV intervention. Although RISE was well-accepted by providers to improve women’s psychosocial functioning, when compared to Hameed’s et al. (2020) systematic review, Hammed et al. reported no conclusive evidence on the effectiveness of psychological therapies. Psychological strategies may have reduced depression and anxiety symptoms in the short term, but it was not clear if these types of techniques (e.g., active listening, motivational interviewing, problem-solving) improved other outcomes such as self-efficacy, PTSD, or safety planning. Services need to measure the specific impact of empowerment and other behaviour change interventions, aiming to develop interpersonal and social skills but also consider comprehensive approaches that integrate women’s needs. According to Wojnicka et al. (2016), there is a need to homogenize and evaluate behaviour change interventions because they report either small effects or the effects are not significant to ending SGBV or IPV. Policy and service improvements should be assessed on aspects such as feasibility, acceptability, demand, potential implementation, integration of services, as concluded by Wuest et al. (2015). Evidence demonstrated that when the services are delivered by an accessible, women-centred clinic with a trauma- and violence-informed approach, women’s needs are met (O’Brien et al., 2017). Characteristics of these types of services include comprehensiveness, integration, continuity and quality, and inclusiveness of health and social care to meet the needs of women who experience IPV. Services need to be delivered within strategies involving a coordinated, collaborative, and integrated perspective (e.g., case management) where the supports address both physical and psychosocial concerns (Rivas et al., 2015). These types of strategies should also be equity-based, to help women recover and to limit further inequities (Ford-Gilboe et al., 2020). A collaborative approach would be a strong driver towards improving women’s lives, as health and social services recognize women’s insight and direction as part of the services (Rogers & Kelly, 2011). An essential consideration towards integrated and equity-based services to address IPV (Garcia-Moreno, Hegarty, et al., 2015; WHO, n.d.-b, 2017) considers education 42 or all, including community members, to challenge negative and violent behaviors, as stressed by Decker et al. (2018). 2.4 Remarks and Moving Forward As presented in this rapid review and synthesis, there is a body of diverse literature related to addressing the needs of women who experience IPV. We need multiple comprehensive health and social services to address the needs of women. Authors considered IPV as a complex public health issue; however, there is still a need to illuminate how to effectively improve services based on detailed considerations about health system integration and equity-based services. These services need to include innovative, integrated and multisectoral actions at different levels, and all of them need to be aligned within a system-based perspective that highlights legislation and policies. Still, it is relevant to clarify the involvement of justice systems to prevent and end SGBV and IPV. Additionally, a better understanding of the structural impact (positive and negative) of health and social services, including processes and procedures, on women’s health will illuminate specific policy actions needed. Also, the consideration of principles such as diversity, inclusiveness, non-stigma, and respect as core organizational cultural values to limit IPV, including decreasing re-traumatization, are needed. Since women’s health priorities vary, interventions should move beyond a one-size-fits-all approach. It is important to ensure healthcare providers have the capacity (e.g., knowledge, attitudes) to deliver effective services, but this is also needed to support and facilitate access to social services regardless of IPV disclosure. From a policy perspective, it is important to recognize that the delivery of services must involve women themselves. By studying this effect through women themselves, health and social services would align with inclusive principles of health equity research (e.g., social justice, inclusiveness) (Rogers & Kelly, 2011; Snow et al., 2018). This rapid review and synthesis was a foundation for this dissertation since it provides international context to set the study. Now there is a need to investigate the impact of health system integration to address women’s health needs and their impact on health equity in Canada. This dissertation illuminates how health system integration and equity-based policies and services have been designed and implemented in Canada (nationally, provincially, locally) to meet women’s health. 43 Chapter 3 presents details on Phase 1 (Scoping Review) for this dissertation. It includes specific methodological approaches, key results, and implications for policy and research. 44 Chapter 3. Scoping Review 3.1 Background As discussed in Chapter 1, health and social inequities are the expression of intentional or unintentional power imbalances rooted in the SDH, specifically, structures (Gkiouleka et al., 2018), and categories of difference such as positions (e.g., income) and identities (e.g., gender) (Braveman et al., 2017). Chapter 1 also showed that the experience of SGBV and IPV reflects an interaction among women’s multiple forms of vulnerability that results from gender inequities, social inequities, and the SDH. Further, the rapid review outlined in Chapter 2 demonstrated how international evidence has advanced the understanding and implementation of policy and service improvements related to care for women who experience IPV. Internationally, IPV against women is recognized as a public health issue (Garcia-Moreno, Zimmerman, et al., 2015; Hardesty & Ogolsky, 2020). As such, there was a need to investigate what and how health system integration and equity-based services have been designed and implemented to meet the health-related needs of women who experience marginalization and IPV in Canada. Researchers have used a wide range of approaches to study and make recommendations to address marginalization and IPV. Approaches include system-based theoretical frameworks, systematic reviews of interventions, and detailed healthcare research, among others. Often, health and social services have improved health outcomes by addressing specific needs such as legal assistance, housing provision, or support in crisis (Niolon et al., 2017). Many of these programs are focused on changing the behaviour of women. A key aspect of these interventions relies on implementing empowerment-based strategies, including their potential impact on developing skills towards self-control, self-confidence, and agency for decision-making processes (Niolon et al., 2017). However, researchers continue to investigate whether multiple approaches (e.g., behaviour change, empowerment-based) also improve outcomes such as self-efficacy, PTSD, or safety planning. In addition to providing support while discussing safety and reducing depressive symptoms (Garcia-Moreno, Hegarty, et al., 2015), IPV interventions need to address other needs related to justice or child-welfare systems. To address these multiple perspectives and improve wellbeing for women who experience IPV, researchers agree there is a requirement for integration and equity-based services (Briones-Vozmediano et al., 2018; O’Donnell et al., 2018). Initiatives based on system integration have addressed the needs of women experiencing marginalization 45 (Farmanova et al., 2019). For women who experience marginalization, services should consider the multiple needs related to the diversity of women’s realities. For example, in the case of women who experience marginalization and HIV, a client-centred model should address clinical level demands as well as macro-level barriers such as systemic stigma (O’Brien et al., 2017). In the case of refugee women experiencing marginalization and IPV, Greene et al. (2019) showed that a cross-sectoral integrated approach to mental health and IPV helped women decrease distress by improving social support and cognitive processing to deal with stressful situations. Further, engaging and involving women in health and decision-making processes have proven effective in addressing SGBV and social exclusion (Snow et al., 2018). The design of health and social services provides initial responses to limit and end violence, but research has shown that approaches to service delivery are fragmented, including being based on different understandings about women’s agency and resistance, and about violence (Herrera & Agoff, 2018). However, there is mixed evidence on how to effectively intervene towards greater health system integration. Since women who experience marginalization and IPV suffer structural barriers to health (e.g., stigma, social and economic disadvantage), features of health system integration and equity-based services have the potential to limit further health inequities. The purpose of this phase of the study was to conduct a scoping review to examine the Canadian literature on health system integration and health equity and how they are meeting the needs of women experiencing marginalization and IPV. The results are the focus of this chapter. For the scoping review, system integration referred to the “tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care” (Valentijn et al., 2013, p. 4). Health system integration was identified as a process to improve healthcare performance that benefits systems, programs, practices, communities, patients, and providers (Armitage et al., 2009). Finally, health equity was considered as the absence of systematic and avoidable obstacles in health between individuals and groups that impact the possibility of being as healthy as possible. Examples of barriers and obstacles include poverty or discrimination (Braveman et al., 2017). 46 3.2 Methods The review was guided by Levac et al.’s (2010) five procedural steps for scoping reviews: a) identifying the research question; b) identifying relevant studies; c) selecting study exclusion-inclusion criteria; d) charting the data; and e) collating, summarizing, and reporting results. 3.2.1 Identifying the Research Question The research question arose from a combination of previous work in system integration and health equity to address women’s health needs, and the interest of the principal author. The following research question was addressed by the scoping review: What does research to meet the health-related needs of women who experience marginalization and IPV in Canada tell us about health system integration and equity-based services for such women? 3.2.2 Identifying Relevant Studies The next step involved a systematic search for scholarly and peer-reviewed published literature indexed in Ovid Medline, EMBASE, and CINAHL databases. The search strategy used a combination of controlled vocabulary and keywords. To satisfy quality and rigour, terminology covered both the subjects or key concepts (e.g., system integration, health equity), and the applicable Medical Subjects Headings (MeSH). The search strategy was supported and reviewed by an expert librarian with scholarly publications in system integration. CINAHL headings were used in CINAHL and MeSH terms were used in Medline and EMBASE. Appendix B presents the conceptual search strategy, including the concepts and MeSH terms used to differentiate the international search (Chapter 2) from the Canadian (national) search emphasized in this chapter; and Appendix E shows an example of the search strategy used for the same database. The search strategy followed specific MeSH headings for women who experience marginalization, taken from a systematic review by Hollowell et al. (2011). 3.2.3 Selecting Study Inclusion-Exclusion Criteria To be included in the review, studies needed to focus on health system integration and health equity. Inclusion criteria were a) peer-reviewed journal articles; b) published in English; c) published at any time; d) reporting on studies conducted in Canada; e) focused on IPV and marginalization; f) studying health outcomes/experiences; g) discussing the impact of health or social services on health; and h) 47 considering only women. The literature search was performed in March 2021. Peer-reviewed records were considered following a four-step process: a) Article identification: Duplicates were excluded (determined electronically through RefWorks® citation management program). b) Article screening: Records were screened using the title and abstract and excluded if they were not relevant or did not meet the selection criteria. An ExcelTM table was used to classify records as: Yes (Y), No (N), and Possible (P). Since the search strategy yielded few records (see Figure 3), all were screened by the lead author. To further expand the search, for those papers meeting the selection criteria, the reference lists of included articles were reviewed, and articles were included when they met the inclusion criteria. c) Article assessment: Full-text records were evaluated for whether they met inclusion criteria. Relevance forms were used to collect information such as type of study and methodological design as well as reason for inclusion or exclusion. d) Articles selected: Papers retained through all steps were included in the scoping review. Figure 3 shows the research strategy decision tree (PRISMA) (Tricco et al., 2018). 3.2.4 Charting the Data Data were extracted into an ExcelTM spreadsheet. Information from articles was sorted based on the following classifications: author, geographic origin, purpose of the study, study design, research population, and key findings. Implications for research and policy action were included if specified. 3.2.5 Collating, Summarizing, and Reporting Results Two approaches were used to analyze data and report results. First, descriptive analysis was used to illustrate the extent, nature, and distribution of studies included. Second, thematic and content analyses were conducted to identify the context, content, constructs, and specific outcomes of the studies (Arksey & O’Malley, 2005). Through a broad-level inductive content analysis, preliminary themes were identified and coded for further analysis. They were then charted, in an iterative manner, based on their relationship to services and service integration. 48 Figure 3 Flow Diagram of Studies (PRISMA) Note: Adapted from: Tricco et al. (2018). 3.3 Results 3.3.1 Descriptive Analysis This review focused on health equity and health system integration of services for women experiencing marginalization and IPV in Canada. Eight studies met the inclusion criteria: Ford-Gilboe et al. (2015); Haag et al. (2019); Hovey and Scott (2019); Mantler and Wolfe (2017, 2018); Mantler et al. (2019); Torchalla et al. (2015); and Varcoe et al. (2019). Studies were mainly conducted in BC and Ontario. There was one study with participation from three provinces: BC, Ontario, and New Brunswick. An overview of the studies included can be found in Table 9. The studies were conducted in different demographic locations. Five were conducted in rural communities: Ford-Gilboe et al. (2015); Hovey and Scott (2019); Mantler and Wolfe (2017, 2018); and Mantler et al., (2019). One was conducted in an urban centre (Torchalla et al., 2015). A study by Varcoe 49 Table 9 Overview of Selected Records Characteristic Output Province of origin • Ontario (n=5) (Haag et al., 2019; Hovey & Scott, 2019; Mantler & Wolfe, 2017, 2018; Mantler et al., 2019) • British Columbia (n=2) (Torchalla et al., 2015; Varcoe et al., 2019) • British Columbia, Ontario, and New Brunswick (n=1) (Ford-Gilboe et al., 2015) Year of publication • 2019 (n=4) (Haag et al., 2019; Hovey & Scott, 2019; Mantler et al., 2019; Varcoe et al., 2019) • 2018 (n=1) (Mantler & Wolfe, 2018) • 2017 (n=1) (Mantler & Wolfe, 2017) • 2015 (n=2) (Ford-Gilboe et al., 2015; Torchalla et al., 2015) Study design • Qualitative (7) o Interview (n=4) (Mantler & Wolfe, 2017, 2018; Torchalla et al., 2015; Hovey & Scott, 2019) o Survey (n=2) (Haag et al., 2019; Ford-Gilboe et al., 2015) o Critical discourse analysis (n=1) (Mantler et al., 2019) • Mixed methods (1) o Tailored approach that involved an Elder-led group and interviews (n=1) (Varcoe et al., 2019) Topics discussed in relation to IPV • Substance use (n=2) (Torchalla et al., 2015; Hovey & Scott, 2019) • Maternal/perinatal care (n=1) (Torchalla et al., 2015) • Indigenous women (n=1) (Varcoe et al., 2019) • Trauma (n=4) (Haag et al., 2019; Mantler & Wolfe, 2018; Torchalla et al., 2015; Varcoe et al., 2019) • Brain injury (n=1) (Haag et al., 2019) et al. (2019) was conducted in two cities: a suburban city and an urban centre. Haag et al. (2019) did not specify where the study was completed. The studies examined women’s health and social outcomes, experiences, and needs in relation to improving health inequities. While most studies focused on women experiencing IPV, Haag et al. (2019), and Mantler and Wolfe (2018) also studied frontline providers and other contributors. Ford-Gilboe et al. (2015) and Torchalla et al. (2015) included Indigenous women, specifically including self-identification in the demographic information, and Varcoe et al. (2019) worked specifically with Indigenous women. Mantler et al. (2019) studied only policy documents. Table 10 summarizes research characteristics and important results per study. 50 Table 10 Summary of Research Studies Source Purpose(s) Research populations Data collection Key results Ford-Gilboe et al., 2015 Analyze patterns of access to services in health, social, violence-specific, and legal sectors among women who had separated from an abusive partner 309 women Longitudinal surveys, involving on-site structured interviews and health assessments • Abuse persists and often escalates post-separation • In women who experience IPV, service use rates are higher than in women in the general population Haag et al., 2019 a) Explore providers’ knowledge of traumatic brain injury (TBI) and its impact; b) Identify existing IPV and TBI services, barriers, and facilitators; and c) Develop recommendations Phase one: 68 agencies providing IPV services completed a survey. Phase two: 22 participants (women and providers) attended a workshop Online surveys and workshop • Organizations offered a wide range of IPV supports • A need for a national strategy to raise awareness about IPV and TBI relationship across sectors and services is needed Hovey and Scott, 2019 Examine women’s experiences with a harm reduction service at a rural women’s shelter 25 women On-site semi-structured interviews • The sense of safety in women influenced their perceptions about a harm reduction approach in a shelter • A balance among individual needs and specific care approaches should be sought Mantler and Wolfe, 2017 Examine how a rural women’s shelter role was changing to meet the needs of women who experience IPV and how the shelter was adapting Service providers (n=6) and women (n=4) Semi-structured interviews • The shelter needs constant and evolving adaptation strategies to address women’s needs, including trauma • Strong partnerships among organizations supporting women are key in addressing IPV Mantler and Wolfe, 2018 a) Examine the acceptability and impacts of two models of trauma-informed social and primary care services; and b) Identify gaps and recommendations Administrators (n=4), service providers (n=10), and women (n=25) Semi-structured interviews • Women identified gaps in service provision (e.g., difficult transitions of care) • Participants recognized that both models of integration offered comprehensiveness to meet their needs 51 Source Purpose(s) Research populations Data collection Key results Mantler et al., 2019 Examine the degree of alignment among provincial women’s shelters and hospital policies on the delivery of and access to services for women who have experienced IPV Not applicable Policy analysis of documents: 1) the Domestic Violence Action Plan for Ontario, 2) the rural women’s shelter policy, and 3) the hospital policy (absence of this policy) • A system-level integration approach is crucial to bridge the gap among IPV-related policies • Policies and services must consider women who are not ready to disclose Torchalla et al., 2015 Explore the perspectives regarding trauma and violence in women who experienced marginalization and substance use during pregnancy and motherhood 31 women completed a questionnaire. Only 27 women were interviewed Quantitative questionnaires and semi-structured interviews • Several factors determine women’s health experiences, outcomes, and encounters with health and social services • Structural enhancements such as housing models and economic support are needed to limit or end IPV against women Varcoe et al., 2019 Test the efficacy of an intervention known as Reclaiming Our Spirits in improving quality of life and health of Indigenous women who experience IPV 152 Indigenous women Interviews including self-report measures of study outcomes at preintervention, postintervention, and six months later • Supports for women who experience IPV need an emphasis on helping posttraumatic progress, specifically trauma • Tailoring services and programs based on women’s needs can help improve health outcomes 52 3.3.2 Thematic and Content Analysis The authors studied multiple aspects of participants’ experiences through questionnaires and/or as part of interviews. Participants reflected on their current health status, status of services received or provided, and personal experiences (e.g., abuse history). This review classified the dimensions or intersections analyzed by authors into five categories: a) demographics and social locations of participants; a) abuse history; c) current service use or status of service being offered and/or used; d) overall health status; and e) gaps, barriers, and recommendations to improve access to services. Appendix F presents the dimensions or intersections explored in each study. An in-depth analysis of these intersections made it possible to identify content related to health inequities and health system integration for women. Results were organized into three themes: a) the importance of incorporating women’s voices in service planning and provision; b) the importance of understanding women’s health experiences and outcomes to inform the redesign of services; and c) system transformation requires integration of services through system-level design. See Table 11 for a summary of critical results. a) The importance of incorporating women’s voices in service planning and provision: Authors studied women’s health experiences and integrated their voices to improve services. Across the studies, the need for services to be more effectively trauma- and violence informed was identified. Torchalla et al. (2015) presented women’s experiences of violence during pregnancy or early motherhood in BC. Women described experiences of stigmatization and gender-based psychological violence in services where there was a lack of violence-specific care approaches, which resulted in their mistrusting the system. Similarly, Mantler and Wolfe (2018) found that women recognized that the lack of a trauma- and violence-informed approach across services and sectors limited the quality of care they received in health-related services but also in the violence sector in rural Ontario. Hovey and Scott (2019) also demonstrated the importance of integrating women’s perspectives with the use of shelters and harm reduction approaches in Ontario. Women reported positive experiences such as a non-judgmental approach, access to services, tolerance, respect, and understanding of substance use. Further, Varcoe et al. (2019) demonstrated the value of using trauma- and violence-informed approaches to incorporate women’s voices as a foundation for equity-based services in BC. Results showed that participants 53 Table 11 Summary of Critical Results Results • Women’s voices revealed that IPV is a complex problem where multiple intersections (e.g., trauma, abuse, violence) impact women’s lives and health • Health system-level designs improved comprehensiveness, inclusiveness, and integration of services • Trauma- and violence-informed care helped women to improve health outcomes and experiences (e.g., women’s quality of life and trauma symptoms) • Integrated models of care based on health equity are needed to enhance women-centred care at all levels of service provision • Services based on health equity can limit social exclusion by supporting women’s healing processes in the long-term “valued having time with the nurses, being listened to, and not being judged, often contrasting the intervention with prior experiences with health care providers and programs” (Varcoe et al., 2019, p. 18). Additionally, the voices of women were incorporated to improve integrated and person-centred care. Authors such as Mantler and Wolfe (2017, 2018) integrated women’s voices to improve service delivery. In their 2017 study, Mantler and Wolfe used women’s narratives to improve health transitions to a shelter, while their 2018 study included women’s perceptions of care to improve two models of care. In Mantler and Wolfe (2017), women highlighted that the role of the shelter needed to evolve constantly to fulfil diverse needs, with three main roles identified: filling “gaps left by existing community supports and health/social services, case management for the evolving complex health and social needs of women accessing the shelter, and system navigation to improve access and outcomes for health and social services” (Mantler & Wolfe, 2017, pp. 8–9). Compared to this study, Mantler and Wolfe (2018) included women’s experiences of integration to improve two healthcare models. The first “facility-integrated model” hosted weekly on-site nurse practitioner visits in two settings, a women’s shelter and another community-based setting. The second “systems-integrated model” was a shelter providing multiple on-site support services (e.g., counselling) with referrals to primary healthcare services. Although women found both models suitable to delivering comprehensive and integrated care, they recognized gaps in service provision. As such, difficult transitions and a lack of continuity of care were identified due to a complicated navigation process, principally in the systems-integrated model that provided referrals to primary health care. 54 Finally, studies highlighted that engagement and collaboration among providers and women is key when planning services. Hovey and Scott (2019) argued that to enhance positive health experiences and outcomes, including a sense of safety, a balance between specific care approaches and individualized needs should be sought. In their study, although most women recognized harm reduction as a positive approach, half of the participants were negatively triggered by smelling alcohol or listening to someone yelling. As such, providers recognized the need to acknowledge women’s insights when planning services. By using harm reduction, providers were understanding of substance use practices and engaged with women to develop collaborative care. In Haag et al. (2019), both women and providers agreed that women who experience IPV need better health and social procedures for the identification, screening, and care for traumatic brain injury (TBI). These practices should include supports such as suitable shelter designs. After a process of engagement and collaboration among participants, Mantler and Wolfe (2017) translated women’s and providers’ insights into strategies to limit violence, such as capacity building for relationships with victim’s supports. The study of the experiences of IPV in relation to social dimensions of violence (e.g., rurality, cultural beliefs) allowed participants to recognize the complexity of violence. b) The importance of understanding women’s experiences and outcomes to redesign services: Authors studied the implications of violence, abuse, and trauma on women’s wellbeing to understand diverse needs, and to design services. The studies demonstrated that the challenges women experienced needed to be considered in services design and delivery to be meaningful and effective for women. Key challenges included high levels of socio-economic disadvantage such as poverty. Ford-Gilboe et al. (2015) presented results of a sample of 309 women who were struggling with economic disadvantage. Although 45% were employed, the majority (59%) had incomes below the Canadian poverty line for a single person. These findings were similar to those of Varcoe et al.’s (2019) study of 152 Indigenous women who faced economic, health, and social disadvantage. In this study, women’s average annual income (CAD $9,570) was significantly below the Canadian poverty line for a single person living in a large city in Canada at the time of data collection (CAD $22,133). The studies revealed how women’s histories of abuse and IPV shaped their health and social needs, which allowed the authors to identify the types of supports needed. Torchalla et al. (2015) found that out of 27 women, 19 had a foster care 55 history, more than half did not have a high school diploma, and 24 received economic governmental support, signaling diverse counselling, employment, and education needs. Ford-Gilboe et al.’s (2015) study of service use demonstrated which services were essential (e.g., family doctors, domestic violence counselling). Almost one in five women reported staying in a shelter in the first 6 months after separation. Likewise, in Varcoe et al. (2015), at least 58 out of 152 women had spent at least one night in a shelter in the past year. Due to the lack of research, the need to study “long-term implications [of IPV] for health such as the development of progressive degenerative neurological disease” in IPV-TBI relationship (Haag et al., 2019, p. 994) was identified. Women’s narratives helped authors recognize that abuse, trauma, and violence intersected in women’s lives to reproduce negative experiences, and health and social inequities. Authors identified that physical, sexual, and/or emotional abuse were repeatedly experienced by women from childhood through adulthood (Ford-Gilboe et al., 2015; Torchalla et al., 2015; Varcoe et al., 2019). In Varcoe et al. (2019), Indigenous women in BC reported high levels of multiple forms of violence: “Over 75% had experienced physical, sexual, and psychological child maltreatment, whereas 84% and 91% reported experiences of childhood physical and emotional neglect […] 71% had been sexually assaulted since age 16” (Varcoe et al., 2019, p. 16). Similarly, Ford-Gilboe et al. (2015) revealed that 66.3% of women had experienced abuse in their childhood, 59% had more than one violent partner in their lives, and 49% reported that the violence was ongoing even after separation. In Torchalla et al. (2015), women’s narratives related to interpersonal, transgenerational, and structural violence showed how women recognized patterns between their parents and themselves or themselves and their own children. Women specified that abuse, violence, and trauma had been passed on from one generation to another and mentioned how crucial it was for them to “break the cycle” (Torchalla et al., 2015, p. 6). Negative experiences of abuse and trauma also continued over time when women did not have their needs met. Ford-Gilboe et al.’s (2015) study of service use demonstrated “associations between aspects of women’s abuse histories, social location, and health, and their use of services” (Ford-Gilboe et al., 2015, p. 428). Authors identified higher service use rates in women who experienced IPV, compared to the general population. The increased service usage rates may have been due in part to lack of access to appropriate services. 56 Finally, researchers identified that women who experience IPV and marginalization often had a difficult time addressing their needs or conditions (e.g., experiences of trauma, TBI) due to limitations in service design and provision. Mantler and Wolfe (2017) identified barriers to service delivery, such as the lack of understanding by providers and decision-makers about the high level of complexity of women’s lives and needs, and service gaps due to geography and the rural context. Barriers to service access were also found by Ford-Gilboe et al. (2015), with limitations including a lack of transportation and childcare, high costs of services, long waiting lists, and no availability of basic and specific services (mental health or counselling) in communities where the women lived. Studies showed women who experienced IPV also faced social barriers to wellbeing that needed structural enhancements. Torchalla et al. (2015) found negative social and peer-group risk models, poor income generation, limited access to housing, and restrictive public health policy related to harm reduction treatments, and highlighted how experiences of abuse and trauma require structural interventions (e.g., innovative housing models) to support the complex healing process. Systemic limitations to meet the needs of Indigenous women were also identified by Varcoe et al. (2019) (e.g., high levels of trauma and discrimination toward Indigenous peoples and communities). Recommendations emphasized the importance of tailoring services based on Indigenous women’s needs and their experiences of SGBV and IPV. Specific obstacles to service provision when designing and implementing shelter services were also identified. Hovey and Scott (2019) identified women’s hesitation to seek support for fear of losing children to protective services, and Haag et al. (2019) found women overlooked small shelters since they might not meet all of their needs. Mantler et al.’s (2019) policy analysis demonstrated that services and policies should be integrated across levels, services, and sectors to improve continuity of care, system navigation, and integration. Two policies studied in Ontario showed disconnection and ambiguity in their perspectives, with authors finding that the mandates, training goals, and objectives in these documents had a siloed approach to care (Mantler et al., 2019). c) System transformation by integration of services throughout system-level designs is needed: Researchers recommended enabling health system integration and health equity at different levels of the system (e.g., macro, meso, micro). From a macro perspective, Torchalla et al. (2015) indicated there is a requirement for macro-structural change such as economic and policy change. 57 Interventions should include policies supporting gender equality, limiting stigmatization of substance use, and protecting women from street violence. Aligned with macro changes, Varcoe et al. (2019) recommended intensive and high levels of support for Indigenous women who experience extreme levels of marginalization due to poverty and systemic racism. A tailored and holistic approach that recognized the complex and multi-level implications of marginalization, including abuse, trauma, and violence, helped to improve health outcomes for women. Women’s quality of life and trauma symptoms such as depressive symptoms, social support, personal agency, and interpersonal agency improved significantly from pre-intervention to post-intervention, which was also maintained 6 months later (Varcoe et al., 2019). Ford-Gilboe et al. (2015) argued investing in resources to reduce or eliminate systemic access barriers such as economic challenges, lack of service availability, and a lack of coverage for services such as dental and counselling. Since the main services women needed were family doctors, social workers, mental health services, and domestic violence counselling, these supports should be prioritized. Haag et al. (2019) stressed the need for political will specifically translated into a national strategy to strengthen IPV-related knowledge across sectors. Approaches should include education, research, and funding to facilitate uptake and integration of services within a range of services for IPV (e.g., screening, care intervention, shelter design). According to Mantler et al.’s (2019) policy analysis, policy alignment, clear overarching goals, and specific tactics to achieve these goals are important factors towards system integration. Since there was ambiguity within the policy perspectives and a disconnect between the stated goals and the actions on how the policies would achieve the goals, the authors emphasized “the need for system-level integration is imperative as this may reduce the gap between provincial and women’s shelter policies, while also dealing with issues related to limited access for women to healthcare services” (Mantler et al., 2019, p. 7). Regarding meso-level changes, authors found that improving clinical and administrative processes including providers’ attitudes, cultural management, use of specific care approaches, or interprofessional collaboration models of care would be key. For Mantler and Wolfe (2017), enhancements should include improving coordination of services across sectors and strengthening community mobilization by raising awareness on the implications of violence. Culture shifts to foster attitude change, support knowledge achievement along with improving collaboration across services and 58 education programs for providers were needed. In Mantler and Wolfe’s (2018) study, frontline providers and administrators highlighted the impact of comprehensiveness and integration where strong partnerships were crucial features in service access. Collaborations were needed to shift from fragmented to integrated services and enable women to navigate systems. Mantler et al. (2019) emphasized the need for integration. Results showed that each policy worked separately to accomplish its own goals without consideration of the goals of other services within the system. Strategies to facilitate integration of systems included “networking, leveraging technology, and recruiting resourceful, able leaders in a hub configuration, which involves the integration of services in a localized access point (CENTRAL Hub Model)” (Mantler et al., 2019, p. 7). Mantler and Wolfe (2018) recommended promoting integration across sectors using a trauma-informed model, particularly to strengthen administrative processes between health providers and the violence sector (e.g., justice system). For Ford-Gilboe et al. (2015), models of care needed to be translated into specific services based on patterns of access among women currently experiencing abuse and living with their partner, women experiencing abuse after separation, and women who were separated and no longer experiencing abuse (Ford-Gilboe et al., 2015). Finally, authors identified micro strategies to improve service delivery at the point of care level, including having equity lenses and meeting clinical needs. Varcoe et al. (2019) suggested action must integrate comprehensive and effective pain assessment and management strategies, and that programs need an ongoing emphasis on supporting posttraumatic stress. Likewise, Ford-Gilboe et al. (2015) found that frontline providers need to do a comprehensive assessment focused on past experiences, abuse, and histories of violence. Studying service quality and its impact on health and quality of life is also important since women who have left abusive partners are actively seeking support to improve their lives. Additionally, Hovey and Scott (2019) stressed the need to examine shelters’ substance use policies alignment with harm reduction and trauma- and violence-informed care. Shelters should establish supportive working interactions with child welfare services. Other important strategies and care approaches included developing women’s capacity as caregivers and enhancing women’s well-being, including building resilience (Torchalla et al., 2015). Providers in Ontario identified IPV services such as medical services and shelters; however, they were not aware of the relationship between IPV and TBI, nor of the brain injury support systems available. Considerations for TBI should include “rehabilitation 59 strategies for return to work and parenting, barriers to successful navigation of current legal and child protection systems, and long-term implications for health” (Haag et al., 2019, p. 994). In Mantler and Wolfe (2018), women responded to how acceptable the services offered were, and if these services inspired them to seek care. For women there is a “need to promote further integration across sectors utilizing a trauma-informed model” (Mantler & Wolfe, 2018, p. 131). Mantler et al. (2019) stressed that to enhance health system integration and equity-based services, shelter policy would need to go beyond women who seek help to specifically consider women who are not ready to disclose. A need for clear action between governance and operational levels is also required. 3.4 Discussion The scoping review examined the evidence for health equity and health system integration of services for women experiencing marginalization and IPV in Canada. Eight studies were analyzed. Results highlighted how health equity and health system integration have been studied and implemented to address the needs of women, and what is required to better meet their needs This review identified that a one-size-fits-all approach is not enough to meet the multiple needs of women. Women’s voices need to be incorporated to inform initiatives to increase their effectiveness and ultimately result in better health and social outcomes. Since women’s needs vary at diverse stages of abuse, there is a need to understand service use rates by women who are still living in an abusive relationship compared to women who have left an abusive partner, as the supports required may differ. Providers recognize the short-term effects of violence such as acute injuries or obstetrical emergencies (higher prevalence of miscarriage) (Roman-Galvez et al., 2021). However, the multiple effects of abuse, harm, and trauma across the lifespan, particularly the long-term effects such as chronic pain or PTSD (Wallace et al., 2021) may not be clearly identified. This is similar to what Haag et al. (2019) highlighted about the relationship between IPV and TBI. When organizations incorporated women’s narratives to redefine services, both women’s satisfaction and community engagement to end violence increased (Mantler & Wolfe, 2017). There were improvements in health outcomes such as better quality of life or improvements in trauma symptoms (Varcoe at al., 2019). By systematically integrating women’s input, services could better address their needs, improve outcomes, and increase satisfaction with services and supports. 60 Results show IPV is a complex problem where specific intersections determine health and social inequities in women’s lives. There was a high frequency and severity of disparities during childhood which continued into women’s adulthood, including levels of poverty, marginalization, and all types of violence (Ford-Gilboe et al., 2015; Torchalla et al., 2015; Varcoe et al., 2019). High levels of disability, chronic pain, symptoms of depression, and PTSD were found in women who had high rates of service use (Ford-Gilboe et al. 2015). These findings are consistent with other research that suggests that the health of women who experience IPV is worse than women of similar age without experiences of IPV and marginalization (Ford-Gilboe et al., 2020; Tutty et al., 2021; Wathen et al., 2018). Major differences in economic disadvantage and rates of violence between Indigenous and non-Indigenous women in Canada were also found (Ford-Gilboe et al., 2015; Varcoe et al., 2019). In light of these results, scholars are advocating analyzing the impact of violence between and within diverse groups of women (e.g., Indigenous and non-Indigenous) (Tutty et al., 2020). Understanding the complex and systemic effects of violence needs to inform effective health strategies; otherwise, as Hovey and Scott (2019) demonstrated, service design, processes, and practices could yield negative health experiences by unintentionally triggering abuse and reproducing harm. When service design does not consider the impact of the social dimensions of SGBV and IPV, including systemic actions towards gender equity, efforts to meet the needs of women may not be effective (Hardesty & Ogolsky, 2020). Health system integration is an effective approach to reduce systemic barriers (O’Brien et al., 2017). Characteristics of system-level designs at all levels are key in service planning and implementation of health system integration. Results from Mantler and Wolfe (2017) showed that meso-level integration strategies such as building collaboration among supportive services, community education and mobilization, and redesigning delivery models facilitated a positive shift to address structural practices of violence against women. Structural practices to limit violence facilitated social change by transforming the cultural and structural patterns surrounding violence. Examples of structural practices to limit violence included fostering an understanding of how trauma and violence affect women’s and peoples' lives, and promoting community recognition and ownership of violence. These approaches have the potential to impact inequities, including long-term goals towards ending violence and creating social change (Kulkarni, 2018). Aligning provincial (e.g., Domestic Violence Action Plan for Ontario) and local shelter 61 policy with overarching goals, along with clear training practices, were also essential to integrate care for women (Mantler et al., 2019). Local level policies for services related to IPV, including practices and specific approaches, need to consider women who have not yet self-identified as being in an abusive relationship or who are not ready to leave the relationship (Mantler et al., 2019; Tarzia et al. 2020). Mantler et al. (2019) showed that women value emotional connection, support, and advocacy interventions within a non-judgmental approach that recognizes their autonomy to disclose. A shift towards a supportive long-term model (e.g., trauma- and violence-informed, culturally appropriate care) that helps women recover and heal is key. As Garcia-Moreno, Hegarty, et al. (2015) argued, the health system role in ending gender-based violence and IPV relies on providing supportive care, advocating for a coordinated action across sectors, and implementing policies and structures that limit system barriers. Strengthening comprehensiveness and integration for better care transitions, whereby women could better access and navigate services were strategies used by Mantler and Wolfe (2018) to improve system and services access and reduce system barriers. Comprehensiveness, inclusiveness, and integration are key attributes to equity-based services (Nakkeeran & Nakkeeran, 2018; O’Brien et al., 2017). Having system-level designs that prioritize people’s needs can reduce fragmentation and siloed care by improving processes related to coordination of care. Some of these processes for system integration involve setting clear goals and tactics to achieve those goals. These strategies would facilitate the alignment of procedures known as normative, organizational, and clinical processes of primary healthcare (Valentijn et al., 2013), which will impact women’s health services, as emphasized by Mantler et al. (2019). A comprehensive framework of primary healthcare features related to health system integration is presented by Valentijn et al. (2013). Characteristics of this framework accord with different levels of service delivery, as presented in the last theme of this review (System transformation by integration of services throughout system-level designs is needed). For example, by creating strong community partnerships and referral processes to address the lack of services in rural contexts, Mantler and Wolfe (2017) improved service access and primary healthcare for women at multiple levels. As per Singer et al. (2020), a person-centred approach is essential to enhancing integrated care at all levels. Adapting health system integration can help design integrated and women-centred services. A health system integration approach highlights the importance of tailoring services based on a woman- 62 centred model. Varcoe et al.’s (2019) development of an Elder-led and trauma-informed intervention for Indigenous women is an example of a tailored approach to improve health outcomes. Research shows that a trauma- and violence-informed approach has the potential to build connection through kindness and care, respect, and understanding without judgement (Levine et al., 2020; WHO, 2021a). International recommendations call for responding to a woman who discloses violence in a way that is empathic, helps address her needs, and prioritizes her safety without intruding on her privacy, using a LIVES (Listening, Inquiring, Validating, Enhancing safety, Supporting) approach (WHO, 2021a). This aligns with Canadian research as well; Varcoe (2018) found that delivery of care must be based on respectfully listening, being alert to red flags for violence, using broad inquiring techniques, validating the person’s worth, and facilitating protection. To address the complexity of experiencing marginalization and IPV means to re-conceptualize the services, including the availability of equity-based services. Characteristics of equity-based services play an important role to inform social change. For instance, the acceptability of services offered (regardless of the level of integration) was key in addressing women’s needs (Mantler & Wolfe, 2018). The sense of safety was also an important component of wellbeing and acceptability of services (Hovey & Scott, 2019). Studying the acceptability of the services delivered is key to understanding if and how services are acceptable (Robards et al., 2019), in this case to women. According to the WHO (2017), accessibility, acceptability, availability, and quality of care are recognized as underlying principles of equity-based services. Services are acceptable when they meet cultural, linguistic, ethnic, and social and health needs; they are available when they are functioning effectively and sufficient services are provided within a community; and they are of high quality when they seek to be safe, effective, timely, efficient, and person-centred (WHO, 2017). When comparing these principles to the way researchers enhanced service delivery in shelters, authors such as Mantler and Wolfe (2017, 2018) and Mantler et al. (2019) demonstrated the need to increase service access, system navigation, and efficacy of services through specific approaches such as outreach services or localized point of care models (e.g., Hub model). Finally, and most importantly, results highlight health equity through “Nothing about us without us” (Charlton, 1998). Authors emphasized the relevance of incorporating the multiple and diverse voices of women who have experienced IPV as a meaningful source of knowledge and evidence to co-transform 63 systems (e.g., Ford-Gilboe et al., 2015; Haag et al., 2019). However, although results show attempts to increase women’s involvement (e.g., Hovey & Scott, 2019; Torchalla, 2015), researchers did not provide details on the level of engagement or spectrum of public participation (e.g., inform, consult, involve, collaborate, empower) (International Association for Public Participation, n. d.). Snow et al. (2018) argue that equity-based services must consider aspects such as women’s inclusion, representation, and non-discrimination. The level of engagement is a determinant of the level of commitment and motivation, which frame the impact on participants, “either changes to health services or a benefit gained through participating, such as gaining new skills” (Snow et al., 2018, p. 7). Unfortunately, evidence still shows that women are not being involved nor engaged in health service research (Gagliardi et al., 2020). However, Mantler and Wolfe (2017) showed how constant, open, and respectful dialogue to share experiences and inform health decisions allowed women to strengthen their empowerment skills. The strategies used by the rural shelter to fulfil changing roles, the process of women’s engagement, particularly, the constant incorporation of the evolving needs of women into the redesign and delivery of services facilitated inclusion and representation (Mantler & Wolfe, 2017). A collaborative and engaging approach to co-transform systems should include a comprehensive assessment of a woman’s position in society to identify how power imbalances have impacted their health, determine inequities, and design appropriate approaches (Braveman, 2014; Braveman et al., 2017). When women sought care from services that were not informed by structural violence effects (e.g., trauma- and violence-informed approach), they described having unpleasant and traumatic experiences in the form of stigmatization and victim blaming (Torchalla et al., 2015). A shift towards the use of structural lenses can help providers improve their practice (Levine et al., 2021). A better understanding of the intersecting impacts of patriarchy and capitalism is also needed (Fellows & Razack, 1998;Rollero & Tartaglia, 2019), which must particularly include how agency and resistance play out against oppression (Herrera & Agoff, 2018). 3.4.1 Implications for Practice and Research Table 12 summarizes implications for practice, policy, and research. The results from this scoping review suggest that women benefited from enhancements in system integration. For women, there is a need for stronger collaboration and integration for care transitions across health and social services. Given that trauma and violence associated with IPV remain, it is crucial to pay attention to how trauma- 64 Table 12 Summary of Implications Implications for practice, policy, and research • Longitudinal analyses to identify if service use changes after separation are needed (Ford-Gilboe et al., 2015) • Research to address whether services offered or obtained meet women’s needs at different stages of abuse is needed (Ford-Gilboe et al., 2015) • Training and support to enable earlier detection of TBI is needed (Haag et al., 2019) • Research on TBI and its long-term effects on survivors’ health, including trauma symptoms to support women’s survivors is needed (Haag et al., 2019) • Research to study providers’ experiences using a harm reduction approach is needed (Hovey & Scott, 2019) • Harm reduction approaches that integrate collaborative practices while respecting women’s choices are needed (Hovey & Scott, 2019) • Research mobilization to translate system integration approaches into supports for women who experience IPV is needed (Mantler et al., 2019) • Models of care focused on the micro-level to increase women’s well-being and resilience are needed (Torchalla et al., 2015) • Researchers need to advocate for a trauma- and violence-informed approaches in harm reduction facilities (Torchalla et al., 2015) • Intensive levels of support for Indigenous women who experience marginalization and IPV are needed (Varcoe et al., 2019) • Tailored interventions considering cultural practices and traditions to enhance social supports in Indigenous women who experience IPV are needed (Varcoe et al., 2019) • The changing role of the shelter and delivery practices (e.g., trauma-informed care), including adaptation strategies impact the acceptability of services (Mantler & Wolfe, 2017) • The expansion of the role of the shelter aligns with a need to shift the design of services to a model of integration of services (Mantler & Wolfe, 2017) • The lack of trauma-informed care across sectors is detrimental to service provision and care (Mantler & Wolfe, 2018) • Studies should assess the impact of trauma- and violence-informed care on women’s health (Mantler & Wolfe, 2018) and violence-informed approaches impact the health and healing of women who experience IPV. Translating system integration approaches into specific supports may bridge health inequities (e.g., stigma). Intensive levels of support are needed for women who experience marginalization and IPV. 3.5 Remarks This scoping review focused on health system integration, health equity, and women experiencing marginalization and IPV in Canada. While efforts have been made across the country, most of the research reviewed was conducted in BC and Ontario. It is also important to highlight the limited work being done in marginalization and IPV; four of the eight studies came from the same research team. The themes underline the high level of complexity related to how to study and address inequities for women. Canadian research has advanced the understanding of marginalization and IPV as a complex 65 social problem that requires cross-sectoral and structural changes to limit or end violence against women. And, while researchers are designing innovative approaches to address women’s needs, there is still a need for evidence on how to design and deliver more integrated, effective, equity-based, women-centred services as well as how to measure health experiences and outcomes. A thorough assessment of social interactions is important to understand women’s needs and to design effective interventions. Women who are at the intersections of multiple forms of marginalization, such as those who experience IPV and mental health issues, or Indigenous women who experience structural racism and economic deprivation, need a comprehensive and integrated systems approach towards health equity. If this is not understood, women may be able to access services, but the services may not meet their needs and this may result in their seeking and using additional services or not seeking services at all. Even worse, as outlined in the literature review, women who have experienced abuse in childhood will likely face violence across their lifespan if inequities are not addressed. As shown by the results, incorporating women’s voices will allow researchers, providers, decision-makers, and policy-makers to identify the type of support women need at the point of care (e.g., non-stigmatizing, trauma- and violence-informed). A solid strategy to strengthen IPV services is needed. From a structural and policy level, all levels of interventions need to better understand how targeted structural initiatives prevent exclusion and promote recovery. A gap found in this review is the lack of evidence to show how improving health system integration impacts health equity. A subsequent step would be to expand the search strategy to include international evidence. Significant questions arose from this review and these were used to inform Phase 2 of the study (Policy Analysis) as well as the overall goal of the research. For example, it is important to understand the impact of specific actions (e.g., models of care, policies) on health experiences and outcomes from a long-term perspective. Chapter 4 presents key considerations related to the Policy Analysis phase, including whether the alignment among levels of policies and services match specifications at the point of care. 66 Chapter 4. Policy Analysis 4.1 Background As discussed in Chapter 3, health and social services responses to violence are concentrated on responding to immediate instances of violence rather than preventing, reducing, and mitigating the impact of violence in women’s lives and society. While these responses are important, they are not aimed at the root causes, and marginalization and IPV continue to be significant problems for women, who are more likely to be victims of severe forms of IPV in comparison to men. More than one in four Canadian women will experience IPV at some point in their lives (Canadian Femicide Observatory for Justice and Accountability, 2018). For women, policies and services to meet their needs must address inequalities that contribute to health and social inequity (Di Cesare, 2014). Although provincial policies have an impact on the health and social services that are delivered and available, evidence suggests there are unmet needs and imperfect alignment among policies, services, and the needs of women victims of violence. For example, in Ontario, Mantler et al. (2019) analyzed policies related to women experiencing IPV. There was a lack of alignment between the Domestic Violence Action Plan for Ontario and the rural women’s shelter policy; these were disconnected and ambiguous in their perspectives, specifically in their mandates, training goals, and objectives. Further, there was no policy or document outlining specific actions or care approaches (e.g., trauma- and violence informed care) designed for women seeking hospital care. Ford-Gilboe et al. (2015) demonstrated that although women experiencing IPV had higher service use rates (e.g., women were 8.5 times more likely to attend a walk-in clinic and 20 times more likely to access an emergency department than women without these experiences) many of them still had unmet needs. The Canada Health Act (Canada Health Act, 1985) is the federal legislation defining the national health principles governing Canada’s health system. Its five principles of public administration, comprehensiveness, universality, portability, and accessibility reflect the values of equity and solidarity. Canada does not have a centrally managed and integrated health system; instead, the federal and provincial governments share responsibilities. The federal government’s role sets the national mandate and provides some financial support to the provinces and territories through health transfer payments. The federal government also funds and/or delivers services to specific groups (e.g., Indigenous people). 67 In contrast, the provinces and territories provide funding, organize and deliver most services. The provincial governments cover medically necessary services without charges at the point of care (Health Canada, 2019). This multilevel and multicomponent organization of services can be challenging when delivering care and services, including those not provincially covered such as dental care, counselling, or prescriptions. Although women who experience IPV often seek help from health providers, shelters, or the police (Ford-Gilboe et al., 2015), the complexities of the Canadian health and social services systems, including the multiple and/or fragmented perspectives in policies and public/private services, can impact the quality, availability, and accessibility of care (Martin et al., 2018). There have been public health policies where the health system (whether federal or provincial) has played a clear role, such as with regard to healthy eating, physical activity, food security, or smoking cessation (Gore & Kothari, 2012); however, the role of the health system seems siloed from other social service systems (e.g., justice) with respect to IPV. The lack of a national strategy/policy to set direction and strengthen IPV-related knowledge among providers is evident (Haag et al., 2019). Health-related policy, including policy development and implementation aspects, is complex. Considerations in public policy such as priority setting, policy formulation, implementation, and evaluation are needed to understand how public policy impacts health systems approaches (Capano & Howlett, 2020). Differentiation between health (or healthy) public policy and public health policy is essential. Health (healthy) public policy is a public policy approach focused on the SDH introduced in Canada in 1986 in the Ottawa Charter for action to achieve health for all by the year 2000 and beyond. This population-focused approach “shifts attention from the planning, funding and delivery of healthcare services alone, to the broader structural and social determinants of health” (Winnipeg Regional Health Authority, 2017, p. 3). It puts health and equity on the policy agenda with the purpose of facilitating healthy lives for individuals and populations (Benoit et al., 2015). In comparison, public health policy is an approach involving actions towards health and wellbeing by influencing laws, regulations, and practices (Benoit et al., 2015; Milio, 2001; Winnipeg Regional Health Authority, 2017). It focuses on social change more than change at individual levels and plays a role in sectors such as healthcare, education, agriculture, or business (Benoit et al., 2015; Lesperance, 2015; Milio, 2001). As such, public health policy is a pillar of health promotion that involves actions towards empowerment and collective decision-making processes. 68 According to Hancock (1985), public health policy is a sectoral approach to the healthcare system that involves policy actions oriented to present issues, whereas health (healthy) public policy is an approach “oriented towards the future state of health” (p. 10) that is more concerned with creating a healthy society. Despite this conceptualization, there is a debate regarding the ways to differentiate the limits among the applicability and use of health (healthy) public policy in health-related contexts (Milio, 2001). As such, policy actions and strategies related to the care of women who experience marginalization and IPV in BC could be identified as part of the decisions and actions to achieving specific healthcare goals in women, but also could be part of a broader understanding of health (healthy) public policy and public health policy. Because healthy public policies aim to improve specific circumstances under which people live (e.g., health services, housing) that consequently impact health status (Benoit, 2013), the goal of this phase of the study was to examine health-related policy documents to understand how they support or hinder actions to limit IPV in BC, including their role towards a more integrated and equity-based health system for women who experience IPV in the province. Figure 4 shows the conceptual approach undertaken for this policy analysis in relation to the differences and similarities between health (healthy) public policy and public health policy, including the position of this policy analysis as part of health-related actions for women who experience IPV in BC. 4.2 Methods 4.2.1 Analytical Foundation Feminist (Lorber, 2010, 2018) and intersectional (Hankivsky et al., 2017) lenses, with an emphasis on the implications for healthcare policy and service delivery (Hankivsky, 2008), were used. This approach facilitated the understanding of women’s health from a macro-structural perspective. 4.2.2 Methodological Framework The framework for analyzing public policies (Morestin, 2012) was used to inform data collection and analysis. The framework was used to document the effects and equity of the policies studied, along with their implementation concerns (see Table 13). Using the framework made it possible to extract and analyze policies from a public health perspective by reflecting on two axes: a) the effects of the policy being studied and b) implementation concerns. The two axes were broken down into analytical 69 Figure 4 Health (Healthy) Public Policy and Public Health Policy Health policy• Includes decisions, plans, actions, and practices to achieve specific healthcare goals•Examples include primary healthcare guidelines for obesity Health (healthy) public policy•Developed by social sectors as well as the health sector to improve population health and quality of life•Focuses on housing, living conditions (education, food security, childcare, transportation), livelihoods, and social and health services•Has an intersectoral approach to policy development and implementation•Aligns with the concept of "health in all policies" to create environments that support people to lead healthy lives•Puts health on the policy agenda in all sectors and at all levelsPublic health policy•Strategic actions led by a public authority or government•Aims to increase or improve the presence of a phenomena, such as health or well-being, within the society or a specific population•Examples of public health policies include sewage disposal, labour laws, vaccinations, tobbaco control, breastfeeding promotion•Focuses on social and environmental change more than individual-level change•Emphasizes the social determinants of health•Aims "to contribute to health-promoting systemic change by influencing policy processes" (Lesperance, 2015, p. 2)Health-related policy 70 Table 13 Dimensions for Analyzing Public Policies Axes Dimension Question D u r a b i l i t y Effects Effectiveness What effects does this policy have on the targeted health problem? Unintended effects What are the unintended effects of this policy? Equity What are the effects of this policy on different groups? Implementation Cost What is the financial cost of this policy? Feasibility Is this policy technically feasible? Acceptability Do the relevant stakeholders view this policy as acceptable? (Morestin, 2012) dimensions impacting decision-making processes. The axis related to the effects of the policy being studied focuses on three dimensions: effectiveness, unintended effects, and equity; while the dimensions for the implementation issues axis are cost, feasibility, and acceptability (Morestin, 2012) (See Appendices G and H). The effectiveness dimension was used to assess whether the policies achieved their goals and objectives. The unintended effects dimension was used to identify the impacts of the policies that are unrelated to the goal or objective being pursued. The equity dimension determined whether the policies impacted differently on various groups based on diverse intersections (e.g., ethnicity, disability), and if these effects would limit inequalities. The cost dimension facilitated the identification of several financial aspects including the associated costs for the government in implementing the policies, the potential costs for other contributors, and the distribution of costs over time. The feasibility dimension examined the availability of the necessary resources (e.g., human; material, including technology; accordance with existing legislation). The acceptability dimension considered whether the policies were deemed appropriate and supported by contributors. Finally, the analysis of durability cut across all six dimensions to examine “the capacity of the policy being studied to remain in effect and to continue producing effects over time (Morestin, 2012, p. 2). 71 4.2.3 Methodological Procedures Definition of Policy Documents: Policies and/or strategic direction documents for the design, planning, implementation, and/or evaluation of structures, processes, and strategies to address the health and social needs of women who experience marginalization and IPV in BC were gathered. Since health services are provincially delivered, this policy analysis focused on provincial policies in BC, to better understand how they were translated into day-to-day action. Other documents such as reports, manuals, or clinical guidelines were used to provide contextual information as background for understanding the policies. To achieve the goal of this study, policies and documents with initiatives for health were considered. However, policies for sectors such as housing/shelter, child care, immigration, and criminal justice that had a potential impact on health experiences and outcomes were identified and examined for their relationship to health. All policy documents included needed to align with at least one of the three policy levels discussed by Howlett (2009): • governance or high policy level, as the macro-level that determines long-term goals and outcomes in specific policy areas; • management or programme level, as the meso-level area establishing accountability to progress towards the higher outcomes; and • operational or on-the-ground level, as the micro-level setting necessary to meet the meso and macro policy needs. Inclusion/Exclusion Criteria: Documents were included if they met the following criteria: • Health and social care-related documents considering strategies to address marginalization and IPV; • Documents guiding the implementation of health equity principles such as accessibility, availability, acceptability, and quality of care (WHO, 2017) for women experiencing IPV; • Policies for social services (e.g., housing/shelter, food, criminal justice system) as they related to health and social services for women experiencing marginalization and IPV; 72 • Documents available at the macro (e.g., ministry level, provincial level organizations responsible for IPV) and meso-micro (e.g., specific public/governmental or private organizations focusing care for women experiencing IPV) levels; and • Publicly available documents from 2010 to 2021, with 2021 being considered in order to include potential policies still in effect or implemented Documents were excluded if they: • Only addressed the needs of children or youth Data Collection and Analysis: Data were collected using the following process: Each of the six dimensions (Table 13) of the framework for analyzing public policies (Morestin, 2012) was divided into sub-tables, with results put into specific columns dedicated to an analysis criterion for that dimension, when one was available. The method for synthesizing knowledge about public policies (Morestin, 2011) was used to support data extraction by identifying content related to specific criteria (see Appendix H). An ExcelTM table was used to classify data per each sub-table. Data analysis involved content analyses (Beck, 2013; Braun & Clarke, 2006) to identify and integrate content related to the effects of the policy being studied and implementation concerns. Data related to the impact or outcome evaluation of the policy actions studied were not part of this analysis. Finally, a policy mapping exercise (Aligica, 2006) was undertaken to chart policy documents from the different sectors over the 10-year timeline. 4.3 Results This policy analysis focused on guiding decisions and actions on health equity and health system integration to address the needs of women experiencing marginalization and IPV in BC policies. Five policies met the inclusion criteria. An overview of the policies can be found in Table 14. The policies contained statements to address issues related to providing services for women who experience marginalization and IPV. For example, British Columbia’s provincial domestic violence plan (2014) encompassed an integrated strategy to increase safety; improve services for women, children, and perpetrators; and facilitate information sharing across systems. Most of the policies outlined a cross-ministerial approach to develop strategies and collaborative work to develop the policies and accomplish goals. Only the document entitled A vision for a violence free BC (2015) did not clarify whether specific 73 Table 14 Overview of the Policies Studied Policy Scope/purpose Policy levels Violence against women in relationships (VAWIR) policy (Ministry of Public Safety and Solicitor General et al., 2010) To set out “the protocols, roles and responsibilities of service providers across the justice and child welfare systems that respond to domestic violence” (p. 2) Management and operational Taking action on domestic violence in British Columbia (Ministry of Children and Family Development, 2012) To set “a coordinated approach to addressing domestic violence across the child and family serving systems in BC” (p. 4) Governance British Columbia’s provincial domestic violence plan (Ministry of Children and Family Development, 2014) To “increase safety for individuals and communities by strengthening the systemic response to domestic violence” (p. 8) Governance A vision for a violence free BC (Government of British Columbia, 2015) To create “a province where all women have the supports they need to help prevent violence, escape from violent situations, and recover if they have been victims of violence” (p. 2) Governance and management Best practice approaches, child protection and violence against women (Ministry of Children and Family Development, 2017) To “promote an integrated response that builds on the strengths between women’s and child welfare services” (p. 6) Management and operational departments collaborated. Although all the policies displayed a provincial perspective for publicly funded organizations, the content of some could also apply to private and not-for- profit organizations (e.g., Violence against women in relationships [VAWIR] policy, 2010). The policy documents included in the analysis were mapped by time (see Figure 5). Other documents that were also mapped in Figure 5 considered addressing IPV from multiple perspectives and services (e.g., Crown Counsel). These additional documents were identified as policy instruments and facilitated policy implementation by supporting the development, implementation, and effects of health and social care policies (Capano & Howlett, 2020). Policy instruments included frameworks, legislation-related documents, specific actions, and/or evaluation reports. These records were not included in the policy analysis, but since some of them were mentioned in the policies, they were included in the policy map. Analyses of the included policies based on the analytical policy dimensions (Morestin, 2012) are presented in the following section. The following three dimensions (effectiveness, unintended effects, and equity) are related to the axis effects of the policy being studied. 74 Figure 5 Map of the Policies Studied and Policy Instruments Identified (2010–2021) 20102014201720212012: Representative for Children and Youth’s report 2012: Provincial Office of Domestic Violence (PODV) 2016: British Columbia’s provincial domestic violence plan, 2nd annual report 2012: BC housing. factors to consider when domestic violence safety planning 2015: British Columbia’s provincial domestic violence plan, 1st annual report (n.d.) Contextual exploration of IPV in BC in RCMP jurisdictions 2013: Final report. Taking action on domestic violence in BC 2012: Work Safe BC: Addressing domestic violence in the workplace 2021: Prosecution service: Crown Counsel Policy: IPV 1, January 2013: Family Law Act [SBC 2011] CHAPTER 25 2012: A framework for addressing violence against women in relationships 2014: Framework for domestic violence courts in BC 2016: FPT justice framework to address violence against Indigenous women and girls Related policy instruments 2010: Violence against women in relationships (VAWIR) policy 2014: British Columbia’s provincial domestic violence plan 2012: Taking action on domestic violence in BC 2015: A vision for a violence free BC 2017: Best practice approaches, child protection and violence against women Policies 75 4.3.1 Effects of the Policies Being Studied Effectiveness: Evaluation of effectiveness focused on the decisions made and actions taken or not taken based on policy actions and their direct impacts for women. Table 15 shows the key approaches taken within each policy for effective strategies to address IPV. The approaches varied. Some policies specified actions towards improving the roles of specific services, departments, or ministries. The VAWIR policy (2010) divided the services into departments with accountabilities for each. While the policy in its entirety stressed the need for integrated cross-sectoral policies for an effective response, individual sections detailed key providers’ responsibilities. This policy also presented an integrated protocol for highest risk cases. A similar approach was undertaken by the policy, Best practice approaches, child protection and violence against women (2017). This policy focused on guiding child welfare providers through the identification of actions needed in situations of IPV. This policy considered the dynamics of violence against women to provide direction on practices such as reporting or safety planning. Policies set priorities for improving processes such as coordination and collaboration. Taking action on domestic violence in BC (2012) aligned a series of actions and strategies to respond to the recommendations of the 2011/2012 Annual Report and 2012/13 – 2013/14 Service Plan from the Representative for Children and Youth (Office of the Representative for Children and Youth, 2012) and led a coordinated and inter-sectoral response to address domestic violence. Several organizations collaborated to meet the goals of the report, address violence, and respond to women’s needs. Additional policies focused on addressing gaps in information sharing through collaboration across sectors. Within the British Columbia’s provincial domestic violence plan (2014), a key action was to collaborate with the Community Coordination for Women’s Safety (CCWS) program to support improvements focused on cross-sector cooperation. Initiatives included “the development of local Violence Against Women in Relationships (VAWIR) committees and Interagency Case Assessment Teams targeting highest risk domestic violence cases” (Ministry of Children and Family Development, 2014, p. 16). These teams and the expanding number of domestic violence units aimed to co-locate police, victim services, and child protection workers to respond to high-risk cases. 76 Table 15 Analytical Dimension: Effectiveness Policy Actions/strategies towards effectiveness Specific strategies Violence against women in relationships (VAWIR) policy (2010) • Set roles and responsibilities across services o Police o Crown Counsel o Corrections o Victim Services o Ministry of Children and Family Development o Court Services Branch o Information for Justices of the Peace and Trial Coordinators o Family Justice Services o Family Maintenance Enforcement Program o Protocol for highest risk cases • Considered a comprehensive definition of violence against women in relationships, including a protocol for the highest risk cases • Focused on the justice and child welfare response, but emphasized collaboration and coordination among all services • Recommended an integrated and cross-departmental response throughout the protocol for highest risk cases Taking action on domestic violence in BC (2012) • Laid out actions and timelines to improve the response to stop violence • Classified actions o Coordination and collaboration o Legislation and policy o Services, supports, and processes o Awareness and training • Defined actions addressing the recommendations in the report from the Office of the Representative for Children and Youth (Office of the Representative for Children and Youth, 2012) • Divided actions into immediate, short-term, and long-term • Included measures to strengthen the work between the Ministry of Health and Ministry of Children and Family Development to improve processes for providers within both ministries (e.g., develop specific protocols) British Columbia’s provincial domestic violence plan (2014) • Focused on the following sections o Public awareness and prevention o Supports and services for survivors and perpetrators o Justice system response o Coordination, information sharing and referral o Research, training, and evaluation o Approaches to address the unique needs of Aboriginal, immigrant and refugee women, and women with disabilities • Took VAWIR policy to level up a three-year project • Included actions such as the creation of the website www.domesticviolencebc.ca with information including definition, statistics, and resources • Created VictimLink BC/Domestic Violence Helpline, a toll-free, province-wide helpline to connect victims with services • Included guiding principles such as promoting safety, sharing responsibility, promoting integrated response, being culturally relevant and respectful, and striving for continuous improvement 77 Policy Actions/strategies towards effectiveness Specific strategies A vision for a violence free BC (2015) • Focused on actions to stop violence within next 10 years • Strategic priorities included o Preventing violence by changing behaviours o Ensuring BC has responsive, innovative, and coordinated services o Supporting women to re-build after violence o Addressing violence against Indigenous women o Fostering strong relationships and new partnerships • Aimed for a system of services and supports including more than 500 victim service and counselling, outreach, victim assistance, and shelter programs • Specified guiding principles such as a trauma-informed, holistic and multi-tiered, collaborative and coordinated, evidence-informed, long-term and sustainable, culturally safe, relevant and responsive approach • Implemented services with specialized responses and processes to sexual assault victims (e.g., docket/court processes) • Established third-party reporting protocols in the justice system to help women report sexual violence through community-based organizations if they did not want to go directly to the police Best practice approaches, child protection and violence against women (2017) • Operational guidance for processes o Voluntary services o Receiving reports o Contacting the police o Determining an appropriate response o Providing a response o Determining the child’s need for protection o Effective ways to protect children o Preparing for Child, Family and Community Service Act (CFCSA) court hearings o Ongoing protective family service • Promoted an integrated response to mothers impacted by abuse, and their children • Designed a coordinated departmental approach • Detailed an approach for providers, including specific operational procedures (e.g., “If it is determined that there is a violence against women situation” [p. 9], it is vital to know the location of the abusive man) • Included supportive services in case of abuse to mothers to improve their skills to continue to care for their child(ren) • Focused on a women-centred approach towards women’s empowerment and safety 78 Other policies enhanced strategies such as raising awareness and improving research, training, and evaluation as ways to deliver effective strategies. Taking action on domestic violence in BC (2012) and the British Columbia’s provincial domestic violence plan (2014) included actions to address the dynamics of violence. Actions included establishing domestic violence leaders to provide training and coordination support to providers. While the Ministry of Justice, the Public Legal Education Institute, and Legal Services in British Columbia would work together to develop legal education resources for the public, the Ministry of Education would develop training on responding to domestic violence for school workers and community partners. Policies also fostered relationships and new partnerships to enhance effective actions. The British Columbia’s provincial domestic violence plan built upon existing partnerships to raise awareness, to involve men and boys in standing up to end violence against women and girls, and to promote education materials focused on VictimLink BC, the domestic violence helpline. Likewise, A vision for a violence free BC (2015) stressed the need to develop partnerships. There was limited information related to the plausibility of the intervention, intermediate effects of the policy, or the impact of contexts on the policy’s effectiveness. Although the relevance of evaluating actions was stressed in the policy documents, there was no overall evaluation framework or approach for IPV policy and services. Finally, there was little information about engaging with women with lived experiences of IPV for policy development in terms of improving the effectiveness of the actions. Unintended effects: Several actions had unintentional effects (positive/negative) with regard to the stated goals. The release of the policy Taking action on domestic violence in BC (2012) led to issuing a revised Family Law Act in 2013 which explicitly defined family violence. The new Act was intended to increase the ability of the courts to address family violence. It had policy implications such as requiring family dispute resolution providers to screen for violence or creating protection orders that would “limit contact and communication between family members where there is a safety risk” (Ministry of Children and Family Development, 2012, p. 9). Justice reform within the policy, Taking action on domestic violence in BC, was another initiative with unintended effects. The reform yielded modifications in BC’s justice system that were reinforced in the next policy, the British Columbia’s provincial domestic violence plan (2014). As such, actions that came into effect after these legislative amendments (March 2013 onwards) indicated changes to align with the new legislation. A “significant enhancement is that family law 79 protection orders are now criminally enforceable” (Ministry of Children and Family Development, 2014, p. 14). The reform also impacted the policy, A vision for a violence free BC (2015). This document stated that the revised Family Law Act “increases the court’s ability to deal with family violence through a variety of measures, including a new criminally enforceable protection order.” (Government of British Columbia, 2015, p. 14). Further, A vision for a violence free BC indicated that domestic violence courts should use the Framework for domestic violence courts in BC (Ministry of Justice, 2014) to outline principles needed when implementing specialized court processes. These processes intended the Crown Counsel to be responsible for handling a file through several stages in a prosecution, to try to reach an earlier resolution without the necessity of a trial. Equity: All documents addressed equity by recognizing the importance of stopping violence against specific groups of women. Overall policy strategies to improve equity, including actions in groups of women, are presented in Table 16. Although the policy documents did not differentiate among the effects of the actions on various groups of women, they highlighted the importance of developing and implementing actions to limit further inequities and violence. Yet, there was little information specifying to what extent inequities would be limited, or the specific effect of the actions on health experiences in the groups of women identified. The groups included Indigenous, refugee, and immigrant women; women with disabilities; and women from the LGBTQ community. Although the approaches varied across policies, all stressed the need to address the unique vulnerability of each group. Actions for Indigenous women were more well developed compared to those for other groups. The efforts towards having an Indigenous response differed across documents but actions were mentioned in policies dated from 2010 to 2017. For instance, the importance of developing an Indigenous-specific response was stated in the policy Taking action on domestic violence in BC (2012), along with the province’s commitment to build a BC Indigenous strategy for IPV. Part of these commitments included establishing a Minister’s Advisory Council on Aboriginal Women (MACAW) to provide advice to the government on how to improve Indigenous women’s lives. The Provincial Office of Domestic Violence (PODV), established in 2012, was committed to work with the Ministry of Aboriginal Relations and Reconciliation and MACAW, “along with other key First Nation, Métis and Aboriginal organizations in addressing domestic violence in Aboriginal 80 Table 16 Analytical Dimension: Equity Source Policy actions/strategies towards equity Violence against women in relationships (VAWIR) policy (2010) • Acknowledged power imbalances in violence against women • Recognized that some groups (e.g., Indigenous women, immigrants, women living with disabilities) were at greater risk of experiencing more types of abuse and more severe violence than women not from these groups Taking action on domestic violence in BC (2012) • Included an action plan inclusive of specific approaches to support Indigenous, immigrant and refugee women, and women with disabilities British Columbia’s provincial domestic violence plan (2014) • Recognized the need for a diversity perspective to meet women’s needs • Considered the needs of children and youth • Considered the need to involve men in addressing violence • Acknowledged the need for an Indigenous-specific strategy to be developed collaboratively with Indigenous communities • Developed the Federal Provincial Territorial Justice Framework (Federal-Provincial-Territorial Ministers Responsible for Justice and Public Safety, 2016). A vision for a violence free BC (2015) • Recognized the effects of structures of power in Indigenous women’s lives • Identified groups such as immigrant, refugee, younger and older women, women with disabilities, and LGBTQ communities as being at higher risk of experiencing violence • Offered two programs (Respectful Relationships Program, Relationship Violence Program) to work with perpetrators convicted of violent offences, adapted to reflect the cultural characteristics of specific groups of men, including Indigenous partners Best practice approaches, child protection and violence against women (2017) • Identified the core principle that the safety and well-being of children depended on the safety of the mother • Used a woman-centred approach: o Building on women’s strengths o Developing trusting and respectful relationships o Empowering women through collaborative decision-making communities and developing an Aboriginal specific response” (Ministry of Children and Family Development, 2014, p. 10). The Federal-Provincial-Territorial (FPT) Justice Framework (Federal-Provincial-Territorial Ministers Responsible for Justice and Public Safety, 2016), developed in 2013 and updated in 2016, was designed to facilitate dialogue with Indigenous groups to improve justice and safety. Other measures involved signing the Memorandum of Understanding Regarding Stopping Violence Against Aboriginal Women and Girls, and the Giving Voice Project, to help Indigenous communities “to speak out and take action” (Government of British Columbia, 2015, p.18). Other groups of women were also considered. People from the LGBTQ community were mentioned in documents such as VAWIR policy (2010) and A vision for a violence free BC (2015). These 81 documents centred on the different needs and higher risks of experiencing severe violence. Only the policy, Best practice approaches, child protection and violence against women (2017), included information from a service delivery perspective; the others did not mention services and supports for women experiencing IPV. The Best practice approaches, child protection and violence against women (2017) emphasized the impact of marginalization on women who have experiences of IPV and analyzed layers of complexity to identify how women experience systemic abuse. For groups such as women with disabilities and refugee women, actions that providers delivering services should consider were included. “Child welfare practitioners need to connect clients with agencies that are knowledgeable about immigration and refugee issues, particularly agencies that understand the dynamics of working with a woman who has been abused by her spouse or sponsor” (Ministry of Children and Family Development, 2017, p. 42). Strategies focused on enhancing social supports for women who were fleeing violence (e.g., income and employment) were incorporated into A vision for a violence free BC (2015) that also explicitly outlined the creation of programs to work with perpetrators. Finally, the British Columbia’s provincial domestic violence plan (2014) discussed the importance of improving housing programs for women experiencing IPV. The following expands on the three dimensions (cost, feasibility, and acceptability) part of the implementation concerns axis. 4.3.2 Implementation Concerns Cost: This dimension focused on financial costs related to the policies (see Table 17). Overall, there were few details on funding, costs, or budgets related to implementation of services. The relevance of adequate funding to support actions and bridge gaps was found in the policy, Taking action on domestic violence in BC (2012). Other strategies to support victims of violence or those who may be at risk of violence were also funded through the policy British Columbia’s provincial domestic violence plan (2014). This document specifically indicated supports including funding for housing programs such as transition housing, safe home (specialized short-term shelters), or second-stage housing. Also, through the initiative Giving Voice (Ministry of Children and Family Development, 2014), organizations received funding to help stop violence in Indigenous communities. The province additionally co-founded the initiative, Be More Than a Bystander, to break the silence about violence against women. Be More Than a Bystander was released within the British Columbia’s provincial domestic violence plan (2014) and 82 Table 17 Analytical Dimension: Cost Source Implementation cost/Financial cost of the policies Taking action on domestic violence in BC (2012) • Proposed a thorough cost-analysis to identify needs, resources, and gaps • Government to commit to adequate additional funding British Columbia’s provincial domestic violence plan (2014) • Invested $5.5 million for the three-year plan to address domestic violence • Provided close to $500K to support the Be More Than a Bystander Campaign to engage men and boys to end violence • Committed more than $40 million in programs and services for victims of crime including women and children impacted by violence • Considered $32 million annually to support more than 800 spaces in women’s transition houses, safe homes, and second-stage housing A vision for a violence free BC (2015) • Dedicated $3 million in funding to support anti-violence initiatives focused on violence against women, and a public awareness action campaign • Continued the three-year, $5.5-million British Columbia’s provincial domestic violence plan started in previous policy (Ministry of Children and Family Development, 2014) • Considered more than $70 million in annual investments in prevention and intervention services to continue work on the recommendations of the Missing Women Commission of Inquiry (Government of British Columbia, 2015, p 2) continued to be funded in, A vision for a violence free BC (2015). Other measures within A vision for a violence free BC, included income assistance through WorkBC Employment Services Centres to meet the employment needs of survivors. And funding for the BC’s Civil Forfeiture program led to projects such as the Fraser Health Authority’s online training (“Human Trafficking – Help Don’t Hinder”) (Government of British Columbia, 2015, p. 20) that helped providers identify victims of sexual exploitation. There was little information related to implementation cost for the government, specific costs for all actors involved (e.g., ministries, organizations), or costs compared to other policies. Feasibility: Policies showed how the strategies were technically viable by including information about how the policy followed legislation or how the policy built upon previous actions (see Table 18). The similarities among specific strategies and policy actions can also be seen in the effectiveness dimension noted earlier (see Table 15). Particularly, Taking action on domestic violence in BC (2012), was aligned with the VAWIR (2010) policy that was first issued in 1996 and aligned with actions highlighted in the British Columbia’s provincial domestic violence plan (2014). In Taking action on domestic violence in BC and British Columbia’s provincial domestic violence plan, the province was already delivering or planning 83 Table 18 Analytical Dimension: Feasibility Source Conformity with relevant legislation Mechanisms to implement the policy Role of authority or actors involved Violence against women in relationships (VAWIR) policy (2010) • Built on VAWIR policy developed in 1993 • Updated several times (1996, 2000, and 2004) to reflect legislative (e.g., Criminal Code) and operational changes • Partnered with local providers on approaches supported by protocols or memorandums of understanding Taking action on domestic violence in BC (2012) • Aligned with the VAWIR (2010) policy • New Family Law Act would promote a better response to family violence • Changes to the justice system • Attempted to address IPV as the first province-wide initiative • Developed an integrated approach to address “domestic violence across the child and family serving systems in BC” (p. 4) British Columbia’s provincial domestic violence plan (2014) • Aligned with actions of the Taking action on domestic violence in BC (2012) plan • Amendments to the Child, Family and Community Service Act (CFCSA) • Followed many of the previous (2012) policy strategies and actions • Used a cross-government approach, considering both different ministries and levels of government A vision for a violence free BC (2015) • Built on provincial work in the previous year • Amended legislation to improve information sharing • Considered a strong focus on the gravity of domestic violence • New legislation such as the Missing Persons Act passed in 2014 to support investigations • Emphasized processes for prevention of and response to violence • Stressed that supports for women need both measures to prevent violence, and actions to help women to scape and recover from it Best practice approaches, child protection and violence against women (2017) • Aligned with service delivery principles of CFCSA, the Aboriginal Operational Practice Standards and Indicators, and Ministry standards • Original version ended in 2004, updated in 2017 • Included amendment 13 to bring the CFCSA in alignment with child welfare legislation • Emphasized that all “relevant services must work together for a coordinated, collaborative response” (p. 7) to deliver several actions, including “Crime Victim Assistance Program, Police-based and Community-based Victim Service Programs, VictimLink BC/Domestic Violence Helpline, […] Outreach and Multicultural Outreach Programs, Victim Court Support Program, and the Victim Safety Unit” (Ministry of Children and Family Development, 2014, p. 13). Taking action on domestic violence in BC (2012) 84 highlighted actions needed to conform with existing legislation, including implementing the amendments to the Child, Family and Community Service Act (CFCSA) that was a strategy articulated in subsequent policies. Also, Best practice approaches, child protection and violence against women (2017), was aligned with service delivery principles of the CFCSA that was amended because of the British Columbia’s provincial domestic violence plan (2014). After the amendments to the CFCSA came into force in 2014, A vision for a violence free BC (2015) emphasized the severity of domestic violence. This change brought the CFCSA into alignment with other child welfare legislation. Best practice approaches, child protection and violence against women also supported service delivery principles of CFCSA. A vision for a violence free BC followed existing measures from the British Columbia’s provincial domestic violence plan such as strengthening community partnerships. Preventing Violence by Changing Behaviours, within A vision for a violence free BC policy, was a strategy to change attitudes in three areas: “school-based prevention initiatives, awareness-raising activities, and anti-violence programming for male perpetrators of violence against women” (Government of British Columbia, 2015, p. 10) Two school programs were established through this policy to increase emotional understanding in children: Roots of Empathy and Seeds of Empathy. There were two other programs to work with perpetrators, the Respectful Relationships Program and the Relationship Violence Program. Little information regarding the quality or characteristics of the cooperation among actors involved was identified. Although the participation of the healthcare sector was stated in some policies (e.g., Taking action on domestic violence in BC 2012, British Columbia’s provincial domestic violence plan 2014), the detailed role and functions or competencies were not clearly defined. No data were identified regarding actions or processes to engage with women with lived experiences of IPV, as collaborators to support implementation. Acceptability: All documents involved several actors to develop, update, and implement policies to enhance the acceptability of the strategies. Through a cross-sectoral approach, ministries and private or not-for-profit organizations worked together to facilitate the internal approval of the actions, bolstered by external endorsement from other agencies. Information on the acceptability of acting on the problem of IPV, the decision-making process, or the policy itself are identified in Table 19. For example, the acceptability of acting on IPV and the establishment of the PODV in 2012 were key to monitoring all 85 Table 19 Analytical Dimension: Acceptability Source Actors involved Acceptability of acting on the problem, decision-making process, or the policy itself Violence against women in relationships (VAWIR) policy (2010) • Ministries of Public Safety and Solicitor General, Attorney General, and Children and Family Development • Led a provincial attempt towards a comprehensive legislative response to violence • Built on interpersonal dynamics of domestic violence to deliver an individualized response Taking action on domestic violence in BC (2012) • Ministries of Children and Family Development, Education, Health, Justice, Social Development, and Aboriginal Relations and Reconciliation, and other offices • Established the Provincial Office of Domestic Violence, which was situated in the Ministry of Children and Family Development • Stressed the responsibility “to monitor, evaluate and report on the responsiveness and effectiveness of domestic violence services, programs, training and initiatives across government” (p. 4) British Columbia’s provincial domestic violence plan (2014) • Ministries of Aboriginal Relations and Reconciliation; Children and Family Development; Education; Health; Jobs, Tourism and Skills Training and Responsible for Labour; Justice; Social Development and Social Innovation; and BC Housing • Built on the work of the anti-violence community sector and initiatives (the provincial Erase Bullying and Together to Reduce Elder Abuse) • Recognized that a coordinated approach to addressing domestic violence was needed A vision for a violence free BC (2015) • [Government of British Columbia] • Led strategic actions towards stopping violence against women over the next decade Best practice approaches, child protection and violence against women (2017) • Ministry of Children and Family Development and a working group of multiple agencies • Used “a coordinated collaborative response including child welfare workers, multicultural support workers and Aboriginal/Metis family support workers” (p. 7) to connect child welfare and violence against women approaches further activities related to stopping and/or limiting violence (Ministry of Children and Family Development, 2012). For the acceptability of the decision-making process, the government and several partners used an integrated approach for most of the policy actions. For instance, A vision for a violence free BC (2015) planned to support coordinated responses to highest risk domestic violence cases. The policy emphasized supporting “integrated and collaborative models of service delivery” (Government of British 86 Columbia, 2015, p. 13). Further, the VAWIR policy (2010) and Best practice approaches, child protection and violence against women (2017) established an operational and horizontal perspective to facilitate health and social care providers’ work. In addition, the Ministry of Children and Family Development and multiple agencies recognized that violence against women is a complex health problem where the safety and wellbeing of children are highly associated with the safety and welfare of mothers. Thus, for both, a strong police response was identified as part of an effective strategy against violence. Although the specification of the police participation varied in each document, the overall guiding principles were based on supporting women with actions against perpetrators. Finally, although some policies called for the involvement of the provincial Ministry of Health to strengthen the acceptability of the actions across healthcare organizations, there was little information about the extent to which the health system participated in implementation concerns. Further, there were no data about a specific health-related office or department within the Ministry of Health with specific functions or roles to evaluate the actions. There was a lack of information related to the acceptability of the policy actions by other actors involved in implementation or the target population (e.g., women with lived experiences of IPV). No data were identified in relation to the acceptability of accountability measures. The next section will elaborate on specific content related to the six dimensions to develop a more integrated and equity-based system for women who experience IPV in BC. 4.4 Discussion A policy analysis was completed to explore what policy documents existed, and how they supported or hindered actions to limit IPV experienced by women in BC over the last 10 years, including the role of policy in moving to a more integrated and equity-based health system for women. For this study, five publicly available provincial documents to improve the conditions of women who experience IPV were identified. The documents analyzed are identified as health policies and public health policies (Benoit, 2013) since all prioritize improving conditions that impact health status due to marginalization and IPV. Prioritizing health in public policy in relation to social issues is a common approach called health in all policies (Townsend et al., 2020). This approach systematically considers the health and equity implications of policy decisions. Although this approach aims to limit barriers to healthcare, it is known that populations who experience marginalization are at a high risk of being negatively affected by policies. 87 As such, policies designed to impact health equity should emphasize the specific impact of their actions on target groups, since the policy actions provided may not align with the multiple realities of people experiencing marginalization (Silva et al., 2013). Unfortunately, this policy analysis could not verify the participation of women with lived experiences in the design or implementation of the policy actions studied. Since the goal of this policy analysis was to examine policy documents to identify whether they support actions to limit IPV in BC, key content related to both the effects of the policy and implementation concerns in terms of more integrated and equity-based services for women who experience IPV in BC are presented in the following sections. 4.4.1 Towards More Integrated and Equity-Based Services for Women Types of Supports: Policies emphasized the supports that women required to meet their needs and the way these services should be designed and implemented. Supports such as child welfare, justice and legislation, and social services including housing or employment assistance were considered across all policies (see Table 15). Although coordinated and integrated services and supports were highlighted among various sectors of the government; multiple public, private and not-for-profit organizations; and providers to create effective services, the participation of the health system regarding specific functions was not clearly stated. To enhance integration, Taking action on domestic violence in BC (2012), British Columbia’s provincial domestic violence plan (2014), and A vision for a violence free BC (2015) policy documents prioritize strategies towards establishing partnerships across agencies. Establishing partnerships across sectors has proven to be effective in improving health outcomes (Shahzad et al., 2019). Benefits of partnerships can help address issues such as “outreach to increase access to services for vulnerable populations, community-based health promotion and prevention programming for specific population groups (e.g., women, youth), and provider capacity building” (Valaitis et al., 2020, p. 11). For hardly reached populations, approaches such as outreach improved patient experience and population health (Valaitis et al., 2020). In, A vision for a violence free BC (2015), access to care through outreach services was a key strategy to support women experiencing IPV. Although the policies established the types of supports that should be implemented, this analysis could not identify whether the implemented supports improved health experiences and outcomes. It is important to determine if these supports have been effective in impacting women’s lives. Suggested service improvements for women included 88 psychological, advocacy, and home visiting interventions; however, evidence is not conclusive about the effectiveness of these in the long term (Hameed et al., 2020; Rivas et al., 2015). Health Equity: Potential impacts of the policies on equity were identified. Policy documents show the BC government’s attempt to deliver a thorough response to address systemic violence against women. All policies emphasize and outline actions to support immigrant, refugee, and Indigenous women, as well as women with disabilities, since these groups are recognized to be at a higher risk of experiencing IPV than women who are not part of these groups. To address health inequities, it is important to understand how the effects of power, including politics, policies, and/or practices, frame health equity, health policy, and consequently health status; particularly, “the importance of recognizing social groups and how institutions and policies which appear value-neutral actually favour dominant groups and embed structural inequalities in society” (Harris et al., 2020, p. 550). This policy analysis found that the approach to equity across policies relied on targeting defined groups of women (see Table 16). Experts who support health equity considerations when designing health policy highlight that political enhancements to address social injustice and inclusion that use a group-differentiated approach can lead to further issues of oppression, if the specific impact of the policies on the multiple target groups is not recognized from the beginning of the design and implementation processes (Young, 2003). Public health policy, including health public policy should challenge group-based imbalances by acknowledging and distinguishing social group differences. As such, group-differentiated public policies are needed to address social justice (Young, 2003). Although the impact of systems of power/oppression is difficult to measure, equity-based analyses and methodologies focused on “understanding of between and within group differences” (Green et al., 2017, p. 215) would benefit health public policy designs based on social group differences. To acknowledge the systemic layers of oppression experienced by women with disabilities, Indigenous, or refugee women, the policy, Best practice approaches, child protection and violence against women (2017), advised providers to ask specific questions about abuse histories and needs. It was stressed that asking questions helped providers to better understand the impact of violence from structural perspectives. Although this policy did not explain how providers would broaden their understanding, it encouraged them to understand the social dynamics of violence and to think about the 89 systemic effects of trauma and violence and long-term symptoms of abuse such as chronic pain. Wallace et al. (2021) examined pain, discrimination, and stigma in people who experience marginalization, such as LGBTQ, Indigenous, and newcomer and refugee groups in BC. Participants’ experiences of pain were shaped by interconnected factors impacting employment, income, and their lives. Overall, social locations and experiences of violence, trauma, and health services that do not meet people’s needs are all interrelated. The authors argued that equity-based responses should support people experiencing pain and marginalization by recognizing pain as a social justice issue. Little research exists on the multiple effects of marginalization and IPV on different groups of women (Brownridge et al., 2022; Weeks et al., 2021). Since many intersecting locations exist for women experiencing marginalization and IPV, there is a need to differentiate the intersections with and among categories recognized as historically oppressed when planning and designing policies and services. This in-depth intersectional analysis will strengthen the understanding of initiatives based on equity, diversity, and inclusion (Rose, 2021). Collaboration and Integration: A collaborative response to improve the navigation of services was identified as enhancing the impact of policies. Policies such as VAWIR policy (2010) and Best practice approaches, child protection and violence against women (2017) promoted collaboration to facilitate care provided at the point of care. Further, the policies reviewed outlined strategies based on cross-ministry and intersectoral approaches to limit system barriers and enhance system integration. Several ministries worked together to develop protocols and service delivery processes for women affected by violence (e.g., outreach, victim assistance, shelter programs) (see Tables 15, 18, 19). There is no evidence at the provincial level of the use of a specific approach to improve integration of services or to address health inequities, but Lucyk (2020) indicates that an intersectoral approach has been taken by the Canadian federal government as of December 2019 to address health inequities. This approach aims to articulate “which ministers should work together, on which issues and to what end” (Lucyk, 2020, p. 1). An intersectoral approach is identified as one of the most common redesign strategies based on integrated and population health-oriented systems of care (Farmanova et al., 2019). Researchers in Canada also recognize an intersectoral approach as essential in health policy (Cohen et al., 2014; Huynh, 2014). Intersectoral approaches are used by integrated health systems that use both population health and person-centred approaches (Singer et al., 2020; Steele Gray et al., 2020). These approaches, 90 particularly used together, aim to address multiple SDH, health inequities, and the health of vulnerable groups by understanding needs and solutions through community outreach (Cohen et al., 2014). Research emphasizes that an effective health system approach to limit IPV relies on providing supportive care, advocating for a coordinated action among sectors, and implementing policies and structures that limit system barriers (Garcia-Moreno, Hegarty et al., 2015; WHO, 2019, 2021a). Unfortunately, this policy analysis could not identify to what extent BC has built system-level integration through an intersectoral approach. The results show variability regarding the level of collaboration and integration among organizations in the province. According to Valentijn et al. (2013), organizational integration, defined as “inter-organisational relationships (e.g., contracting, strategic alliances, knowledge networks, mergers), including common governance mechanisms” (p. 6) aims to support processes and structures to deliver comprehensive services to a defined population. These authors stated that a process towards integration has four stages: segregation, linkage, coordination, and integration. The stages are interconnected and not mutually exclusive, and depend on the duration of the commitment and the extent of shared decision-making among organizations. Since these types of arrangements depend on the levels of flexibility and commitment among organizations, the linkage and coordination stages are often achieved. This aligns with what was identified in the policy analysis, where the level of integration of health and social services in BC seems to range between the linkage and coordination stages. Although all policies stressed the need for more collaborative, coordinated, and integrated services, little information was identified about the quality of the characteristics of the relationships among organizations involved in the delivery of care to facilitate implementation (see Tables 18, 19). Valentijn et al. (2013) stressed that in the linkage and coordination stages, each organization retains its autonomy, which requires the involved organizations to constantly negotiate and evaluate the outcomes of the collaboration, resulting in an uncertain and changing environment. It is important to identify whether policies are translated into daily organizational practices to limit violence and their impact on women in BC. Organizational and service integration for women experiencing IPV through Ontario services has increased access to and acceptability of services (Mantler et al., 2018, 2020), and improved system navigation (Mantler et al., 2018). It would be useful to examine the status of organizational and service integration in BC. 91 Another mechanism impacting the integration of organizations and services is called process integration. Process integration (Singer et al., 2020) can support the integration of services, especially at the point of care. Process integration refers to “courses of organizational actions or activities intended to integrate patient care services into a single coordinated process across people, functions, and operating units over time, and it is often referred to as clinical integration” (Singer et al., 2020, p. 199). All policy documents used a collaborative approach with the involvement of several actors from policy design to implementation processes (see Tables 18, 19). Although it appears that BC aimed for a collective approach to support policy implementation, detailed information regarding the level of collaboration of specific healthcare organizations such as hospitals or primary healthcare settings was not available. According to Ansell et al. (2017), a collaborative approach may reduce the gap between design and implementation by helping policy makers improve policy execution. By recognizing that the wellbeing of children is associated with the safety and welfare of the mothers, agencies worked across levels and sectors to execute an effective response, including police and justice responses, to protect women and their children (Ministry of Children and Family Development, 2017). However, since the responsibility for policy implementation for health, police, and justice falls on provincial governments in Canada (Raphael & Sayani, 2019), specifications on how to effectively integrate and implement processes for women’s services across the continuum of care should be clear at all levels of service provision. Since there was significantly more information related to specific actions of social services such as shelters than specifications regarding collaboration of healthcare organizations, clinical collaboration to improve overall health status may have been limited. Policy Direction: From 2010 to 2017, most of BC provincial policy goals were aligned with the design and implementation of strategies to meet women’s needs (see Table 15). Documents built upon each other to strengthen existing work and address the complex needs of women, even prior to the timeframe of this policy analysis (e.g., the VAWIR policy [2010] was first issued in 1996). Through the implementation of specific supports such as victim service units or a domestic violence helpline, most policies reinforced linkages among actions and increased the viability of strategies over the long term. Also, legislative changes were designed and implemented through the policy, Taking action on domestic violence in BC (2012), and recognized and articulated in subsequent documents such as the British 92 Columbia’s provincial domestic violence plan (2014) and A vision for a violence free BC (2015). Policies released in 2013 and since then were also aligned with these legislative changes. Several factors affect policy implementation processes to facilitate alignment across policies; therefore, policy design and policy-making processes require policy goals and implementation strategies be “congruent and convergent” (Howlett, 2009, p. 74). As such, Taking action on domestic violence in BC (2012), British Columbia’s provincial domestic violence plan (2014), and A vision for a violence free BC (2015) had a similar approach to link planning, organization, and implementation of strategies. Since this policy analysis did not identify additional policies or policy directives in BC on IPV related services from 2017 onward, the direction of actions related to the care of women who experience IPV in BC seems uncertain. Further, given the current situation with the COVID-19 pandemic impacting the care of women who experience IPV, it is important to identify the impact of COVID-19 and the increase in IPV rates in the province. New policies will need to consider the implications of the pandemic. Results of this policy analysis indicate the overall provincial policy agenda for IPV. Although the policy agenda aimed for coordination, collaboration, and integration across ministries and organizations as ways to set provincial policy direction, it seems the response was only aligned, as such multiple organizations have different responses when implementing actions. Burnett et al. (2019) argued that health systems should design measures and align them with the antiviolence social sector, which is known to plan and deliver actions involving justice and shelters. Another consideration when setting the public health policy agenda relates to emphasizing how health equity needs in specific populations would be addressed and identifying the differentiated impact of policies and actions. By using a health policy approach, equity considerations are prioritized when setting the policy agenda (Hancock, 1985; Winnipeg Regional Health Authority, 2017). Although all policies highlighted the need to address health inequities in multiple groups of women, none of the policies recognized how women were or would be involved in setting the policy agenda, supporting policy direction, or developing or evaluating policy. By considering a health equity approach, women’s engagement in planning and delivery of their own services at higher levels of the decision-making process, such as agenda setting, are relevant for building capacity and appropriate resources (Snow et al., 20 18). It appears that this was not the case in the policies reviewed. This is an essential component that seems to be missing in the policy process, from development through 93 implementation and evaluation. By defining a process to include women’s insights in both the design and implementation of IPV-related policies in BC, more integrated and equitable services for women would be possible. 4.4.2 Strengths and Limitations for Health System Integration and Health Equity Strengths: All documents aim to provide direction for specific actions from governance, management, or operational perspectives for women experiencing IPV. Ensuring IPV-related policies are applicable at various policy levels (Howlett, 2009) facilitates the support of women from a system perspective and creates a more comprehensive understanding of abuse. The BC government and several partners worked towards an equity-based approach (see Tables 15, 16) to address systemic violence since the release of the VAWIR policy (2010). Specific actions are designed to address power imbalances in multiple groups of women experiencing IPV (Ministry of Children and Family Development, 2014). Through an intersectoral approach, the province articulated legislative changes, including changes in the justice system (Ministry of Children and Family Development, 2012). These modifications led to actions needed to ensure effective legislation across BC. Several documents such as frameworks, reports, or changes in legislation (see Figure 5) to support and articulate actions to impact women’s lives are also identified. As noted, these documents facilitate policy implementation (Capano & Howlett, 2020). The linkage of actions from prior policy documents to current policies impacted the implementation of actions. The general development of the five policy documents met policy formulation criteria and used a wide range of designs (Capano & Howlett, 2020). On one hand, a cross-sectoral systemic reform is articulated over the identified time period that includes adaptation of key actions (e.g., legislative and justice systems changes). On the other hand, there are minor adjustments to existing policy arrangements, such as the alignment shown between strategies of the policies Taking action on domestic violence in BC (2012) and British Columbia’s provincial domestic violence plan (2014). To enhance system integration for women who experience IPV, policy documents could benefit from incorporating specifications on how to integrate across the continuum of care regardless of levels and sectors. Limitations: Since the release of the British Columbia’s provincial domestic violence plan (2014), the province fostered partnerships across sectors. As such, the PODV, established in 2012, is identified 94 as the agency that would monitor and oversee progress related to limiting violence against women; however, there was little information on how this agency would accomplish this task (e.g., performance evaluation) (Ministry of Children and Family Development, 2014). Also, the British Columbia’s provincial domestic violence plan (2014) has a strategy to improve service integration to enhance information sharing and referral processes among agencies; however, a proposed initiative to create VAWIR committees to enhance referral processes was not mentioned in documents accompanying the plan, nor in the subsequent policy, A vision for a violence free BC (2015). Given that referral models continue to be an important gap, with long wait times for consultation with specialist services, in integrating services in the Canadian health system (Martin et al., 2018), clarification on how these gaps impact community partnerships, including detailed responsibilities and timelines, is needed. Community-based programs such as outreach services are mentioned as part of the strategies to address inequities for women (Government of British Columbia, 2015); however, clarity on the characteristics of these services would support implementation. An identified gap is the limited information on the costs dimension (Table 17). Policies emphasized the relevance of funding and/or supporting specific programs to have an impact on systemic violence (Government of British Columbia, 2015), but how the agencies or local organizations promote health outcomes through services such as housing is not discussed in detail. Although the FPT Justice Framework (Federal-Provincial-Territorial Ministers Responsible for Justice and Public Safety, 2016) was developed to understand the different priorities of Indigenous women compared to non-Indigenous women in terms of justice and safety (Ministry of Children and Family Development, 2014), there was little information on how this framework would be supported. While this policy analysis found policy instruments such as reports related to specific policies (see Figure 6), a complete analysis of the impact of policy instruments on health status, including the role of institutions and structures created to articulate actions was not part of this study. 4.5 Recommendations 4.5.1 For British Columbia As Raphael and Sayani (2019) argue, gaps in implementing health equity-based public policy in Canada need to be addressed. Due to the complexity of the Canadian health system in governance and 95 coverage of services (Martin et al., 2018), and particularly with the provincial mandate to organize and deliver care, it is vital to evaluate actions, especially those that are continuous over years. The reason for the lack of policies after 2017 needs to be assessed as well. It appears that having a cross-sectoral approach facilitated the implementation of major legislative reforms (e.g., amendments to the Child, Family and Community Service Act) and supported the overall integration of services. However, an impact evaluation of these changes is needed. There is a need to set clear accountability measures and practices across sectors as well. The involvement of social (e.g., shelters) and justice services has benefited women; however, there is a need for enhancing the participation of the Ministry of Health in the design and delivery of specific actions. A stronger intersectoral collaborative approach with a clearer role for the health system to support women will facilitate providers’ understanding of their responsibilities towards limiting IPV against women and in society. 4.5.2 For IPV Policy Garcia-Moreno, Hegarty et al. (2015) suggest that a comprehensive response to limit IPV requires more integrated, collaborative, and coordinated connections between sectors. “Consensus evidence suggests that health services need to work closely with specialist services, including the police, to enhance safety for women and children” (Garcia-Moreno, Hegarty et al., 2015, p. 1572). However, there is mixed evidence about how to design and implement policies based on health equity and health system integration. There is little agreement on how equity considerations should be defined when designing and delivering equity-based services. Specifically, “the trade-off between efficiency and equity, or between equity considerations, should be operationalized” (Reckers-Droog et al., 2019, p. 1). While specific approaches aim to evaluate health-related equity impacts such as improvements in health outcomes, these experiences or outcomes may not be comparable between or within groups of women. Since women’s engagement in health policy design and service delivery is needed to build equity-based services (Snow et al., 2018), women’s participation in these processes is key. However, this policy analysis could not identify women’s involvement or if their voices or opinions were incorporated in the design or delivery of the policy actions. Since challenges exist in integrating health and social services to IPV, setting clear policy goals and specifications on how to translate these goals into action is important to achieve health systems integration, as found in the analysis of IPV-related policies in Ontario (Mantler 96 et al., 2019). Although policies set overall direction for action, clear guidance is needed to improve the care of women who experience IPV at the point of care, especially in relation to the role and functions of the social, justice, and health sectors. Finally, guidance on developing public health policy and public policy formulation should be used to create appropriate policies in these areas related to IPV (Benoit, 2013; Cusack, 2013; Winnipeg Regional Health Authority, 2017). 4.5.3 For Policy Analysis Research From a research perspective, there is a need to further investigate IPV as a complex phenomenon that requires multiple approaches, theories, and methodologies to be more fully understood and addressed. Gear et al. (2022) argued that IPV is a complex issue where there is a high level of interconnections among many elements, making it hard to predict and limit what outcomes will occur. Specifically, assessing the impact of the interactions among policy levels is important. From a health policy research perspective, it is important to understand the impact of the policies across social services such as shelter and justice (e.g., police) on the health and lives of women. 4.6 Strengths and Limitations of the Policy Analysis To my knowledge, this policy analysis is the first of its kind to study policy documents for the design and implementation of health and social services for women who experienced marginalization and IPV in BC in the past 10 years. The use of the framework for analyzing public policies (Benoit, 2013) allowed me to apply scientific rigour to the study of public policy issues related to provincial health problems. The analysis of policy issues including implementation, costs, and operational concerns differentiates this research from other research that focuses on social, economic, or political disciplines. This analysis aimed to explain policies and aspects related to their development and implementation. As part of the limitations, this analysis studied existing policies without including an analysis of policy-related documents (e.g., policy instruments) or regulatory aspects (e.g., plans to improve specific actions or services). Due to the complexity of studying the effectiveness of policy actions, this study did not evaluate the impact of the policy actions on health outcomes and experiences of women experiencing marginalization and IPV, providers, or decision- or policy-makers. Thus, several aspects of the policy cycle (Capano & Howlett, 2020) such as agenda setting, policy formulation, or policy evaluation are not considered in detail. Interviews with policy-makers and other contributors would enhance the 97 understanding of the analysis. Although working groups included participation from community organizations that engage and support women, the policy analysis could not verify women’s direct participation. 4.7 Remarks This policy analysis identified five policy documents to establish accountability to achieve specific goals towards limiting IPV in BC. The scope of the documents was mainly focused on governance; however, operational procedures at the micro level were also identified. Additionally, explicit services were recognized as part of the supports that women need to meet their needs. The policies analyzed considered child welfare and justice as core services; however, the role and function of healthcare is not specific. As such, further and detailed participation of the health system is needed to align the response of services such as shelters and justice. There seems to be partial integration across organizations and services, including health, social, and justice. This policy analysis identified a key mechanism to address health inequities by improving partnerships and service collaboration. To address health inequities, all policies emphasized the need to understand the diverse needs of different groups of women when designing policies and services; however, none clearly recognized the relevance of engaging women with lived experiences of IPV to identify their specific needs. Several policies were developed and implemented by building on previous policies, with the aim of providing a longer-term response to IPV. Unfortunately, some actions were broad and limited their implementation at organizational or operational levels. Although it appears the province has advanced the integration of organizations and services related to the care of women who experience IPV, a more in-depth approach involving women’s and contributors’ interviews, is needed to identify the impact of the policy effects, particularly over the long term. This policy analysis provided important information to address the overall goal of this dissertation in terms of how BC is addressing the needs of women who experience IPV. It also demonstrated the need to incorporate women’s and contributors’ voices and experiences related to the design and implementation of specific policy actions and services. It supported the results of the geographically narrowing study design, moving from a national to a local level, as foundational to Phase 3, the KT discussion session, of this study. 98 Chapter 5 presents results related to women’s and contributors’ perspectives to improve specific policies, services, and procedures for women who experience marginalization and IPV in the Southern Interior of BC. 99 Chapter 5. Knowledge Translation Discussion Session 5.1 Background As discussed in Chapter 4, there were limitations in the design and implementation of policies and actions to meet the needs of women who experience marginalization and IPV. Since the policy analysis could not identify whether women’s voices were incorporated into the planning and delivery of these actions, this phase of the study aimed to study and integrate women’s voices, as well as the voices of decision-makers and service providers. This chapter presents the final considerations of this three-phase study involving a geographically narrowing approach from national to local levels. Health and social care research based on patient-oriented principles (CIHR, 2014) aims to better understand and demonstrate why and how knowledge exchange, dissemination, and coproduction is central to improving healthcare (Banner et al., 2019). As stated in Chapter 1, there are differences between knowledge dissemination and diffusion. Knowledge dissemination is an “active process to communicate results to potential users by targeting, tailoring and packaging the message for a particular target audience” (Gagnon, 2010): this is a “make it happen” perspective. Knowledge diffusion takes a “let it happen” perspective, where dissemination is a passive, unplanned, and uncontrolled process (e.g., conferences), and service users need to seek out the knowledge (Gagnon, 2010). For health and social services to be effective, approaches need to reflect the needs of those using the services (Banner et al., 2019), and incorporate specific strategies for knowledge exchange and coproduction (CIHR, 2014). According to Snow et al. (2018), practices such as “developing a process of information sharing, and considering benefits to those being engaged” (p. 10) need to be discussed and established with people who experience social exclusion, such as many women who experience IPV. These participants often find the engagement process complicated and disconnected from their lives and realities. Asking people with lived experiences of marginalization to engage in research puts an additional responsibility on them to learn about the process and may minimize the importance of their values and experiences (Snow et al., 2018). By participating and engaging in health and social research, women will have opportunities to make decisions related to the services they need and that impact their lives. For Phase 3 of the study, a virtual KT Discussion Session allowed me to involve and connect with women with lived experiences of IPV, as well as contributors from both health and social services, and to 100 obtain their input for action. The goal was to bring people together to share relevant research findings and gather their perspectives and recommendations on the services delivered and offered to women who experience marginalization and IPV in the Southern Interior of BC. 5.2 Methods 5.2.1 Analytical Foundation This dissertation used KT (CIHR, 2012) and equity-oriented (Banner et al., 2019; Snow et al., 2018) approaches to facilitate an inclusive process that promoted coproduction, exchange, and dissemination. Specific end-of-grant and IKT (CIHR, 2012) strategies facilitated the implementation of the research and uptake of results. The research team included a knowledge user from Interior Health Authority in BC along with researchers from the UBC (Okanagan and Vancouver). The phases of the spectrum of public participation (e.g., inform, consult, involve, collaborate, empower) (International Association for Public Participation, n. d.) were used to improve the understanding of the impact of oppression on women and undertake an equity-based approach to health research. An intersectional lens (Bailey et al., 2019) provided a way to understand health and social inequities, marginalization, and IPV in terms of power imbalances. Specific methodological procedures are presented next. 5.2.2 Methodological Procedures Data Collection. A virtual KT discussion session with women with lived experiences of IPV, key contributors from BC, and other interested contributors was the main data collection method. This event was organized to exchange and discuss the results of Phases 1 (Scoping Review) and 2 (Policy Analysis) and to identify recommendations regarding health equity and health system integration. Sampling Approach: Convenience sampling (Thorne, 2016) to reach women with lived experiences of IPV and contributors was used. We looked for maximum variation (Marshall & Rossman, 2006) in age, geographic representation, and diversity. For women with lived experience, we sought involvement from participants belonging to diverse social categories of difference (e.g., Indigenous, LGBTQ) and from socially excluded groups (e.g., those experiencing homelessness, single mothers). We also sought participation from a Peer Advisory Group from the Interior Health Authority. For contributors’ participation we looked for variation in roles (e.g., managers, providers [e.g., social worker, nurse], decision-makers, policy-makers). 101 We sought participation from lead managers of local health and social organizations (e.g., shelters) and other supports such as sexual abuse centres, or supports for immigrant, refugee, and other groups. Inclusion/Exclusion Criteria • Women and/or self-identified (e.g., cisgender, transgender, non-binary) women 19 and over • Women who experienced IPV and marginalization • Contributors such as policy-makers, decision-makers, managers, health and social care providers who deliver care to women experiencing marginalization and IPV • Contributors providing formal social supports in BC Recruitment Approach: We asked health and social services organizations and committee members to contact women who met the inclusion criteria. We asked these organizations to contact women by email or in-person and invite them to participate in a KT discussion. We shared information about the type of content that would be discussed in the event and emphasized that participants did not need to answer any question they did not feel comfortable answering. An email invite (see Appendix I) was printed and provided to women for the in-person invite. When women were interested in more information, they were offered a “permission to contact form” (see Appendix J) to sign. For those who did so, I contacted them to talk about the study. Women could contact me directly using the contact information in the email invitation. Information about the study, including the purpose and content of the discussion, was provided to women in a follow-up phone call. Women who were interested in participating received a follow-up email and/or phone call with written and oral consent forms (see Appendices K and L) and a list of supports with telephone numbers and website links of organizations that they could contact if needed. Contributors received an email invitation and consent form directly to the publicly available email address on their organizations’ websites. They also received the invite (see Appendix M) via an email sent to individuals via the Graduate Student Researcher and Committee members’ networks. Additionally, an email invitation was sent to the lead managers of local health and social organizations. The consent form and the agenda (see Appendices N and O) were emailed to all contributors when they agreed to participate in the study. The consent form and the agenda included information about the type of questions to be discussed at the session. Up to two reminders were sent to organization contributors. 102 We provided the opportunity to give oral consent over the phone prior to the session and at the beginning of the session. Discussion Approach and Data Collection Process: Prior to the event, a summary report of preliminary results was sent to the women and contributors who had agreed to attend the discussion session. During the discussion, participants were encouraged to share their insights on health and social policies and services for women experiencing IPV in BC. They were asked their thoughts and perceptions by answering three to five semi-open-ended questions. Guiding questions were adapted for both groups, the women and the contributors (see Appendix P). In the case of the women with lived experiences, we asked about the services they received, and how integration of services and equity-based care have been implemented from their lived experience perspective. We asked about specific social services they considered to be priorities and whether policies and services met their needs. The questions followed a trauma- and violence-informed approach, and care was taken to not reproduce abuse or revictimize them through inquiry. The women were also given the option of answering the questions at the end of the session, if they did not want to share their input during it. They could write their responses and send them privately through the chat, or email them directly to YDL. They were encouraged to connect to supports during the session or afterward if they needed or desired help. We asked contributors for their perspective on how policies, structures, and processes (e.g., organizational procedures) supported or hindered the integration of services and equity-based care from their practice. If contributors wanted to share written observations, they could connect with research team members after the discussion. Finally, we asked both groups for recommendations on how to translate evidence into action, and invited them to share feedback on specific questions regarding the overall discussion. The discussion session was held virtually through UBC Zoom. As per the discussion guide (Appendix P), an overarching session and three breakout sessions were used to discuss specific points with participants. The overarching session was facilitated by myself while a research team member (Dr. Oelke, Dr. Varcoe, and Dr. Mema) facilitated the discussion in one of the three breakout rooms. Each of the breakout rooms had two to three women and three to four contributors. Participants were asked to introduce themselves, but they were also given the option to pass or to use a pseudonym. There was a 10-min break during the 2-hour session. 103 Data Analysis: The KT discussion was audio recorded and transcribed using Office 365 transcribing features. Notes were taken and comments in the chat were also saved. The transcripts, notes, and comments from the chat were analyzed for common themes (Morse, 2016) with the use of NVivoTM® version 12. An iterative analysis included thematic and content analyses (Beck, 2013; Braun & Clarke, 2006) to identify themes. Themes were identified and integrated with the recommendations from participants for actions to implement system integration and health equity for women who experience marginalization and IPV. A synthesis of results was completed and shared with participants for their feedback. This feedback was incorporated into a final summary report that was shared with participants (see Appendix Q). 5.2.3 Ethical Considerations Rogers and Kelly (2011) emphasized the importance of seeking participation and representation among “non-dominant groups [and avoiding] comparative science based on homogeneous groupings” to advance health equity (p. 402). This is a core statement about ethical values such as inclusiveness; however, when studying populations who experience marginalization, seeking involvement can foster non-discrimination, respect for human rights, and social justice through power-sharing in the decision-making processes. As such, the use of frameworks (e.g., feminism) allowed me to understand the production of knowledge as an iterative process where the knowledge itself and its ownership may reflect power imbalances (Sweetman et al., 2010). The intent of the KT discussion was knowledge creation as a way to improve outcomes for women who experience marginalization and IPV. For the analysis of complex interactions of phenomena such as studying populations who have experienced historic processes of exclusion, the use of specific frameworks (e.g., intersectionality) helped to conceptualize other ethical principles such as integrity, responsibility, trustworthiness, and fairness. Conducting research with women who experience IPV requires an in-depth understanding of the complexity of power imbalances framing health experiences and outcomes, from both an interpersonal and a systemic level. These reflections require equity-based perspectives to build on ethics and encourage the pursuit of further principles (e.g., autonomy, beneficence, justice) for these populations. As described by Banner et al. (2019), this study relied on relational ethics and horizontal collaborative 104 processes among researchers and contributors. Phase 3 of the study received approval from the UBC (Okanagan) and the Interior Health Authority ethics boards. 5.2.4 Specifications About Confidentiality and Inclusiveness This project followed the measures for privacy and confidentiality approved by Interior Health and UBC Behaviour Research Ethics Boards. All documents and recordings were identified only by a code number, and there were no hard copies of data. The electronic consent forms were stored separately from electronic data. All electronic files were stored on a password-protected UBC One Drive folder. Digital recordings were deleted after the transcripts were verified; all other files will be stored for 5 years after publication of the dissertation on the UBC Okanagan secure network and then deleted. Unauthorized persons will not have access to any data or information. Participants are not identified by name in any final reports of the finished study. Issues of confidentiality and consent were discussed at the beginning of the discussion and participants were informed that they had the option of not answering any question. The oral consent form was read at the beginning of the event and people were informed that they could ask the researcher to stop at any time to clarify information. If they did not want to participate at any point in the session, they could communicate this and drop the call at any time. Each woman with lived experiences received CAD $50 as a recognition of their time and expertise. 5.3 Results The session included seven women with lived experience, 12 contributors, and four research team members for a total of 19 participants. Women with lived experiences came from the Southern Interior of BC and joined the session individually or in groups of two. Contributors came from the Southern Interior of BC or BC more broadly and joined the session individually. One overarching theme, that experiences should drive service planning and delivery, and two subthemes: a) the importance of understanding women’s needs; and b) transforming health and social systems were identified. Finally, gaps in services and supports identified by participants are presented. 5.3.1 Women’s Experiences Should Drive Service Planning and Delivery All participants emphasized that women’s experiences should be considered as drivers in planning and delivering services related to IPV. As such, there is a need to understand women’s 105 experiences. Also, all participants stressed the need to incorporate the diversity of women’s needs and identified several improvements towards more integrated and equity-based services. a) The Importance of Understanding Women’s Needs: Women have multiple and varied health and social needs, and understanding the diversity of these needs is essential when designing and providing care. Several contributors agreed that decision makers and providers need to comprehend the variability of women’s needs for services to be effective: “most of my clients […] are usually in need of different services or different programs other than counselling or other than victim services” (Contributor 10). As such, finding the right approach for service provision requires a recognition that women’s needs and experiences change over time, and so supports will need to be adapted and will be required for long periods of time. To support women’s recovery and healing processes, it is crucial to have “[a] less [...] linear approach and [asking] just what does this individual need? [at that specific time] It does not matter how long it will take” (Contributor 5). Many of the women further recognized that facing multiple health and social inequities caused them to need various and specific supports. Unfortunately, although the women had sought and accessed care for years, they felt the supports had not been enough to address their needs. One woman shared that she has had multiple disabilities, as well as substance abuse and mental health concerns, but felt that the supports had not been there; she also experienced homelessness and would have liked more support with that issue. Since women’s recovery and treatment processes vary and change over time, multiple and tailored approaches are also needed. Contributors highlighted that understanding the changes related to the needs of women over time will help them to learn to tailor the care. “If we are [going to] support somebody then we need to know what they need […], because otherwise we are using a model that […] is not working and that has not worked, and we are assuming that we know what folks need instead of asking them what they need” (Contributor 6). When discussing how to understand the health and social needs of women experiencing IPV, the needs of groups of women such as Indigenous women, transgender women, and women with disabilities were further analyzed. Since these groups often experience systemic barriers such as stigma and discrimination, the women emphasized the need to acknowledge these needs when planning and delivering services. Participants particularly talked about the relevance of understanding Indigenous beliefs and practices. For Indigenous women, the meaning of leaving an abusive partner was discussed 106 as part of understanding women’s health and social needs. Leaving an abusive relationship may also mean leaving the culture, language, and traditions, which will impact the recovery process. The needs of women who were part of the LGBTQ community were also discussed. Participants highlighted that the current policies and services, including shelters, are set up for gender binary people, which do not fit the needs, priorities, realities, and contexts of women who are part of the LGBTQ community. As such, those services and policies create further barriers to appropriate support, thus generating further structural abuse and violence. Build trust to understand and meet women’s needs: Women mentioned services where they felt unheard and how these negative experiences did not help them to address their needs. Although women would like to build a positive relationship with providers to better communicate with them, including feeling heard, valued, and supported, it had been hard to find providers to trust. Women and contributors agreed that building trusting relationships was fundamental to understanding and addressing women’s needs. For participants, fostering positive relationships was a process defined as a two-way procedure where women and providers have different beliefs. For women, it is possible to rely on providers and develop positive relationships when they see themselves being supported by providers’ advice that can meet their needs: “women need to feel like they know they are getting helped, not going around in circles” (Woman with lived experiences of IPV 5). For contributors, it is possible to develop positive relationships by knowing that the advice they give to women regarding the supports offered or needed match women’s expectations: “having those concrete supports that we can turn to and then make sure and know that they are going to work out, so that people are not being told they can go somewhere and then finding out that it is not actually helpful” (Contributor 7). Since understanding and meeting women’s needs is key to developing reliable connections, questions such as where or when women receive care, what type of care is available, and how effectively the care that addresses women’s needs requires clarification in the encounters between women and providers. Another essential consideration towards building reliable and positive relationships rested on believing women’s truth about their lived experiences and opinions of IPV. One contributor recognized how the lack of trust from providers limits addressing women’s needs: “we still too often don't believe women, and we still don't actually ask them what they require in terms of receiving service and accessing 107 it safely, and equitably” (Contributor 2). To promote more equitable relationships and help with understanding women’s needs, contributors stressed the need for a shift in the location of service provision: “we could […] meet somebody in the community or in [a] […] warmer, less medical clinical space, [it] may also help in building that trust, [since we show that] we are not just part of this massive corporation” (Contributor 5). b) Transforming Health and Social Systems: The following expands on two main subheadings for this subtheme. Incorporate Women’s Experiences in Service Planning and Delivery: Participants recognized women’s experiences and encounters with health and social services as significant sources of knowledge to transform systems towards more integrated and equitable care. Understanding women’s experiences was essential to improving services; as such, participants agreed that women’s participation in all levels of service provision is key. Participants agreed that by using specific health and social approaches in researching and designing services and supports (e.g., patient-oriented research; patient-engaged service design), the voices of women with lived experiences should be brought into decision-making processes “because ultimately they are the ones that are the most affected by the supports and services that are provided, to the extent that that's been successful in terms of changing healthcare policies and practices in other contexts” (Contributor 2). Participants stated that there has been an attempt to integrate people with lived experiences in service planning and provision; however, contributors recognized that there were several barriers for women who experience marginalization and IPV to get involved and engaged in health and social service improvements. Contributors agreed that services must seek active participation of women: “we need to look at what is that balance between ensuring voices are heard and that the things we create or disseminate are actually appropriate and needed” (Contributor 2). To incorporate women’s voices into policy and service design and delivery related to IPV, contributors stressed that the lack of integration in services related to IPV and particularly the lack of specific research in this topic limited organizations in including the participation of women. “There isn't a lot of good research in this area like there isn't a lot of focus and how we integrate those different services that are needed across what we call sectors, so across justice, healthcare, social services, housing, all of those things are not well linked” (Contributor 4). 108 Particular attention was paid to how to incorporate Indigenous women’s voices into the design and delivery of services: “because in some of the culture, like our culture, understandings and our ways of living are different from non-Indigenous, and I think also having more lived experienced voices being part of these differences […] getting our voices to be a part of the research” (Women with lived experiences of IPV 3/4, unable to differentiate which of the women shared). Integrating women’s experiences to improve service delivery would make it possible to limit negative impacts on women’s health: “otherwise you might be creating systems with good intentions, but they might be harmful, traumatic, all different kinds of things” (Contributor 6). Women expressed their concerns and mentioned encounters where they did not feel their needs were met: “there was no real follow through with the police and then when I got referred to victim services, there was really no follow through with that” (Woman with lived experiences of IPV 6). When lived experiences and views were not incorporated and translated into service planning and delivery, women experienced negative and traumatic encounters with services. Redesign Systems Towards More Integrated and Equity-Based Services: Participants identified the types of changes in essential policies and services needed to improve women’s health. Improvements in housing supports were highly recommended for a more comprehensive, integrated, and equity-based response for survivors of IPV. Contributors agreed that accessibility and availability of housing services were often reduced. One contributor stated that in 4 years of working as a social support worker, she has not been able to support anyone in need of housing services, including shelter. Women confirmed that it can take years to receive housing supports. One woman recognized that the lack of available of housing supports impacted her options or opportunities to leave an abusive partner “for 3 years” (Woman with lived experiences of IPV 5). Both women and contributors emphasized that housing supports need to focus on “more second-stage housing […] so that people have a stable home from which to do the things that need to be done and receive the supports that hopefully will be provided” (Contributor 1). All participants agreed that since housing affordability limits women’s options to leave an abusive partner, several actions are needed. For example, policies and services need to increase the maximum time that women are allowed to stay and have more permissive policies regarding receiving guests, bringing pets, and using substances. In terms of accessibility of shelter services for women who 109 are part of the LGBTQ community such as trans women, one contributor specifically stated that she has had to deny shelter supports to trans women because the lack of inclusive services for women. Additionally, participants discussed considerations related to delivering more integrated and equity-based services in the justice system. When addressing women’s children’s safety under the current justice system, often the children are removed from their mothers: “a lot of times, if mom is in an unsafe situation, the onus is on her to provide safety for the kids, and they will remove the children and then often things get worse” (Contributor 9). The implications of removing children from their mother had a detrimental impact on women’s wellbeing, including feeling guilty. Further, since women experiencing marginalization and IPV faced systemic oppression, all services, particularly the justice system, need more integrated and equitable mechanisms to create a helpful system for women (e.g., respectful, culturally safe, tailored). If women decide to disclose, the response of services must be supportive. Policies and services should assist women to feel safe, not judged, and valued, so when women trust the provider and system, and judge it is worthwhile to disclose, the service provider’s role needs to be supportive at all times. For many women who are experiencing violence in various contexts, they already do not trust or feel safe in the context of a policing scenario, so to be already in a place of trauma and then be forced to, I do not know, pretend to feel safe or share their story with people who represent this system of oppression that may have hurt them and not protected them in the past is a huge barrier to even seeking out support. (Contributor 2) Improvements in processes such as tracking and transferring of health records across the systems were also identified as key to increase the integration of services. Furthermore, a contributor stated: “an updated resource database which would be […] updated […] constantly and that could include a lot of the housing transition, home counselling service, or different kind of services” (Contributor 10) was crucial. Contributors considered that strengthening supports such as economic and employment assistance was fundamental to limiting the multiple health and social inequities that women face: “financial support to provide support for their family, support for their community. Giving them a job” (Contributor 6). The importance of financial support in limiting further social and economic inequities was also discussed. A contributor stated that since women who experience IPV often experience financial 110 abuse, the health and social response, particularly the housing, job, and economic supports, need to be aligned and integrated. Thus, both short-term (e.g., economic aid) and long-term financial support (e.g., financial loan program) are needed. Other specific policy and service enhancements were suggested to enhance integrated and equity-based care; for example, facilitating and strengthening service access at the time that women are seeking help would help them meet their needs and begin to recover. Women stressed the importance of not being referred elsewhere when they decide to seek care from a specific organization, since the reason to seek care was the discomfort experienced and need for support. Additional improvements towards better integration of health and social services included having standardized protocols and guidelines to support women across the province, including in emergency departments and ambulatory care. One contributor specified how having integrated, women-centred care would impact women’s health: “if a woman shows up and she's experienced violence and she doesn't have a primary care provider, here's the path we put her on, here's the resources we recommend, here's where she goes, and we would know the places we send her have the training or are part of the same group. We're all on the same page” (Contributor 2). Participants also suggested that improvements in the mental health sector are key to delivering integrated care. Women and contributors recommended improvements to the organization and delivery of mental health services. “There are currently community mental health services, but they may not be exactly responding to the needs or be exactly what the woman of our programs are looking for, and it would be nice if there were a really trauma-informed [approach]” (Contributor 10). Specific changes to mental health services to be inclusive of the diverse needs of different groups of women were highlighted: “mental health support […] to help recover from the trauma and build those coping skills in a diverse way, so not only access to mental health, but access to Indigenous-specific mental health practices, and other culturally diverse mental health [services]” (Contributor 7). Further, since Indigenous women tend to experience marginalization and stigmatization in the healthcare system, contributors advocated for a harmonized practice, including creating a space that addresses women’s safety and considers their needs and lived experiences in such a way that it offers “people the opportunity to speak their truth” (Contributor 6). 111 Additionally, participants identified considerations related to why and how these policy and service enhancements should be developed. For example, to understand why these changes and improvements in service provision need to be developed, a contributor emphasized that women who have experienced marginalization have experienced multiple social and health inequities that they did not create. As such, we need to ask what is adequate and needed, especially considering “that women shouldn't have to fix all the things when they're already dealing with all these challenges that have been forced on them” (Contributor 2). In the case of Indigenous women, it is vital to integrate Indigenous’ voices and perspectives into discussions about health and social services and policies; however, contributors recognized that there is a need to identify the right approach to integrate Indigenous women’s voices. An adequate health and social service delivery approach to including Indigenous women’s perspectives needs to limit putting unnecessary pressure on women “to fix the problems that someone else created for them” (Contributor 2). Participants agreed that improving integration of services and care across sectors is important to limit further health inequities related to not having available and accessible services that often lead to delays in seeking care, particularly for women experiencing homelessness or poverty: “we need more cooperation to better connect our clients to different resources. So, I find multiagency or multidisciplinary cooperation is crucial” (Contributor 10). Since the delivery of services seems uncoordinated and fragmented, contributors recommended a patient navigator: “It would make sense to have people in place that would help provide that navigation function because it must be quite overwhelming to try to think through all these different ways of doing things” (Contributor 1). Finally, all participants identified that innovation and changes to the traditional way of delivering services will help address the needs of women. An example of an innovative pilot project in Alberta was raised, where the abuser had to leave the house instead of the women and their children. Although the project was not discussed in detail, it was presented as a new way to deliver services that could be explored. Further, if women wanted their partners to come into the shelter for counselling, this should be allowed since this is what women need. Likewise, a one-stop single point of access, or hub model where women could receive services for many of their concerns in a single setting was identified as a strategy to enhance integration of services. “We talk about [a] one-stop service model that would be great to incorporate victim service, financial support, childcare service, housing and financial support – different 112 kinds of like [services] in [a] one-stop service model so [the] client can access the [services] all at one […] place” (Contributor 10). Having a single point of access as a healthcare approach for women who experience IPV was also recognized by all participants as a way of increasing equitable services for women. By working together, organized and more integrated, services can be developed to mitigate the trauma and violence that women experience when they receive care in multiple and fragmented settings which may not consider appropriate care approaches (e.g., trauma- and violence care, harm reduction). “There's different people providing different services with different levels of their own knowledge and training and preconceived notions” (Contributor 2). A woman-centred approach was mentioned as a suitable model to address women’s concerns and impact women’s health equity, since each woman’s experience is unique. Women-centred care responses are needed to recognize women’s unique realities and that they have specific needs to be met. Another recommendation towards more equity-based policies and services made by contributors was to offer employment to women with lived experiences of marginalization and IPV who wish to participate and engage with health and social research. Contributors recommended creating a position in which organizations can bring women in to discuss policy and service improvement; this would support women financially and contribute to better health outcomes. Lastly, a contributor emphasized that since IPV is a social public health problem, public and comprehensive preventive approaches where governments invest in violence prevention where people and communities participate are needed. The participation of all sectors will help stop violence. For instance, “community-based approaches and education programs to support children, men, and people who perpetuate IPV, to challenge negative behaviours and limit negative or violent practices are essential” (Contributor 5). These programs should also consider the social context where women live, such as rural and remote communities. One contributor stressed that to limit violence against women, it is important to create safe community spaces that normalize conversations about the importance of positive and healthy sexuality as well as consent discussions where people could access these programs and feel safe. 5.3.2 Gaps in Policy, Service Planning, and Delivery for Women who Experience IPV Participants recognized several gaps in care delivery for women. Table 20 shows the key barriers identified. While the challenges for women to access the care they needed to address their needs varied, 113 Table 20 Gaps in Policy and Service Planning and Delivery Gap Insights 1) Ineffective referral processes • No way to ensure follow through in a referral process • Lack of communication across services/organizations and with women 2) Restrictive shelter designs and policies • Services did not consider pets, guests, or substance users • Shelter policies and services were designed for binary-oriented people • Needs of women from the LGBTQ community have been not considered when designing and delivering services 3) Complicated and competing funding mechanisms • Providers faced multiple, difficult mechanisms across levels and sectors to obtain funding • Organizations did not have access to continuous funding • Providers faced difficulties meeting the requirements of funders across levels and sectors 4) Lack of community-based approaches • Limited approaches for women to build community ties and feel supported • “When you go into housing, you cannot have any alcohol or guests over, even when they send you to a hotel. You are sitting there all by yourself, so it is important for us to feel like we are part of the community” (Woman with lived experiences of IPV 5) 5) Fragmentation and lack of coordination across sectors • High levels of fragmentation limited the quality and availability of care • “Having two separated minimum care teams for things that just are so intertwined for that individual, that does not feel great as a practitioner” (Contributor 5) • Multiple and fragmented perspectives of services and policies duplicated service efforts and further impacted care 6) Inadequate system navigation strategies • Siloed approach to design and provision of services is ineffective • Little support or guidance for women to help them navigate services • Women feeling unsupported, lost, and left behind despite actively seeking care for a long time • “IPV has been in my life since I was 14, through seven relationships, which led to drug addiction, mental health issues, disabilities, childcare issues, discrimination, lack of support from police and victim services, lack of follow through on homelessness, post-traumatic stress disorder, self-care, etc. I am 35 years old in recovery but still fine. I am overwhelmed with how to deal with these issues like education, financial, mental health support” (Woman with lived experiences of IPV 6) 7) Poor alignment between women and providers’ expectations of healthcare • Women and providers’ beliefs and attitudes did not align • Women placed their expectations on service providers’ skills to recognize and manage IPV properly • Contributors highlighted that women’s expectations may not mesh with the skills of frontline providers 114 Gap Insights 8) Lack of awareness of the complexity of experiencing IPV • Providers did not understand multiple changing needs of women • Lack of awareness of the impact of violence on women’s health, particularly in the long term (e.g., chronic pain) • “When a person […] has anxiety or trauma and is having difficulties coping or making appointments, or reading their plans, and there is a frustration from the service provider as opposed to real understanding the depth of the trauma or the anxiety or the mental health or all of those” (Contributor 9) 9) Identification of mental illness and comorbidities in a timely manner • Lack of support for people experiencing mental illness or post-traumatic stress disorder • Mental health services often dismissed or did not address women’s concerns • Mental health services were designed to deliver only counselling • Providers did not understand the impact of violence and abuse on women’s health 10) Lack of training on trauma- and violence-informed care • Lack of appropriate care approaches (e.g., trauma- and violence-informed), including appropriate language, principally when police are involved • “The way police will just throw around the term ‘oh it is a domestic’ […] it is almost a pejorative term as opposed to […] using more respectful language and more appropriate language” (Contributor 2) • Need to improve services received in nonviolence-related sectors (e.g., employment, schools) 11) Lack of available IPV-specific supports at right time, in the right place and for the right period of time • Women were often referred out when organizations were at overcapacity • Service availability was limited, especially in crises • “The whole limits on shelter stays, you know this notion of 30 days, it is ludicrous when you look at the list of things you have to go to your lawyer. You have to go, you know you might have to go see your GP. You are trying to find a new school for your kids. You are trying to find somewhere you can live. You are dealing with your former partner, or you might be in the court system, and you are supposed to do all this in a crisis in a 30-day period” (Contributor 2) 115 limitations were evident across levels and sectors. Barriers such as punitive shelters and policies deterred women from seeking shelter services. Some of the women sought care through referrals and outreach organizations for a long time, sometimes even decades, but they often felt unheard and their needs were unmet. Although contributors pointed out that organizations aim to address women’s needs, women often experienced systemic abuse in forms of stigma and discrimination from health and social care systems. Many policies and services were impractical for women who were fleeing violence and would have needed multiple supports for long periods of time. 5.4 Discussion A KT discussion session was held to hear women and contributors’ experiences and insights into health and social care delivered and offered for women who experience marginalization and IPV in the Southern Interior of BC. Specific recommendations for policy and service improvements were identified. 5.4.1 Strengthen Integration and Equity-Based Services for Women who Experience IPV Tailor Policies and Services to Address Women’s Needs: To improve women’s lives, participants emphasized the need for a better understanding of how women’s needs vary and change. They stressed that since women’s needs are diverse between and within groups, policies and services should be adapted and tailored appropriately. However, in marginalization and IPV contexts, women and contributors recognize the current limitations in understanding women’s needs and translating them into practice, specifically to improve health and social care. To ensure knowledge uptake and use, Ward et al. (2012) encourage emphasizing the relationship between knowledge users, including people with lived experiences, and their needs, specifically how they shape the interaction between translation and exchange. Women expressed that they felt unheard with unmet needs in services that did not recognize or understand their needs. Similar feelings were expressed by providers, including frustration with the lack of options to support women. It appears that the association between women’s needs and the ways that these needs have been translated into action (e.g., policies, services) have not resulted in appropriate changes. In the case of complex social problems, such as marginalization and IPV, and knowledge use in complicated contexts (e.g., policy development, social change) (McCormack et al., 2002), the translation, dissemination, and exchange of people’s needs in the form of knowledge is required to ensure effective knowledge uptake and use (Ward et al., 2012). By incorporating women’s 116 voices and the diversity of women’s needs into the health and social care decision-making processes, KT approaches are most likely to translate policy into practice. As Banner et al. (2019) highlighted, KT approaches are likely to succeed if they reflect the needs of those using services. Participants identified that efforts towards understanding the diversity of the needs of groups of women who experience marginalization and IPV have not been adequate. They recognized that current shelter policies and designs need improvement to develop more equity-based services for specific groups of women. Women who are part of the LGBTQ community have been left behind in terms of receiving care and addressing their needs; there are no available and accessible supports for this group. As part of specific improvements, Yerke and DeFeo (2016) recommend raising awareness and reducing service barrier access given that almost half of the LGBTQ community experiences IPV, a rate that is significantly higher compared to people who are not part of this community. According to Peitzmeier et al. (2020), IPV is a risk factor for several health conditions (e.g., poor sexual health, poor mental health, substance use) in transgender populations. There is a unique vulnerability component of abuse in transgender populations compared to cisgender individuals that may not present “as abusers leverage trans-related vulnerability to gain power and control” (Peitzmeier et al., 2020, p. 9). The occurrence of these issues is higher among transgender individuals of colour and people with disabilities (Wirtz et al., 2020). Although several steps are recommended to address IPV in the LGBTQ community (e.g., recognizing the issue, offering support, and helping ensure safety) (Ard & Makadon, 2011), contributors agreed that there are limitations to finding effective strategies to understand, translate, and tailor knowledge into practice and help women to improve their lives. As Sadika et al. (2020) indicated, there is limited evidence on how to tailor specific supports for people of diverse gender identities experiencing IPV. It seems that research about the impacts and implications of IPV on the LGBTQ community is increasing; however, studies providing guidance related to how implementing these enhancements, including what tools and/or methodologies are effective, are limited. The lack of understanding of Indigenous women’s needs also limited the efforts towards health equity and tailored services for women. For example, women emphasized the gap between Indigenous practices and beliefs, and the way services are currently provided for them. Contributors stated that stigma and discrimination are major issues during service encounters. To address the gap between 117 knowledge and understanding of IPV as experienced by Indigenous women, Haag et al. (2019) recommended analyzing the multiple intersections of marginalization, stigma, and colonization linked to structural barriers to service provision when designing IPV policies and services. According to Puchala et al. (2010), leaving an abusive relationship for Indigenous women intersects with traditional healing processes such as bringing hope, recovery, and restoring peace to women and to the community. Smye et al. (2020) identified contextual aspects of Indigenous women’s lives that shaped women’s experiences of leaving and/or staying with an abusive partner: “(a) the context of state-Indigenous relations; (b) complex trauma, stigma, and discrimination; (c) kinship and ties to communities and the land; and (d) health, healing, and resistance” (p. 1). Participants stressed that efforts to understand the needs of other groups such as women with disabilities, women with mental illness, or women who live in rural communities have been limited as well. Given that the impact of IPV varies due to structural conditions and intersections, to support groups of women who historically have been socially excluded, researchers encourage service providers to study the intersections impacting health status such as disability, ethnicity, gender identity, social location, economic status (Shah et al., 2016). Addressing inequities for women would mean recognizing health as a political matter. As Gore and Kothari (2012) emphasize, addressing issues related to the SDH means changes in sociopolitical structures such as policies, organizations, and practices that intentionally or unintentionally impact people’s health. Involve Women in Health and Social Decision-Making Processes: Women and contributors agree that women’s voices are a meaningful source of knowledge that need to be incorporated into health and social research, policy, and practice to transform systems. However, they recognized the limited opportunities for women who experience marginalization to participate in health and social research and practice. Patient and public engagement refer to the processes through which people’s needs, realities, and preferences inform and contribute to health and social policy and service planning and delivery, with the goal of improving policies and services and making them more appropriate and acceptable for people using them (Abelson et al., 2010; Snow et al., 2018). The success of patient and public engagement strategies depends on several factors. In the context of women who experience health and social inequities, there is a further goal to promote inclusive patient engagement by considering diversity in these initiatives (Roche et al., 2020; Shimmin et al., 2017). By considering diversity, inclusion, and 118 representation in patient engagement strategies, factors such as trust, self-awareness, acceptance, and communication will be identified by providers as essential in the processes of shared decision-making in healthcare (Elwyn et al., 2016). Contributors acknowledge that women’s roles and participation in policy and service improvements is essential to limit further health and social inequities, yet none of the women with lived experience in the KT discussion session had any formal opportunities to share their opinions about the services they received. Since a lack of representation and inclusion reinforce abuse, violence, and inequities, Kulkarni (2018) urges organizations to facilitate survivor participation in the form of “establishing advisory boards, hiring peer support specialists, creating speakers’ bureaus, tenant groups and organizing policy advocacy initiatives” (p. e7). To enhance engagement of women in policy and service improvements, specifications about their participation and involvement in the planning and delivery (e.g., inform, consult, involve, collaborate, empower [International Association for Public Participation, n. d.]) should be an iterative discussion within organizations. Snow et al. (2018) highlighted the relevance of discussion with women with experiences of marginalization, and the direct and indirect benefits of participating in health and social research at every stage of the research process. Participants identified additional factors influencing the participation of women in health and social care planning and delivery. Women’s involvement in shared decision-making in healthcare is determined by the characteristics of the engagement strategies. As such, finding the appropriate strategy to enhance women’s involvement and engagement (e.g., permanent job or partnership, one-day or temporary event, brief consult) will impact participation processes. Tailored engagement strategies and approaches have the potential to overcome further exclusion through traditional engagement processes (Healthcare Excellence Canada, 2020; Snow et al., 2018). Further, the continuum of participation of women in higher stages of the engagement process often require an intense commitment (e.g., collaboration and empowerment) and may have an additional impact on limiting further health and social inequities by supporting them to build new skills such as “reducing isolation, developing community networks, and furthering personal growth and employability” (Snow et al., 2018, p. 7). Components that underly the relationship between women as service users and knowledge holders, and providers (e.g., trauma- and violence-informed care, intersectionality, reflexivity) strengthen inclusive patient engagement strategies 119 (Healthcare Excellence Canada, 2020). As such, the planning and delivery of equity-based services that are contextually tailored, culturally safe, and trauma- and violence-informed will help women improve their health outcomes (Ford-Gilboe et al., 2018) and also improve patient engagement strategies. When women participate in healthcare research related to IPV, they see the value in sharing their experiences and find the process to be beneficial for their healing journey (Dichter et al., 2019). Specific Enhancements in Health and Social Policies and Services Related to Care for Women who Experience IPV: Results from the KT discussion session showed what and how specific service and policy improvements in health system integration can support women’s health. Community-based approaches where women could feel supported and part of the community are key to women’s wellbeing. Currently, women have to leave their homes, jobs, and connections in the community to stay isolated at secondary housing services, and this can further limit healing, health, and moving forward in their lives. As such, participants highlight that having approaches such as a woman-centred hub model where women could access multiple services in a single setting could improve the integration of services and help women develop specific skills towards self-control and empowerment. Stronger systems integration will limit systemic barriers such as service access or stigma. According to O’Brien et al. (2017), women-centred care is inclusive, collaborative, integrated, and empowering because it prioritizes women’s ownership over decisions impacting their lives. A women-centred approach has the potential to improve integration of services and health equity as it addresses the complexity of the multiple intersections of women’s needs, from urgent medical needs (e.g., acute injuries, depressive symptoms) to a systemic, complex, and long-term approach (e.g., chronic pain, stigma) (Garcia-Moreno, Zimmerman et al., 2015; WHO, n.d., n.d.-b, 2019, 2021a). For women experiencing IPV, integration of health and social systems should help them seek care, facilitate service access, support when disclosing, and assist them along the recovery process (Garcia-Moreno, Zimmerman, et. al., 2015). However, women highlight that although they have sought care for years, even decades, there are still multiple difficulties in accessing supports, and this is also affected by women’s levels of safety and their trust in the services. For example, women emphasized the need to receive care at the time they are seeking it, and not be referred, since their level of discomfort is affecting them at that specific moment. If women decide to disclose their experiences to health and social 120 services providers, the response must always be supportive. As such, a service provider’s role is to create those safe and supportive conditions instead of encouraging disclosure. A supportive response is a determinant of equity-based care. Further, since women who experience marginalization and IPV have experienced violence in multiple environments, attention to the practices implemented in scenarios such as the justice system is fundamental for women to trust in services, providers, and people. Unfortunately, all of the encounters between women and the police were identified as traumatic and negative by participants. These negative experiences with the justice system underline an important gap in policy planning and service delivery, as police services are often the initial service where women seek care. When redesigning policies and services, MacGregor et al. (2014) recommend paying attention to the IPV obstacles related to emotional distress and resistance between providers and women with lived experiences. Recognizing that IPV is a difficult-to-engage topic may allow providers to use evidence towards effectively designing implementing, evaluating, and reporting on KT enhancements for IPV (MacGregor et al., 2014) in the justice system. The lack of awareness of the impact of systemic abuse and the complexities of women’s lives have shaped the understanding of women’s lives in terms of developing and implementing more integrated and equity-based services and policies. MacGregor et al. (2014) highlighted four themes to improve IPV knowledge: a) measurement tools and KT strategies are underused; b) KT efforts are barely linked to health outcomes of people exposed to violence; c) there is a lack of evidence about the long-term effectiveness of KT interventions; and d) authors’ beliefs and attitudes about barriers, facilitators, and effective or ineffective KT strategies are not supported by evidence. These considerations accord with contributors’ insights about improving services and policies and the gaps related to translating women’s knowledge into tailored service enhancements. For example, providers often face implementation barriers in the form of inadequate or unavailable resources for women experiencing IPV. Although effective KT approaches aim to engage with women to coproduce knowledge (CIHR, 2012, 2014), research addressing knowledge and service gaps for women who experience IPV, specifically, studies to understand interactions between experiencing recent IPV and various health issues (Bacchus et al., 2018), is limited. There is also limited implementation science research towards understanding enablers and barriers to implementing interventions based on coproduction, and what is effective and 121 what is not. Despite limited guidance towards enhancements for women experiencing IPV, all participants pointed out that improvements should reflect trauma- and violence-informed care approaches. Services and policies related to the care of women need to include elements of intersectional trauma-informed IPV into policy and service design, implementation, and evaluation processes (Kulkarni, 2018). Recommendations include: “1) expanding survivors’ roles/input; 2) strengthening funding streams and organizational commitment to anti-oppressive, survivor-defined, trauma-informed services; 3) forging cross-sector advocacy relationships; and 4) building knowledge through research and evaluation” (p. 1). Expanding survivors’ roles aligns with what participants identified regarding existing supports not integrating women’s roles and knowledge. These recommendations will go a long way towards supporting health systems integration and health equity. 5.5 Recommendations The results of this phase demonstrate the need to understand the multiple and diverse needs of women and groups of women to design and deliver more integrated and equity-based policies and services in the Southern Interior of BC; however, much of this information can be extrapolated to care and provide services for women experiencing IPV provincially, nationally, and internationally. A better understanding of these needs will help providers and decision-makers tailor policies and services appropriately. If this does not happen, women will continue to experience negative and structural abuse, as identified by women in the KT discussion session, with multiple events of systemic violence in the form of shame and victim blaming. Further, it is essential to find more equitable mechanisms such using plain language, avoiding judgement and listening deeply, or sharing insights and lessons learned (Healthcare Excellence Canada, 2020) to build trustworthy relationships and inclusive engagement processes between women and providers. An equity-based approach (Ford-Gilboe et al., 2018) can support providers to recognize and operationalize social justice principles (e.g., fairness) underlying the theoretical concept of health equity into practical strategies that are relevant at the point of care. As such, it is important to reconceptualize patient engagement processes through health equity and social justice lenses by incorporating a trauma-informed intersectional analysis (Shimmin et al., 2017). 122 There is a need to strengthen the participation of women with lived experiences of marginalization and IPV as drivers of health and social services. As such, a formal and intentional process of integrating women’s voices into the design of services and policies should be implemented. Women’s involvement in shared decision-making in healthcare will improve the alignment between the understanding and translation of women’s experiences, and the supports that are planned and delivered. Although specific tools and methodologies have been designed to enhance the participation of people who experience social exclusion (BC Patient Safety and Quality Council et al., 2018; Healthcare Excellence Canada, 2020; Roche et al., 2020; Shimmin et al., 2017), research on IPV shows heterogeneous KT strategies limit guidance towards implementation of specific service improvements for IPV (MacGregor et al., 2014). Specific considerations include the need to differentiate the effects between recent and past IPV experiences, particularly in relation to the impact of trauma and abuse in health outcomes such as the presence of mental illness, chronic health issues, or chronic pain. As noted in Wallace et. al (2021), the experiences of chronic pain in people who have suffered marginalization are related to multiple intersections of violence (e.g., trauma, discrimination). Implementation science and practice approaches are needed to identify enablers and barriers to deliver specific interventions based on coproduction. Identifying the effectiveness of collaborative social and care improvements will help providers design and deliver more inclusive, integrated, and equity-based responses with women and for women who have experienced marginalization and IPV. Further, since evidence recognizes IPV as a complex health and social issue and not only a biomedical one (Garcia-Moreno, Hegarty, et al., 2015; Garcia-Moreno, Zimmerman, et al., 2015), there is a need to identify and limit further health and social inequities and social injustices. As such, policy-makers and providers across sectors and levels of care need to integrate trauma- and violence-informed care, culturally safe care, and harm reduction approaches to tailor policies and services to meet women’s needs. Finally, in the case of innovative community-based and woman-centred approaches recommended by participants, it is crucial to consider preventive actions where adults of all genders, children, and people who reproduce violence challenge this behaviour and learn healthy mechanisms to relate to one another. Augusta-Scott et al. (2017) developed a comprehensive analysis of key innovations 123 in interventions to address IPV in Canada. Tailored responses to women abused by partners and specific interventions with men who have perpetrated IPV are fundamental, yet the authors emphasized the need for integrating system-level interventions for IPV across systems, including a restorative justice response. Participants in the session identified the justice and police response as a key limitation to addressing women’s needs. Therefore, a better understanding of the connections among “women’s justice preferences and their perceptions and experiences within the current justice system illustrate complex and difficult trade-offs faced by survivors in achieving physical, social, and economic safety” (Decker et al., 2022, p.1). 5.6 Strengths and Limitations 5.6.1 Strengths This KT discussion session is the first strategy of which I am aware to gather women and providers’ perspectives on health and social services related to the care of women who experience marginalization and IPV in the Southern Interior of BC. The session allowed the research team to present the results of previous phases of this study and develop, together with participants, recommendations for action. The women’s and contributors’ insights provided specific direction for action for certain health and social policies and services related to care for women experiencing IPV. Having multiple women with lived experiences of IPV expressing their opinions and concerns related to policies and services helped to support them from an equity-based perspective and comprehensive understanding of abuse. The diverse experiences of the women were recognized as needed drivers to transform health and social systems. Using a trauma- and violence-informed care approach may support women to play a role in creating a more integrated and equity-based system for women. 5.6.2 Limitations A barrier related to the recruitment process for participants to join the KT discussion session was found. The use of electronic platforms facilitated contributor recruitment; however, the recruitment for women with lived experiences may have resulted in a different sample if other methods had been used (e.g., posters, in-person invite). As such, the sample of women participants is not intended to represent the diverse groups of women and geographies in the Southern Interior of BC. Another limitation may have been the virtual nature of the session. Due to COVID-19 restrictions and other limitations of the research 124 team members, it was decided to use a virtual platform for the event. The short length of the discussion may have also impacted the involvement of participants, specifically the women. Although they were willing to discuss, it is known that patient-oriented research is a process where timing and specific techniques facilitate engagement processes. This session is a first attempt to include the diversity of women’s experiences and voices into system transformation; however, to facilitate KT, knowledge exchange, and coproduction of knowledge, a full continuum of participation and engagement of women is needed (Snow et al., 2018). Another gap may have been related to the fact that all of the women came from a Peer Advisory Group in BC; possibly having some women who were not part of this group might have produced different results. 5.7 Remarks A KT Discussion Session was held to identify and integrate women’s and contributors’ knowledge and analyses of health and social services for women who experience marginalization and IPV in the Southern Interior of BC. Participants engaged in an online discussion to share experiences, attitudes, and beliefs in order to translate, disseminate, exchange, and coproduce specific knowledge to enhance services for women. The identified theme and subthemes highlight the need to understand the diversity of women’s needs to ensure effective knowledge uptake and use. By recognizing women’s experiences and voices as drivers for system transformation, service and policy enhancements are more likely to succeed as they will better reflect the needs of the women being served. As shown, women’s positive and negative experiences are a meaningful source of knowledge when they are understood as part of the KT, dissemination, and exchange process of uptake and use. The recognition of women as knowledge users and knowledge holders is essential towards coproduction of knowledge. Since women with lived experiences of marginalization and IPV are sources of knowledge and not just users of others’ knowledge, this acknowledgement can help policy-makers and providers integrate women’s insights. Further, an ongoing, formal, and intentional process to integrate women’s voices and direction into the design and delivery of health and social services, and that includes specific mechanisms applicable to health and social services design and at the point of care, will help to tailor policies and address needs and health and social inequities. Several barriers across levels and sectors are impediments to women meeting their needs and recovering. As such, innovation across levels is 125 needed. A hub model enhancing a woman-centred approach will help women address their needs in a more timely manner. Changes in housing services and policies, including less restrictive designs for second-stage housing such as shelters, are also important. Service enhancements towards improving system integration and equity-based services should consider supporting women to seek care, enabling service access, and assisting when disclosing and during the healing process. Delivering services at the point of care should be through trauma-and violence-informed care, including practices and language that do not harm and violate women. Chapter 6 presents the final conclusions of the study. As the last chapter of this dissertation, it integrates key results and highlights from the three phases: Scoping Review (Phase 1), Policy Analysis (Phase 2), and KT Discussion Session (Phase 3). 126 Chapter 6. Synthesis and Conclusion Chapter 6 integrates key results and highlights of this dissertation in terms of its contributions to knowledge in health and social services practice, policy, and research. It presents considerations regarding the main goal, objectives, and the general impact of this study, including implications of each phase of the study along with overall implications. It also includes strengths and limitations. Finally, it presents implications for research and practice, including policy and education. 6.1 Recap Marginalization and IPV have negatively impacted women’s lives and societies in such a way that there is an international call to limit and end it (Garcia-Moreno, Hegarty, et al., 2015; Garcia-Moreno, Zimmerman, et al., 2015). The WHO has released guidelines and protocols to identify and deliver better health and social services for women who experience IPV and marginalization (WHO, 2019, 2021a). Although public health and social services have responded to the call to end violence against women, they still struggle to meet the needs of women. Understanding women’s experiences and addressing their needs requires an in-depth analysis of the complex dynamics of violence, policy, and service responses to IPV, and should consider the multiple intersections of women’s lives. For service and policy enhancements to be effective, the use of specific frameworks and lenses along with equally specific analyses and measurements underlying the factors impacting women’s health and social experiences is required (Ford-Gilboe et al., 2015; Tyler et al., 2019). Although researchers have advanced the understanding of strategies for women who experience IPV (Hameed at al., 2020; Rivas et al., 2019), often these enhancements have focused on protecting the safety of the victims at the individual level, including a focus on acute injuries (Hardesty & Ogolsky, 2020). However, a comprehensive understanding explaining the root-causes and effects of the intersections is still needed. The implementation of health and social approaches with implications for addressing health equity for women requires an exploration of initiatives addressing the complexity of individual and population needs. Since equity-based improvements must address the multiple needs of diverse women (e.g., Indigenous, LGBTQ community), an essential consideration is the integration of their voices and experiences from an intersectional perspective, meaning between and within various groups (Braveman, 2014, 2017). Further, since general considerations of health system integration approaches (e.g., quality 127 of care, effectiveness) (Singer et al., 2020), align with features such as quality of life and population health (Valentijn et al., 2013), and as these features impact people’s lives, the benefits of improving the health and the lives of women need to be measured against enhancements specifically planned and delivered for women who experience marginalization and IPV. Finally, since IPV against women is a complex social problem often rooted in the SDH and principally the contexts of women’s lives (e.g., poverty, discrimination, service access) (WHO, n.d.-b, 2017), understanding the processes that women experience towards empowerment and ownership, and hence towards their health and wellbeing, will help identify and intervene with regard to the specific factors influencing their health and lives. As there is little research about the impact of system integration and how it might address women’s health and social needs and impact health equity, this study facilitated an understanding of how health system integration enables, or does not enable, health equity for women who experience marginalization and IPV at three levels—national, provincial, and local, including policies and service enhancements. In this final chapter, I reflect on how these research results could be used to improve health system integration and health equity for women in BC who experience marginalization and IPV. See Figure 1 in Chapter 2 (p. 17) for an in-depth discussion each of the three phases of this study 6.2 Overview of the Three Phases of This Study Three interconnected phases were developed (see Figure 1) to address the specific objectives of this study. Each phase offered new insights on the exploration of integrated and equity-based services for women who experience marginalization and IPV in BC. The three phases provided an overview of health equity and health systems integration with the potential to address the needs of women. Phase 1 (Scoping Review) mapped national research evidence in the fields of health system integration, health equity, and women experiencing marginalization and IPV in Canada. The review was used to identify and assess scholarly published literature related to these topics. Key elements of the review found concern with the high level of complexity associated with studying and addressing health inequities in women in Canada. The review also identified research and care processes and approaches undertaken or identified by researchers as successfully meeting women’s needs, particularly in BC and Ontario. In Phase 2 (Policy Analysis), the evaluation of publicly available provincial policy documents found policy actions and measurements to establish accountability to achieve specific goals towards limiting and ending IPV, 128 including delivering care in BC. An in-depth policy analysis of the documents was conducted to identify the impacts and equity focus, along with their implementation concerns. Finally, Phase 3 (KT Discussion Session), involved an online discussion session with women with lived experiences of IPV and key contributors regarding the design and implementation of services and policies related to the care of women. A diverse group of participants reviewed the results of the previous two phases and together developed specific recommendations for action. Participants also reflected on their own experiences and practices related to health equity and health system integration as a means of transforming health and social systems. The discussion facilitated the inclusion of women’s voices to limit power imbalances in healthcare research and service delivery. An overview of each of the three phases, including key results, is provided in Table 21. Each phase contributed to answering the research question: How can health system integration enable health equity for women who experience marginalization and IPV? By addressing the primary and secondary objectives, specific knowledge in health and social service research was produced, and major contributions from each phase were highlighted. 6.3 Towards More Integrated and Equity-Based Services for Women Experiencing IPV in BC The next sections integrate key considerations for the design and delivery of policies and services for women who experience marginalization and IPV identified in each phase and in the study as a whole. 6.3.1 IPV as a Complex Health and Social Issue IPV in Canada is a health and social problem (Cotter, 2021). Combining IPV and non-intimate partner violence, women 15 years of age and over still experience higher rates than men in seven provinces and territories (Cotter, 2021). As documented, several efforts have been developed to limit violence against women. The analysis of the themes identified in the Scoping Review underscore the level of complexity related to health and social inequities for women who are marginalized and experience IPV. To address women’s inequities, a better understanding of marginalization and IPV as complex social problems requiring systemic and structural changes to limit violence will help contributors design and provide policies and services. The nurse-family partnership (Jack et al., 2021) is a program that started in the United States and is aimed at supporting women through pregnancy and child rearing, with the primary intended outcome being reduced child maltreatment. It is an educational-based house visitation 129 Table 21 Key Results per Phase Phase Objectives Key results Major contribution per phase Phase 1: Scoping Review 1. Identify how system integration and health equity have been designed and implemented to meet the needs of women who experience marginalization and IPV in Canada • Identified eight Canadian scholarly studies meeting the inclusion criteria • Recognized IPV as a complex problem where multiple intersections (e.g., trauma, abuse, violence) impacted women’s lives and health • Identified characteristics of system-level designs such as comprehensiveness, inclusiveness, and integration of services that enhanced integrated and women-centred care • Demonstrated how trauma- and violence-informed care improved health outcomes and experiences for women (e.g., women’s quality of life and trauma symptoms) • Identified integrated models of care based on health equity as essential to enhancing women-centred care • Identified how services based on health equity limited social exclusion by supporting women’s healing processes over the long-term Key considerations for health equity and health system integration, including implications for practice, policy, and research applicable for Canadian health and social services Phase 2: Policy Analysis 2. Identify how policies and structures enhance or limit system integration and health equity for women who experience marginalization and IPV in BC 2.1 Identify barriers and enablers to implementing system integration and health equity for women who experience marginalization and IPV in BC • Identified five provincial policy documents guiding decisions and actions for the design and delivery of services for the care of women who experience IPV • Recognized that policies build upon each other to facilitate a longer-term response to IPV • Specified actions towards improving specific services, departments, or ministries’ roles related to the care of women who experience IPV • Provided direction on specific actions on governance, management, and operational perspectives • Addressed health equity by recognizing the importance of stopping violence against specific groups of women • Involved several actors in developing, updating, and implementing policies to enhance the acceptability of the strategies • Identified a cross-sectoral approach where ministries, private, or not-for-profit organizations worked together to facilitate the internal approval of the actions, and the external endorsement by other agencies Detailed data, reflecting on the effects and equity promotion of the policies analyzed, and implementation concerns 130 Phase Objectives Key results Major contribution per phase Phase 3: KT Discussion Session 3. Develop recommendations for actions to support health equity through system integration for women who experience marginalization and IPV in BC and the Southern Interior of BC • Brought together seven women with lived experiences of IPV, 12 contributors, and four research team members to participate in an online session to share relevant results from the previous two phases • Gathered participants’ perspectives and recommendations on the services delivered and offered to women who experience marginalization and IPV in the Southern Interior of BC • Demonstrated that organizations should help women provide their views on the way services improve or limit their health • Identified that women's experiences and needs are multiple and vary over time, and as such multiple and tailored care approaches are needed • Identified the importance of building trusting relationships to understand and address women’s needs • Identified how some groups of women (e.g., Indigenous, LGBTQ community) need specific services to meet their needs • Identified that the integration of women’s experiences and voices is essential to improve services • Identified that improvements in housing, financial, and employment supports are needed • Recommended a one stop model of care that is woman-centred and uses trauma and violence-informed care Shared results from Phases 1 and 2, and gathered participants’ perspectives on health system integration and equity-based services for women who experience IPV in the Southern Interior of BC Disseminated results of Phase 3, including a summary sent to women with lived experiences and decision-makers to continue the KT process Overall contribution Strengthened the knowledge about how health system integration and equity-based services can improve women’s health and lives 131 program for first time young women who have experienced social and economic disadvantage (Jack et al., 2012, 2015, 2021) and has recently included efforts to reduce IPV in women. After adaptations, the modified IPV intervention helped nurses support women who experience IPV in Canada. The authors conclude that for interventions to be effective to limit IPV, they should consider the complexity of women’s experiences of IPV (Jack et al., 2021), as found in the scoping review. As noted, Canadian research has contributed to an understanding of the complexity of experiencing IPV in multiple contexts by studying the diverse intersections of women’s experiences (see Scoping Review results). However, there are challenges to improve the understanding of this complexity, as demonstrated by efforts to enhance services using a one-size-fits-all approach (Rivas et al., 2019) and the lack of specific methods to measure health equity (Tyler et al., 2019). Ford-Gilboe et al. (2016) developed a self-report measure to capture the complexity of IPV in women’s lives. The instrument aims to conceptualize and measure IPV in terms of the severity of violence by considering the cultural, economic, and gendered contexts in which IPV occurs. The instrument facilitates an understanding of the complexity of IPV from a systemic perspective and a comprehensive assessment of women’s lives. The study of systemic abuse and violence contributes to understanding IPV in Canadian women’s lives; this is highlighted in the scoping review and has been recognized internationally (Garcia-Moreno, Hegarty, et al., 2015; Garcia-Moreno, Zimmerman, et al., 2015; WHO n.d., n.d.-a, n.d.-b, 2019, 2021a). Yet, for the study of complexity in public health policies, such as the ones identified in the Policy Analysis, there are further challenges to consider, including the limited use of specific qualitative research methodologies to understand complex phenomena (Gear et al., 2018; Van Belle et al., 2017). Authors in the scoping review (e.g., Mantler at al., 2019) benefited from the use of qualitative methodologies for the analysis of policy documents related to the care of women who experience IPV. 6.3.2 Engaging Women with Lived Experiences As noted in the results of the scoping review and the KT discussion session, the integration of women’s experiences and voices in policy and service design is crucial for more integrated and equity-based systems. The scoping review reveals that integrated, equity-based systems for women who are at the intersections of multiple forms of marginalization, such as women who experience IPV, need policy and service design that engage women and better consider their insights, experiences, and evolving 132 needs. Participants in the KT discussion also expressed that to enhance the understanding of women’s lives and needs, a recognition of the importance of incorporating women’s experiences and opinions as drivers of health and social systems transformation is required. Understanding and incorporating women’s voices allowed researchers and contributors in Canada to identify the types of supports that women need (e.g., non-stigmatizing and violence-specific) and how the supports should be designed and implemented (see Scoping Review results). The participation of people with lived experience has increased in the past decade and has improved patient-oriented research and practice, as well as a higher likelihood of KT and implementation (Banner et al., 2019). In the case of women with lived experience of IPV, Dichter at al. (2019) show the importance of direct outreach to women to invite them to participate in interviews about IPV experiences: “[their] participation was feasible and effective, and proved more fruitful for recruitment than reliance on provider or patient self-referral” (p. 1). Women with lived experiences of IPV are willing to contribute to improvements in care through participation in research, as found in the KT discussion session (see Chapter 5). The session facilitated sharing lived experiences that were identified as a meaningful source of knowledge. In the KT dissemination and exchange cycle of uptake and use in health and social research, sharing lived experiences is key to identify gaps, barriers, and facilitators (Banner et al., 2019). To promote the understanding and use of IPV knowledge, women with lived experience need to be acknowledged as knowledge holders and users along with a recognition of the diversity of their needs (Ward et al., 2012). If the relationship between women’s needs, including being recognized as knowledge holders, and the way policies and services are translated into action is not recognized, women may access services, but the services will not meet their needs and they will likely continue facing inequities and violence across their lives, as shown in the scoping review. 6.3.3 Addressing the Diverse Needs of Women Addressing health inequities requires identifying the diverse needs of different groups of women when developing policies and planning services, as identified in the BC policies analyzed. Specific groups of women (e.g., immigrant, refugee, Indigenous, women with disabilities, women who are part of the LGBTQ community) are at a higher risk of experiencing marginalization and IPV (Di Cesare, 2014; Lee, 2019; Stockman et al., 2015; Wallace et al., 2021), than women who are not part of these groups. However, the policy actions studied did not specify how to address power imbalances and structural 133 violence against these groups. It is known that IPV is a form of interpersonal violence, is an abuse of power, and relates to structural forms of violence (Lee, 2019). Since women who experience IPV often experience poverty, discrimination, and stigma, and these are forms of structural violence, there is a need to improve policies, services, structures, and processes that impact the way societies are organized to limit further social and health inequities in women who experience IPV. Harris et al. (2020) highlight that to address inequities, it is important to understand the effects of power since all policies have positive or negative impacts; as such, policies and structures unintentionally may favour dominant groups and create further inequities. The policy analysis considered the group-differentiated approach (see Policy Analysis/Equity section) taken by the BC government to address health and social inequities in women who experience IPV in BC. As discussed, this approach can lead to further power imbalances. Public policies and services need to recognize and embrace social group differences to limit further group-based power imbalances (Young, 2003). To strengthen the understanding of between and within group differences, and the systemic layers of oppression experienced by diverse groups of women, health and social enhancements based on equity, diversity, and inclusion (Green et al. 2017; Rose, 2021) at all levels should be prioritized. A socioecological framework (Heise, 1998; WHO, n.d.-b) can help policy and decision-makers, providers, and researchers understand the social dimensions of IPV. Canadian researchers are encouraging a better understanding of how structural processes impact health outcomes, from a structural and policy level to a point-of-care level, as presented in the scoping review. 6.3.4 Partnership and Collaboration As shown in the policy analysis, reliable partnerships and collaborations among organizations and services are key mechanisms to improving health system integration. Coordination between and within services, specifically the recognition of collaboration as a core competency for interprofessional collaborative practice is a key feature to deliver integrated services (Suter, Arndt, et al., 2009; Suter, Oelke, et al., 2009; Valentijn et al., 2013). Goicolea et al. (2015) explored the links among context, intervention, and outcomes that impact primary healthcare teams’ response to IPV. To strengthen relationships between providers and women, it is important to continuously engage in a learning process, including team culture and values related to IPV management (e.g., trauma- and violence-informed care). The authors concluded that macro structural processes such as policies for integrated health and social 134 care responses to IPV (e.g., good coordination and referral systems) have facilitated the adoption of IPV interventions. According to Goicolea et al. (2019), specific team-level factors and dynamics, such as the self-perception of readiness to deliver care and the ability to implement a woman-centred approach, promote better healthcare responses for women experiencing IPV. Although health systems response to violence against women varies, there are several common recommendations. Garcia-Moreno, Hegarty, et al. (2015) and Garcia-Moreno, Zimmerman, et al. (2015) highlight that addressing IPV needs a commitment across sectors, including having IPV as a higher priority in health and social policies, and budget allocations. As such, political leadership and governmental investment are key. Additionally, the health system’s roles should support a cross-sectoral health and social response. The responsibility of the health system should contribute “to prevention of violence recurrence and mitigation of the consequences, address associated problems, such as substance misuse and depression, and provide immediate and ongoing care” (Garcia-Moreno, Hegarty, et al., 2015, p. 1568). Results of the policy analysis reveal a cross-sectoral and integrated mandate is necessary to address and limit IPV in BC. The mandate across all policies centred on macro-level strategies such as governance; however, for some policy documents, certain strategies such as setting guidance for the delivery of services were additionally applicable at the point of care (e.g., Violence against women in relationships policy [2010]; Best practice approaches, child protection and violence against women [2017]). As a factor impacting policy implementation and adoption (Capano & Howlett, 2020), a cross-sectoral mandate was supported by a “building up” approach across all policies, to provide continuity and consistency. The policies in BC built upon each other, each aiming to provide a comprehensive and longer-term response to IPV in the province. Although this building up approach facilitated the implementation of actions such as legislative changes and justice reform in the province, it was also identified as too broad and non-specific from an operational perspective, which limited the execution of actions at the organizational and point-of-care levels. Briones-Vozmediano et al. (2018) recognized that when there is a system mandate (e.g., macro level) to integrate health and social care responses to IPV, there will be multiple local responses to integrate services and care, which tend to be isolated and fragmented. In their study, providers’ responses to IPV ranged from abstaining from delivering care to women and not even participating in any IPV management, to totally engaging with women and 135 facilitating a more integrated and woman-centred response. The authors recognize that a healthcare response to a social non-biomedical health problem such as IPV will remain biomedicalized and will be based both on the motivation of health and social care providers as well as organizational factors. Research reveals organizational factors contribute to the effectiveness of IPV enhancements. Goicolea et al. (2015) show that when providers feel supported in their medical decisions by the established efforts and responses of other services, including connection and collaboration (e.g., referral systems), IPV interventions appear more effective. To enhance the impact of organizational factors for service delivery, system-level responses to IPV such as increasing education and training on trauma- and violence-informed, anti-racist, and equity-based care helps providers to deliver more integrated and equitable care (Cullen et al., 2021; Toccalino et al., 2022). 6.3.5 Designing Services and Supports This study shows that a more integrated and equity-based system is possible by improving what type of supports are designed and how they are delivered. The scoping review, policy analysis, and KT discussion session identify explicit supports that women require to meet their needs, and how these supports should be provided. The scoping review shows how shelters and specific tailored approaches such as trauma- and violence-informed care and harm reduction can support Canadian women. In the policy documents studied, the government of BC considered child welfare and justice as core services, and through collaboration and coordination the province achieved specific goals towards addressing and limiting IPV in BC. In the KT discussion session, participants stressed that housing services and policies, specifically, less restrictive designs for second-stage housing, employment assistance, and financial programs will support women in their recovery journey. Further, this study demonstrates that innovative approaches across levels and sectors is an effective strategy towards a more integrated and equity-based system. The scoping review identified tailored and specific approaches to address women’s needs across Canada. For example, a tailored design for the care of Indigenous women in BC helped improve health outcomes (Varcoe et al., 2019), and changes in the design and delivery of care in a rural shelter in Ontario facilitated the delivery of care, including the engagement and participation of the community to limit violence against women (Mantler et al., 2017). Further, because there are barriers limiting women in meeting their needs and recovery, as presented in the KT discussion session (see pp.127–129), a hub 136 model or one-stop model will facilitate the delivery of services and help women meet their needs in a more timely manner. Additionally, a hub model will enhance a woman-centred approach because women could go, regularly meet, and engage with providers who understand their multiple and specific needs. This engagement between women and providers will help women build positive relationships with providers. Trauma- and Violence-Informed Care. The three phases of this study show that delivering point-of-care services to women who experience marginalization and IPV should use trauma-and violence-informed approaches, including practices and language that do not harm and re-victimize women. In the scoping review, trauma- and violence-informed care, along with harm reduction approaches, were frequently used to limit further inequities (e.g., Hovey & Scott, 2019; Torchalla et al., 2015; Varcoe et al., 2019). The policy analysis also found that using these approaches to enhance the impact of policy actions across levels of care was relevant. In the KT discussion session, the lack of specific training and understanding of the impacts of structural and systemic violence on women was identified through women’s negative experiences, particularly in encounters with the police. Women’s disclosure of experiences of violence was facilitated by the provider’s empathic, respectful, and non-judgmental behaviour (Dichter et al., 2019). 6.4 Strengths and Limitations 6.4.1 Strengths This study is the first of its kind, as far as I know, to investigate how to improve health system integration and equity-based services for women who experience marginalization and IPV in Canada, BC, and the Southern Interior of BC. The comprehensive methodological design, involving a geographically narrowing approach from national to local levels offered several benefits. First, the scoping review contained a comprehensive search strategy to identify current national peer-reviewed evidence on the topics. Further, in the case of the policy analysis, the specific methodological approach with the use of the framework for analyzing public policies (Benoit, 2013) made it possible to apply a scientific and methodologically comprehensive approach to the study of public health actions to address and limit IPV in the province of BC. Finally, the KT discussion session was the first local effort to enhance women’s involvement in health and social research related to IPV in the Southern Interior of BC. 137 The evidence collected through all components of the study is aligned with national and international literature emphasizing how to improve services through health system integration and equity-based services for women who experience marginalization and IPV. The complementary approaches for each phase facilitated the integration of results from every phase and for the study as a whole. Each phase built upon the others to achieve a dynamic and iterative process of coproduction of knowledge. As such, the scoping review and the KT discussion session show the need for stronger collaboration and integration across services. Since the impacts of trauma and abuse associated with IPV persists over time, it is crucial to pay attention to specific delivery approaches that support women over the long-term, such as trauma- and violence-informed care. Finally, the use of theoretical approaches and specific lenses such as feminist intersectionality enhanced the understanding of health and social inequities of women’s lives from an equity-based standpoint. Marginalization and IPV in women were recognized as complex systemic social problems that need multiple perspectives, methodologies, theories, and assessments to be studied and addressed. As such, the use of integrated KT approaches facilitated the involvement of women’s participation and recognition of women’s experiences and voices as drivers of services and policy planning and implementation. 6.4.2 Limitations Study limitations are associated with the policy analysis and the KT discussion session. The policy analysis was impacted by time constraints and resource limitations, particularly the lack of time to analyze complementary documents identified, such as the policy instruments (e.g., Federal-Provincial-Territorial Ministers Responsible for Justice and Public Safety, 2016). The KT discussion session limitations relate to funding and logistics in holding the session. First, there was no budget for the study to support the recruitment processes related to printing invitations (e.g., posters, brochures). Second, holding the session during the COVID-19 pandemic meant the session had to be held virtually via UBC Zoom. Third, recruiting participants for the KT discussion session was also impacted by the pandemic. For example, local health and social services were in high demand to control the pandemic, imposing limitations to participation in the study. Also, the participation of women with lived experiences of IPV who might have been interested may have been precluded by lack of access to electronic devices. 138 Through this study, health system integration and its direct impact on the health equity of women who experience marginalization and IPV could not be determined, particularly in terms of health outcomes, since the study did not include impact or outcome evaluation. As such, future research should evaluate provincial policies and actions as they relate to the care of women. To advance the study of health equity and health system integration for this population, there is a need to explore what an integrated, equity-based, and woman-centred approach for women who experience IPV looks like, how it can be effectively implemented, and the intended outcomes. Also, interviews with women and contributors could assist in further identifying the impact of policies, actions, structures, and processes on women’s lives and their needs in a more in-depth way. A final limitation relates to power and privilege in academics through the inclusion of published articles only. Since the scoping review relied entirely on published literature, considerations such as who is published and what is published are aspects attached to power and privilege, and reflect social inequities (Curry & Lillis, 2018). 6.5 Implications This study advances knowledge of health system integration and equity-based care as important approaches for women who experience marginalization and IPV by illuminating how specific actions could improve health and social services. System-level design based on health equity has the potential to meet women’s needs (Briones-Vozmediano et al., 2018; Garcia-Moreno, Hegarty, et al., 2015). Likewise, considering health-equity in the planning and delivery of more integrated care approaches for women will improve their health outcomes and overall wellbeing (Dichter et al., 2019; Ford-Gilboe et al., 2018, 2020; O’Brien et al., 2018). Specific considerations on the implications of this study, particularly on policy, implementation of services, and future research are presented in Table 22. 6.6 Conclusion This study facilitated the understanding of how health system integration, including policies and service enhancements, enables health equity for women who experience marginalization and IPV. The results of this study aim to keep an equity-based approach in mind when developing system-levels designs. Detailed results demonstrate what aspects of health system integration relate to improving health inequities and limiting systemic causes of health inequities in women who experience marginalization and IPV. The studies analyzed in the scoping review revealed many promising ways to 139 Table 22 Summary of Implications of the Study Implications for research, policy, and practice, including education Research Policy Practice and Education • Explain the root causes of IPV and effects of the intersections of women’s lives and needs (Lee, 2019; Varcoe et al., 2019) • Evaluate the impact of health system integration approaches (Singer et al., 2020; Wallace et al., 2021) to address women’s needs and their effect on health equity • Enhance the engagement of women with lived experiences in health and social care research (Banner et al., 2019) • Facilitate the inclusion of women’s voices and experiences of IPV to improve care (Dichter et al., 2019) • Research how structural and organizational processes impact health outcomes (Goicolea et al., 2015; Tyler et al., 2019) • Assess the impact of trauma- and violence-informed care on women’s health and outcomes (Kulkarni, 2018) • Identify whether policies and services planned and offered meet women’s needs (Lavoie et al., 2018; Rogers & Kelly, 2011) • Map the Canadian health system response, including policy actions and strategies for the care of women experiencing IPV (Goicolea et al., 2013) • Evaluate the effect of the multiple policy actions taken by the government in the past decade to meet women’s needs in BC • Analyze national policy documents related to the care of women who experience IPV (Mantler et al., 2019) • Promote equity-based and women-centred care for women who experience marginalization through system-level designs (O'Brien et al., 2017) • Design policies that address the complexity of IPV in women’s lives (Ford-Gilboe et al., 2016; (Garcia-Moreno, Hegarty, et al., 2015; Garcia-Moreno, Zimmerman, et al., 2015) • Facilitate the inclusion of women with lived experiences into policy planning and implementation (Snow et al., 2018) • Evaluate if services delivered meet women’s needs (Ford-Gilboe et al., 2015) • Explore how connection and collaboration with other sectors (e.g., referral systems) impact IPV strategies (Goicolea et al., 2019) • Enhance cultural change and interprofessional collaboration among providers (Suter, Arndt, et al., 2009) • Enhance intensive levels of supports for groups who have higher risk of experiencing marginalization and IPV (e.g., immigrant, Indigenous, LGBTQ) than women not part of these groups (Tutty et al., 2021) • Training to enable earlier detection of experiences of IPV (Haag et al., 2019) enhance the health and wellbeing of women who experience marginalization and IPV across the country, with an emphasis on BC and Ontario. They also revealed challenges faced by providers and women with lived experiences of IPV, including the complexity of IPV and how a lack of understanding limits women and providers’ relationships; even worse, how this limitation further impacts organizations from meeting 140 women’s needs. The BC government has embraced important changes to limit violence against women in the last decade; however, there is a lack of evaluation and assessment of the effectiveness of the policy actions implemented, including outcomes evaluation. It appears that the macro cross-sectoral approach aimed to facilitate the implementation of actions has limitations in being translated into integrated local processes for the delivery of care. It would seem there is a siloed approach: many organizations are willing to support women but need clearer paths for accountability and working together. It is expected that this study could provide specifications as to concrete and achievable strategies to advance health equity in women. Lastly, the inclusion of women’s voices in health and social research is an action towards improving health equity. Through a discussion with contributors, women spoke up and against the supports that have negatively impacted their lives. From a health-equity perspective, this exercise can be empowering and support women’s recovery processes. It is recommended to strengthen the role of women in service and policy planning and delivery in the Southern Interior of BC. Finally, the results can support women with lived experience and contributors (e.g., researchers, providers, managers, decision-makers) to recognize their efforts related to health system and equity improvements. The overall results derived from this study, such as highlighting innovative approaches that can be used to effectively improve women’s lives, will enable more meaningful use of evidence in health system integration and equity-based research. The results encourage us to recognize individual and social roles towards responsibilities in health and social inequities. By questioning power differences among structures, practices, attitudes, processes, and/or policies, people and societies will hold each other accountable towards social justice. As such, a strong call to action is needed in limiting health and social inequities, particularly for women with lived experience of IPV and marginalization. 141 References Abelson, J., Montesanti, S., Li, K., Gauvin, F.-P., & Martin, E. (2010). Effective strategies for interactive public engagement in the development of healthcare policies and programs. Canadian Health Services Research Foundation. Alderson, S., Westmarland, N., & Kelly, L. (2013). 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Integrating equity, gender, human rights and social determinants into the work of WHO: Roadmap for action, 2014–2019. https://iwlearn.net/resolveuid/01642534-3293-4207-9f07-6d03be5c1951 World Health Organization. (2017). Country support package for equity, gender and human rights in leaving no one behind in the path to universal health coverage. https://apps.who.int/iris/bitstream/handle/10665/325057/WHO-FWC-GER-17.1-eng.pdf?ua=1 World Health Organization. (2019). RESPECT women: Preventing violence against women. https://www.who.int/publications/i/item/WHORHR1819 World Health Organization. (2021a). Caring for women subjected to violence: A WHO curriculum for training health-care providers, revised edition, 2021. https://www.who.int/publications/i/item/9789240039803 World Health Organization. (2021b). Violence against women. Key facts. https://www.who.int/news-room/fact-sheets/detail/violence-against-women World Health Organization & Pan American Health Organization. (2012). Intimate partner violence: Understanding and addressing violence against women. https://apps.who.int/iris/bitstream/handle/10665/77432/WHO_RHR_12.36_eng.pdf 170 World Health Organization, United Nations Population Fund, & United Nations High Commissioner for Refugees. (2020). Clinical management of rape and intimate partner violence survivors: Developing protocols for use in humanitarian settings. https://www.who.int/publications/i/item/9789240001411 Wyatt, R., Laderman, M., Botwinick, L., Mate, K., & Whittington, J. (2016). Achieving health equity: A guide for health care organizations. IHI White Paper, Institute for Healthcare Improvement. Wuest, J., Merritt-Gray, M., Dube, N., Hodgins, M. J., Malcolm, J., Majerovich, J. A., Scott-Storey, K., Ford-Gilboe, M. & Varcoe, C. (2015). The process, outcomes, and challenges of feasibility studies conducted in partnership with stakeholders: A health intervention for women survivors of intimate partner violence. Research in Nursing & Health, 38(1), 82–96. https://doi.org/10.1002/nur.21636 Yerke, A. F., & DeFeo, J. (2016). Redefining intimate partner violence beyond the binary to include transgender people. Journal of Family Violence, 31(8), 975–979. https://doi.org/10.1007/s10896-016-9887-y Young, I. M. (2003). Inclusion and democracy. Oxford Scholarship Online. https://doi.org/10.1093/0198297556.001.0001 171 Appendix A 6S Pyramid and Levels of Public Health Evidence. Health-evidence.ca. (2009, November 25). Levels & Sources of Public Health Evidence. Retrieved [June, 2020] 172 Appendix B Conceptual Search Strategy Concept Keywords Medical Subject headings (MeSh) 1) Health system integration integrat$ ADJ2 (organization$ OR health OR healthcare OR care OR service$ OR system$ OR patient) Delivery of Health Care, Integrated/ 2) Women’s health Women or female exp Women/ Female/ 3) Marginalization and vulnerability in women. Socially disadvantaged women Intersections included: immigrant, abused, low income, unemployed, minorities (racial/sexual/ethnic), mental health, substance use disorders, obesity, disability, sexual and gender minorities, Indigenous, etc. * 4) Intimate partner violence Domestic violence/abuse, intimate partner violence, exp Spouse Abuse/ or Domestic Violence/ or exp battered women/ or exp Intimate Partner Violence/ ((abuse$ or violen$) adj4 (partner$ or wife or wives or spouse$ or domestic)).tw. 5) International Except Canada 6) National/Canada Canada and/or any province (canad* OR "british columbia" OR "Colombie britannique" OR alberta* OR saskatchewan OR manitoba* OR ontario OR quebec OR "nouveau brunswick" OR "nova scotia" OR "nouvelle ecosse" OR "prince edward island" OR newfoundland OR labrador OR nunavut OR nwt OR "northwest territories" OR yukon OR nunavik OR inuvialuit) *Specific MeSH for #3 followed strategy for “vulnerable and socially disadvantaged population” taken from the systematic review done by Hollowell et al. (2011). 173 Appendix C Main Sources to Guide and Track Source Search strategy Results Healthevidence.org (Nov 5th, 2020) Results for: [(("Intimate Partner Violence" OR "IPV" OR "abuse")) AND (("Equit*" OR "inequity" OR "Disparit*" OR "Health Status")) AND (("Delivery of Health Care" OR "Integrated" OR "Health Care" OR "system$")) AND ((women or female))] Not met criteria, some related are: Article Authors Date Rating 1. Interventions that address intimate partner violence and HIV among women: A systematic review Marshall K.J., et al. 2018 Moderate (accessed) 2. School-based health centers to advance health equity: A community guide systematic review Knopf J., et al. 2016 Moderate (didn’t meet criteria) Healthevidence.org (Nov 5th, 2020) Results for: [(("Intimate Partner Violence" OR "IPV" OR "abuse")) AND (("Equit*" OR "inequity" OR "Disparit*" OR "Health Status")) AND (("Delivery of Health Care" OR "Integrated" OR "Health Care" OR "system$")) AND ((canad* OR "british columbia" OR "Colombie britannique" OR alberta* OR saskatchewan OR manitoba* OR ontario OR quebec OR "nouveau brunswick" OR "nova scotia" OR "nouvelle ecosse" OR "prince edward island" OR newfoundland OR labrador OR nunavut OR nwt OR "northwest territories" OR yukon OR nunavik OR inuvialuit))] AND Limit: Population = Female 0 TRIP (Nov 5, 2020) [(("Intimate Partner Violence" OR "IPV" OR "abuse")) AND (("Equit*" OR "inequity" OR "Disparit*" OR "Health Status")) AND (("Delivery of Health Care" OR "Integrated" OR "Health Care" OR "system$")) AND ((women or female))] Systematic reviews 118 Evidence-based synopsis 147 Guidelines: Canada 43: after screening of title and abstract, only 2 met IPV criteria Woman Abuse: Screening, Identification and Initial Response Intimate Partner Violence During the Perinatal Period 174 Source Search strategy Results National Guidelines Clearinghouse (NGC) http://guideline.gov NGC doesn’t work anymore for FREE CMA (November 5th, 2020) Intimate partner violence (the rest of terms/strategy didn’t yield anything) Only one A BIT related item but not women specific AND NOT IPV specific Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience (NOT INCLUDED) Registered Nurses Association of Ontario (RNAO) http://www.rnao.org/bestpractices/index.asp (Nov 5th, 2020) RHAO yield same item than one from TRIP Other items related from the RHAO website: -Summary of recommendations (Nursing Best Practice Guideline) - Woman Abuse Supplement Only -Woman Abuse Webcast Q and A Woman Abuse: Screening, Identification and Initial Response (THIS IS A SUMMARY AND RECOMMENDATIONS DOCUMENT) It can be linked to the one above in TRIP source https://rnao.ca/sites/rnao-ca/files/storage/related/656_BPG_Women_Abuse_summary.pdf Healthevidence.org Nov 6th, 2020 From Health evidence, there was only one item from 2015 (Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse) There are few systematic reviews available for these specific terms/MeSH NOTE: Results of the searches and articles are saved on my account Example of the only search that yield 2 items: [("IPV" OR "Intimate partner violence" OR 'abuse') AND ((canad* OR "british columbia" OR "Colombie britannique" OR alberta* OR saskatchewan OR manitoba* OR ontario OR quebec OR "nouveau brunswick" OR "nova scotia" OR "nouvelle ecosse" OR "prince edward island" OR newfoundland OR labrador OR nunavut OR nwt OR "northwest territories" OR "yukon" OR "nunavik" OR "inuvialuit"))] AND Limit: Date = Published from 2015 to 2020 Population = Female Only one item met criteria: A comparison of the types of screening tool administration methods used for the detection of intimate partner violence: A systematic review and meta-analysis (NOT AVAILABLE) From health evidence.org the item is: https://www.healthevidence.org/view-article.aspx?a=advocacy-interventions-reduce-eliminate-violence-promote-physical-psychosocial-19435 There is a synopsis of synthesis: https://healthevidence.org/documents/byid/19435/Ramsay2009_EvidenceSummary_ENUpdate.pdf From the complementary searches: https://healthevidence.org/view-article.aspx?a=comparison-types-screening-tool-administration-methods-detection-intimate-28512 175 Source Search strategy Results Evidence-based nursing Evidence-based medicine Evidence-Based Mental Health American College of Physicians Journal Club (ACP Journal Club) [("IPV" OR "Intimate partner violence" OR "abuse") AND ("Delivery of Care" OR Integrat* OR "Healthcare" OR "sytem")]" and title "[("IPV" OR "Intimate partner violence" OR "abuse") AND ("Delivery of Care" OR Integrat* OR "Healthcare" OR "sytem")] Filter by date and others Nothing Public health+ (November 6th, 2020) [("Intimate Partner Violence" OR "IPV" OR "abuse") AND ("women" OR "female")] Limits: - 2015: 3 items - 2018 and 2019: not relevant/applicable Results for 2015 that met criteria, only 2 (ITEM 2 WAS ALREADY FOUND ABOVE) 1. Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review Source: Fam Pract. 2015 May 6. pii: cmu091. Relevance: 5.00 Newsworthiness Rating: 5.00 2. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Source: Cochrane Database Syst Rev. 2015 Dec 3;12:CD005043. Relevance: 5.00 Newsworthiness Rating: 5.0 2015 items: Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. 176 Source Search strategy Results Cochrane November 6th, 2020 Cochrane has its own filters/search Terms used: P: female P: Intimate partner violence Note: Nothing yield when trying other terms like ‘systems, healthcare, equity’ Only one related item yield for 2020 BUT NOT SPECIFIC Psychological therapies for women who experience intimate partner violence Only one related item yield for 2020 BUT NOT SPECIFIC (NOT INCLUDED) Psychological therapies for women who experience intimate partner violence Medline November 6-10, 2020 It yields 61 items (Internationally) Specific search strategy is saved in my account 177 Appendix D Sources per Level and Resources to Guide and Track the Search Level of the 6S Pyramid Publicly Available YES / NO Critical Appraisal Required YES / NO Total No. Results Link to Saved Search Strategy & Results SUMMARIES Evidence-Based Texts NO NO Clinical Evidence http://www.clinicalevidence.com Dynamed http://www.ebscohost.com/dynamed Stat!Ref Pier http://pier.acponline.org/index.html UpToDate http://www.uptodate.com Not FREE access SUMMARIES Guidelines YES NO Guideline Advisory Committee (GAC) http://www.gacguidelines.ca/index.cfm?pagepath=GAC_Endorsed_Guidelines&id=21080 Note: only archive accessible Not access to GAC 178 Level of the 6S Pyramid Publicly Available YES / NO Critical Appraisal Required YES / NO Total No. Results Link to Saved Search Strategy & Results YES YES National Guidelines Clearinghouse (NGC) http://guideline.gov Note: includes guidelines from the following organizations • National Institute for Health and Clinical Excellence (NICE) Public Health Guidance http://guidance.nice.org.uk/PHG?textonly=false • Registered Nurses Association of Ontario (RNAO) http://www.rnao.org/bestpractices/index.asp • Canadian Medical Association (CMA Infobase) http://www.cma.ca/index.cfm/ci_id/54316/la_id/1.htm • Center for Disease Control and Prevention (CDC) Turning Research into Practice (TRIP) Database http://www.tripdatabase.com Note: filter search by “Guidelines” NGC doesn’t work anymore for FREE TRIP database: Systematic reviews 118, which yield: Evidence-based synopsis 147, which yield: Guidelines: Canada 43: after screening of title and abstract, only 2 met IPV criteria (only 1 was kept) RHAO yield same item than one from TRIP Other 3 items related from the RHAO website, but only 1 met criteria: -Summary of recommendations (Nursing Best Practice Guideline) -Woman Abuse Supplement Only -Woman Abuse Webcast Q and A CMA yield only 1 item NGC: NA Results from TRIP: Woman Abuse: Screening, Identification and Initial Response Intimate Partner Violence During the Perinatal Period RHAO yield similar document to TRIP. This one is a summary and recommendations linked to the one above (Woman Abuse: Screening…) The 1 from RHAO is called: Summary and Recommendations https://rnao.ca/sites/rnao-ca/files/storage/related/656_BPG_Women_Abuse_summary.pdf Results from CMA: Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience (NOT INCLUDED) 179 Level of the 6S Pyramid Publicly Available YES / NO Critical Appraisal Required YES / NO Total No. Results Link to Saved Search Strategy & Results SYNOPSES OF SYNTHESES YES NO Health Evidence www.healthevidence.org Note: summary statements via PDF icon *access to full-text of articles limited Center for Reviews and Dissemination (CRD) http://www.crd.york.ac.uk/CMS2Web/ *access to full-text of articles limited • Database of Abstracts of Reviews of Effectiveness (DARE) • Economic Evaluation Database (NHS EED) • Health Technology Assessment (HTA) Database From Health evidence, only 1 synopses of synthesis but from 2012) Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse) There is one more item BUT not available (A comparison of the types of screening tool administration methods used for the detection of intimate partner violence: A systematic review and meta-analysis) There are few systematic reviews available for these specific terms/MeSH but not met criteria -Not access to CRD From health evidence.org https://www.healthevidence.org/view-article.aspx?a=advocacy-interventions-reduce-eliminate-violence-promote-physical-psychosocial-19435 Only access to 1 item I couldn’t access to the Systematic review and metanalysis NO NO Evidence-Based Abstract Journals Note: prior to 2010 • Evidence-Based Nursing http://ebn.bmj.com • Evidence-Based Medicine http://ebm.bmj.com • Evidence-Based Mental Health http://ebmh.bmj.com • American College of Physicians Journal Club (ACP Journal Club) www.acpjc.org 180 Level of the 6S Pyramid Publicly Available YES / NO Critical Appraisal Required YES / NO Total No. Results Link to Saved Search Strategy & Results SYNTHESES YES NO Health Evidence www.healthevidence.org *access to full-text of articles limited YES YES CDC Guide to Community Preventive Services www.thecommunityguide.org The Centre for Reviews and Dissemination (CRD) http://www.crd.york.ac.uk/CMS2Web/ *access to full-text of articles limited **quality filter applied • Database of Abstracts of Reviews of Effectiveness (DARE) • Economic Evaluation Database (NHS EED) • Health Technology Assessment (HTA) Database McMaster Health Knowledge Refinery (McMaster PLUS) http://hiru.mcmaster.ca/hiru/HIRU_McMaster_PLUS_projects.aspx *access to full-text limited **quality filter applied • Public Health+ • Nursing+ • Obesity+ • KT+ • Rehab+ • Evidence Updates EPPI-Centre http://eppi.ioe.ac.uk (reviews related to health promotion, education, employment, social care, crime and justice) • Database of Promoting Health Effectiveness Reviews (DoPHER) http://eppi.ioe.ac.uk/webdatabases/Intro.aspx?ID=2 Cochrane Collaboration http://www2.cochrane.org/reviews/ Note: only abstracts of syntheses *access to full-text limited PubMed Clinical Queries http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml#reviews Note: under the limits tab, then publication type, click meta-analyses to limit to meta-analyses *access to full-text limited Turning Research into Practice (TRIP) Database http://www.tripdatabase.com Note: filter search by systematic reviews *access to full-text limited Only results from: Public health yield 3 items, only 2 met criteria (item 2 was already found above) 1.Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review 2.Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner links in abuse Results and links can be found in Appendix C NO YES Cochrane Collaboration • Cochrane Library (Cochrane Database of Systematic Reviews) http://www.thecochranelibrary.com/view/0/index.html 181 Level of the 6S Pyramid Publicly Available YES / NO Critical Appraisal Required YES / NO Total No. Results Link to Saved Search Strategy & Results SYNOPSES OF STUDIES NO NO Evidence-Based Abstract Journals Note: prior to 2010 • Evidence-Based Nursing http://ebn.bmj.com • Evidence-Based Medicine http://ebm.bmj.com • Evidence-Based Mental Health http://ebmh.bmj.com American College of Physicians Journal Club (ACP Journal Club) www.acpjc.org Nothing from: EBN: no matching results EBM: no results EBMH: no results ACP: no results STUDIES YES YES McMaster Health Knowledge Refinery (McMaster PLUS) http://hiru.mcmaster.ca/hiru/HIRU_McMaster_PLUS_projects.aspx *access to full-text limited **quality filter applied • Public Health+ • Nursing+ • Obesity+ • KT+ • Rehab+ • Evidence Updates PubMed Clinical Queries http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml#reviews *access to full-text limited Trials Register of Promoting Health Interventions (TRoPHI) http://eppi.ioe.ac.uk/webdatabases/Intro.aspx?ID=5 Turning Research into Practice (TRIP) Database http://www.tripdatabase.com *access to full-text limited Turning Research into Practice (TRIP) Database http://www.tripdatabase.com *access to full-text limited Medline database: 61 articles were yield from 2015-2020 (Robeson & Yost, 2021) 182 Appendix E Search Strategy for Ovid Medline Database Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions(R) <1946 to March 11, 2021> 1 (integrat$ adj2 (organization$ or health or healthcare or care or service$ or system$ or patient)).tw. 43123 2 Delivery of Health Care, Integrated/ 13187 3 1 or 2 51264 4 (Women or female).tw. 1637438 5 exp Women/ 37868 6 Female/ 8947109 7 4 or 5 or 6 9244705 8 3 and 7 12998 9 exp Socioeconomic Factors/ or exp Social Class/ 462595 10 (equity or inequalit$ or equalit$ or unequal$ or inequit$ or disparit$ or gap or gaps or gradient$ or disadvantag$ or socioeconomic$).tw. 720626 11 health inequalit$.tw. or Health Status Indicators/ or *Health Status Disparities/ or *Healthcare Disparities/ 48664 12 exp Poverty/ or exp Medical Indigency/ or vulnerable populations/ 58026 13 exp Minority Health/ or exp Minority Groups/ or population groups/ or exp ethnic groups/ or health services, indigenous/ 174666 14 (ethnic or (black adj2 asian)).tw. 86284 15 (multiethnic$ or multi ethnic$ or multiracial$ or multi racial$).tw. 9746 16 exp Prisoners/ or prison$.tw. 25799 17 exp refugees/ or "Emigrants and Immigrants"/ or "Transients and Migrants"/ 33689 18 (immigrant* or refugee* or migrant* or asylum seeker*).tw. 51963 19 exp gypsies/ or travel?er*.tw. 13305 20 exp Homeless Youth/ or exp Homeless Persons/ or homeless$.tw. 13690 21 exp Spouse Abuse/ or Domestic Violence/ or exp battered women/ 14152 22 ((abuse$ or violen$) adj4 (partner$ or wife or wives or spouse$ or domestic)).tw. 16358 23 ((neighbo?rhood or economic or rural or urban) adj2 (depriv$ or poverty)).tw. 3204 24 (disadvantag* or deprived area* or innercit* or inner cit*).tw. 90274 25 Mental Disorders/ or exp eating disorders/ or exp mood disorders/ or exp "schizophrenia and disorders with psychotic features"/ 438011 26 Learning Disorders/ or Mental Deficiency/ 68775 27 ((mental$ or learning or cognitiv$) adj2 (retard$ or handicap$ or disab$ or difficult$ or impair$)).tw. 137897 28 exp Prostitution/ or sex worker*.tw. 9539 29 Adolescent Health Services/ or exp Adolescent/ or exp Pregnancy in Adolescence/ 2073999 30 (teen$ or youth$ or adolescen$).tw. 357488 31 (late adj2 (book$ or initiat$ or attend$)).tw. 1420 32 exp Obesity/ or exp Obesity, Morbid/ 221017 33 (obese or obesity).tw. 312127 34 exp HIV Infections/ or HIV/ 295311 35 (HIV or HIV-pos$ or HIV-inf$).tw. 319992 36 exp Street Drugs/ or exp Narcotics/ or exp Cocaine/ or exp Crack Cocaine/ or exp Heroin/ or exp amphetamines/ or exp methadone/ 191813 37 exp substance-related disorders/ or exp Substance Abuse, Intravenous/ or exp amphetamine-related disorders/ or exp cocaine-related disorders/ or exp marijuana abuse/ or exp opioid-related disorders/ or exp heroin dependence/ or exp phencyclidine abuse/ or exp psychoses, substanceinduced/ or exp substance abuse, intravenous/ or substance withdrawal syndrome/ 284321 183 38 exp alcohol-related disorders/ or exp alcoholism/ or exp alcohol-induced disorders/ 114498 39 (first nation or first nations or first peoples or (native$ or indian$ or aborigin$ or indigenous) or (inuit or eskimo$ or metis)).tw. 344534 40 exp American Native Continental Ancestry Group/ or exp Oceanic Ancestry Group/ 32165 41 (sexual and gender minorit*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] 5039 42 or/9-41 4976293 43 8 and 42 6265 44 exp Spouse Abuse/ or Domestic Violence/ or exp battered women/ or exp Intimate Partner Violence/ 16550 45 ((abuse$ or violen$) adj4 (partner$ or wife or wives or spouse$ or domestic)).tw. 16358 46 44 or 45 22583 47 43 and 46 129 48 (canad* or "british columbia" or "Colombie britannique" or alberta* or saskatchewan or manitoba* or ontario or quebec or "nouveau brunswick" or "nova scotia" or "nouvelle ecosse" or "prince edward island" or newfoundland or labrador or nunavut or nwt or "northwest territories" or yukon or nunavik or inuvialuit).mp. 244734 49 47 and 48 7 50 limit 49 to (abstracts and english) 7 *Lines 9-41 for “vulnerable and socially disadvantaged population” were adapted from the systematic review done by Hollowell et al. (2011). 184 Appendix F Overview of Dimensions or Intersections Studied Source Measurement Ford-Gilboe et al., 2015 • Demographics and social location included age, years of education, population density, annual household income (using Statistics Canada’s low-income cut-offs) • Service use and unmet needs. Past month service use was established with self-reports. Services were classified within five categories: general health, mental health, social services, violence specific services, and legal services o Use of social assistance, disability benefits, and employment insurance, this was collected by using reports of receiving such benefits • Capacity to access services and barriers was asked with three questions, an example is “level of confidence in ability to access services from not at all confident (1) to very confident (4)” (p. 422) • Abuse history and IPV severity, past experience was measured using the 30-item Index of Spouse Abuse. Continuing abuse was measured by asking a single question: “is the abuse ongoing? (p. 422) • Health status was assessed through: o Women’s physical health, using the Physical Component Summary Score of the Short Form 12 Health Survey Version 2 o Chronic pain grade (the Chronic Pain Grade) to measure disability-related chronic pain. Women were asked the interference of their pain, worst pain intensity, and numbers of days lost due to pain and disability o Mental health, using self-report measures of symptoms of depression (the 20-item Center for Epidemiologic Studies-Depression Scale), and PTSD symptomatology using the 17-item Davidson Trauma Scale Haag et al., 2019 Traumatic brain injury- related knowledge and existence of IPV-related services from contributors. Hovey & Scott, 2019 • Demographic information included number of stays at the shelter, age, having children, and information related to licit/illicit substance use. • Participants were also asked about their experiences on harm reduction at shelters. Examples of questions included: “We are looking at the use of harm reduction approaches in women’s shelters. How did you personally experience the harm reduction approach at [Shelter]? If you were to create the ideal shelter for abused women, what would it be like?” (p. 428) Mantler & Wolfe, 2017 • Demographic information considered level of education, marital status, income, ethnicity, housing situation, dependent children, primary work status. A questionnaire was used for it. • Status of health and social services use was determined with two open-ended questions; an example is “What is the current status of services being offered/utilized at the shelter?” (p. 3) • Barriers and challenges were addressed through three open-ended questions; an example is “Where is the greatest gap in health and social service and care provision?” (p.4) • Strengths and successes were asked using three open-ended questions; an example is “What are the strengths of the rural shelter?” (p. 4) 185 Source Measurement Mantler & Wolfe, 2018 • Demographics were collected with a questionnaire including age, education, marital status, housing, work status, dependent children, ethnicity. • Status of services offered was assessed using the perceived acceptability of services and perceived impact of the models of integration on health. o Perceived acceptability of services was assessed with four open-ended questions, an example is “How does the service encourage/discourage women to access care?” (p. 124) o Perceived impact of the models of integration on health was assessed with three open-ended questions, an example is “What is the impact of the services being offered on health?” (p. 124) • Gaps and recommendations were addressed with three open-ended questions; an example is “What services would you like to be offered?” (p. 124) Mantler, Jackson & Walsh, 2019 A critical discourse analysis using critical, feminist, intersectional lens. The selected policies were 1) Domestic Violence Action Plan for Ontario (ODVAP), 2) the rural women’s shelter policy, and 3) the hospital policy Torchalla et al., 2015 • Demographic information included age, ethnicity, marital status, education, total number of children. The results have been reported elsewhere. • Women’s’ experiences and perspectives on trauma and addiction, substance use, childhood maltreatment, adult abuse experiences, and general and PTSD-related distress were obtained through the interview. Examples of questions included: “Can you describe to me how your drug use started? How was your mental health, how did you feel?” (p. 3) Other questions about the women’s relationships were explored. Varcoe et al., 2019 • Demographic information was collected using survey questions: employment status, income, work experiences, dependent children and child support, housing situation and shelter use in the last year, and self-identification as being Indigenous. • Women’s abuse histories. Experiences of abuse histories, including IPV were measured using the Composite Abuse Scale. Questions on sexual abuse experiences and childhood maltreatment were also considered. Experiences of sexual assault were assessed using two questions from the Canadian Violence Against Women Survey • To explore women’s experiences of the intervention and the effectiveness of it, interviews included standardized self-report measures of health outcomes. Primary and secondary outcomes were measured. o Seven self-report instruments measured. For primary outcomes: quality of life, using the Sullivan’s Quality of Life Scale; and trauma symptoms, using the PTSD checklist, Civilian Version. For secondary outcomes: depressive symptoms, using the Center for Epidemiologic Studies Depression Scale Revised; chronic pain disability, using the pain disability score from Von Korff, Ormel, Keefe, and Dworkin’s Scale; social support, using the 13-item support scale of the Interpersonal Resources Inventory; personal and interpersonal agency, using the Personal Agency Scale and Interpersonal Agency Scale; and mastery, using Pearlin’s self-report, seven-item Mastery Scale Appendix G Overall Data Extraction Table and Sub-tables Needed per Dimension Source Status Effectiveness Unintended Effects Equity Cost Feasibility Acceptability Author A Effectiveness Plausibility of the intervention Effectiveness of the policy under study Intermediate effects of the policy Impact of context on the policy’s effectiveness Author A Unintended Effects Positive Negative Anticipated Unanticipated Author A Equity Differential effect of the policy on various groups Effects of social inequalities in health Author A Cost Implementation cost for the government Cost for other actors Cost compared to other potential policies Cost-effectiveness Distribution over time Visibility Author A Feasibility Conformity with relevant legislation Existence of pilot programs Automaticity Directness and hierarchical integration Quality of the cooperation between actors Author A Acceptability Acceptability of acting on the problem Acceptability of the policy Acceptability of the decision-making process Author A Appendix H Criteria for Analyzing Public Policies Dimension Criteria Effectiveness • Plausibility of the intervention logic • Effectiveness of the policy under study as means of addressing the target problem • Intermediate effects of the policy • Impact of contexts on the policy’s effectiveness Unintended Effects • Unintended effects of the public policy (by these positive or negative, anticipated or unanticipated) Equity • Differential effects of the policy under study on various groups • Effects on social inequalities in health Cost • Implementation cost for the government • Cost for other actors • Cost compared to that of other potential policies • Cost-effectiveness • Distributions of cost over time • Visibility Feasibility • Conformity with all relevant legislation • Existence of pilot programs • Automaticity • Directness and hierarchical integration • Number of actors involved • Quality of the cooperation between actors • Ability of opponents to interfere • Availability of human resources required • Availability of material resources required • Availability of technological resources required Availability • For each actor concerned: -Acceptability of acting on the target problem -Acceptability of the decision-making process -Acceptability of the actors involved in implementation -Acceptability of accountability measures -Acceptability of policy under study: o Assessment of its effectiveness, unintended effects, equity, cost, and feasibility o Assessment of the degree of coercion involved Adapted from Morestin et al., (2011). 188 Appendix I Invitation to Participate in a Knowledge Translation Discussion for Women (Email Invitation) Health Equity and Integration for Women Experiencing IPV The goal of the research is to study local and provincial level policy-related to health and social services for women who experience intimate partner violence (IPV). This involves policies (e.g., plans, strategies, actions) from public, private, research, not-for-profit, and every type of organization or provider in the community to care for the health and well-being of women who experience IPV. Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will develop recommendations for improving integration of services and health equity for women in the future. This study is being carried out in British Columbia (BC). You can take part in the online discussion session to provide your insight. We would like to invite you to take part in an online discussion to talk about the health and social policies and services to address the need of women who experience IPV. The session will be held on December 3rd at 10.00 (Kelowna time). You can participate, if you: • Are a woman and/or self-identified woman 19 years and over in BC • Have lived experiences of IPV • Have sought health and social services for IPV in BC • Able to speak English and understand the information on the consent form (attached) Talking about IPV may be sensitive for some and may bring up some unpleasant past experiences. You do not have to answer any question if you do not want to. Questions will be asked about policies, health and social services, and specific recommendations for improvement from your perspective. You are welcome to answer questions at the discussion or you can send your answers privately. You may skip any question if you wish. A list of resources will be provided for you to consult. You may also experience privacy risks given the sensitive nature of the topic of IPV and its impact on you or others. We will ask people both at the beginning of the session and at the end, not to discuss information shared at the session outside of it. You can also choose to use a made-up name instead of your own and not turn on the camera to protect your privacy. The discussion session will be held online using UBC Zoom. It will take about 2 - 2.5 hours in length. You will receive a $50 honorarium when you participate in the session. A copy of the consent form is attached with more information on the discussion. If you have questions about the session or would like to receive more information, please contact Yazmin Davila (contact information is listed below). Please also RSVP by <insert date> so we will better know how many people plan to attend. RSVP is not required but would be helpful for the facilitators. Regards, Lead researcher: Nelly D. Oelke, Associate Professor, School of Nursing, University of British Columbia, Okanagan (UBCO). Telephone: 250-807-9880 or email: nelly.oelke@ubc.ca Doctoral Student: G. Yazmin Davila-Lara, School of Nursing, UBCO. Telephone: 250-807-9948 or email: yazmin.davila@alumni.ubc.ca Resources for Participants General Resources: 1. HealthLink BC, Telephone: 8-1-1, website: www.healthlinkbc.ca 2. BC Mental Health and Substance Use Services. Call 310-6789 (310 Mental Health) or visit website: www.bcmhsus.ca 3. Crisis Centre BC Toll Free: 1-866-661-3311, website: https://crisiscentre.bc.ca/ 4. Crisis Intervention & Suicide Prevention Centre of BC Toll Free: 1-800-SUICIDE (1-800-784-2433), website: https://crisiscentre.bc.ca/ 5. BC Partners for Mental Health and Addictions Information – HeretoHelp, website: www.heretohelp.bc.ca 6. Crisis Line Association of BC, website: https://www.crisislines.bc.ca/mapcrisis-lines 7. BC Psychological Association COIVD-19 Support, website: https://www.psychologists.bc.ca/covid-19-resources Women Specific Resources: 1. Victim Link BC. Call 1 (800) 563-0808. TTY: 604-875-0885. Text: 604-836-6381. Email: VictimLinkBC@bc211.ca Website: https://www2.gov.bc.ca/gov/content/justice/criminal-justice/victims-of-crime/victimlinkbc 2. Women Against Violence Against Women (WAVAW) and Rape Crisis Center. Call 604-255-6344 and 1 (877) 392-7583 for 24-Hour Crisis, or visit website: https://www.wavaw.ca/ 3. Battered Women’s Support Services at 604-687-1868 and 1 (855) 687-1868 toll-free. Website: https://www.bwss.org/ 4. AMS Sexual Assault Support Centre. Call 604-827-5180 for support worker accompaniment for patients attending the UBC Hospital's UCC or visit website: https://www.amssasc.ca/ 5. Vancouver Rape Relief and Women’s Shelter. Call 24 hr. crisis line at 604.872.8212, or visit website: https://rapereliefshelter.bc.ca/ 6. BC Women’s Hospital and Health Centre at 604-875-2424 and 1 (888) 300-3088 toll-free. Email: comm@cw.bc.ca and website: http://www.bcwomens.ca/ 7. Ending Violence Association of BC at 604-633-2506. Website: https://endingviolence.org/ 8. Mosaic – Stopping the Violence at 604-254-9626. Email: mosaic@mosaicbc.com Website: https://www.mosaicbc.org/services/counselling/stopping-the-violence/ 9. Family Services of Greater Vancouver at 604-731-4951. Website: https://fsgv.ca/ 10. Vancouver Aboriginal Community Policing Centre Society at 604-678-3790. Email: executivedirector@vacpc.org and website: https://vacpc.org/ 11. Legal Services Society of BC at 604-408-2172 and 1 (866) 577-2525 toll-free. Website: https://lss.bc.ca/ 12. Vancouver Police Department Victim Services Unit at 604-717-2737. Website: https://vpd.ca/report-a-crime/information-for-victims/ 13. BC Society for Male Survivors of Sexual Abuse at 604-682-6482. Email: victimservices@bc-malesurvivors.com website: http://bc-malesurvivors.com/ 191 Appendix J Permission to Contact Form (For Women) Health Equity and Integration for Women Experiencing IPV You are being invited to give consent for Yazmin Davila’s, or a qualified member of her study team to contact you at some time in the future to invite you to participate in a research study. The goal of the research is to study local and provincial level policy-related to health and social services for women who experience intimate partner violence (IPV). This involves policies (e.g., plans, strategies, actions) from public, private, research, not-for-profit, and every type of organization or provider in the community to care for the health and well-being of women who experience IPV. Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will develop recommendations for improving integration of services and health equity for women in the future. This study is being carried out in British Columbia (BC). You can take part in the online discussion session to provide your insight. Are you willing to learn more about the study: Health Equity and Integration for Women Experiencing IPV? (Circle one) YES NO If yes, you will be contacted a later date. Please include your contact information below. ☐[Specify, e.g., Telephone]:______________________________________________ ☐[Specify, e.g., E-mail]:_________________________________________________ You authorize your health service provider to disclose your telephone number, email address, or/and name to the research team for the purpose of being contacted to learn more about this study. Efforts will be made to safeguard your contact information. The information will be kept confidential and shared with only myself and the lead researcher. You have been made aware of the reasons why the contact information is needed and the risks and benefits of consenting or refusing to consent. This consent is effective immediately. Your consent to be contacted can be revoked by you at any time. Patient’s Name (please print): ___________________________________ Patient’s Signature:______________________________________________ Date:______________ Clinician’s Name:_____________________________________________________ Regards, Lead researcher: Nelly D. Oelke, Associate Professor, School of Nursing, University of British Columbia, Okanagan (UBCO). Telephone: 250-807-9880 or email: nelly.oelke@ubc.ca Doctoral Student: G. Yazmin Davila-Lara, School of Nursing, UBCO. Telephone: 250-807-9948 or email: yazmin.davila@alumni.ubc.ca 192 Appendix K Knowledge Translation Discussion Signed Consent Form for Women Health Equity and Integration for Women Experiencing IPV Lead researcher: Nelly D. Oelke, Associate Professor, School of Nursing, University of British Columbia, Okanagan (UBCO) Telephone: 250-807-9880 E-mail: nelly.oelke@ubc.ca Doctoral student: G. Yazmin Davila Lara, Graduate Student, School of Nursing, UBCO. Telephone: 250-807-9880 E-mail: yazmin.davila@alumni.ubc.ca Research team members: Colleen Varcoe, Professor, School of Nursing, University of British Columbia, Vancouver (UBCV) E-mail: Colleen.Varcoe@ubc.ca Silvina Mema, Medical Health Officer, Interior Health Authority, Kelowna, BC E-mail: Silvina.Mema@InteriorHealth.ca Funding: There is no funding for this study. This study is being part of a PhD dissertation which will be publicly available on the internet. What is the purpose of this study? The experience of Intimate Partner Violence (IPV) in women is a frequent public health problem in British Columbia (BC). The experiences of IPV have a major impact on physical and mental health in women, which increases the need for them to seek services. The goal of the research is to study local and provincial level policy-related to health and social services for women who experience IPV. This study is being carried out in BC. You can take part in an online discussion session to provide your insight. Who can take part in the discussion session? You can take part in the session if you: • Are a woman and/or self-identified woman 19 years and over in BC • Have lived experiences of IPV • Have sought health and social services for IPV in BC Note: You must be able to speak or read English and understand this consent form. What does taking part involve? You are invited to take part in a virtual discussion session to be held via UBC Zoom for BC. Your Zoom user information will be stored on servers in Canada. We will share the results of our policy study before the discussion session. Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will develop recommendations for improving integration of services and health equity for women in the future. The results of the discussion will be combined with the policy analysis results and summarized in a whole report. We anticipate that about 15 - 20 people will take part in the discussion. The session will be 2- 2.5 hours in length, and will be audio-recorded and transcribed through UBC Zoom. The session will be facilitated by Yazmin Davila and one or two more research team members. A research assistant, graduate student, or undergraduate student will take notes. They will sign a confidentiality agreement. Are there any risks to taking part in this study? Talking about IPV may be sensitive for some and may bring up some unpleasant past experiences. You do not have to answer any question if you do not want to. Questions will be asked about policies (e.g., plans, strategies, actions), health and social services, and specific recommendations for improvement from your perspective. You are welcome to answer questions at the discussion or you can send your answers privately. You may skip any question if you wish. We will provide a list of resources for you to contact following the session. You may also experience privacy risks given the sensitive nature of the topic of intimate partner violence and its impact on you or others. We will ask people both at the beginning of the session and at the end, not to discuss information shared at the session outside of it. As noted above you also can choose not to answer any of the questions. You can also choose to use a made-up name instead of your own and not turn on the camera to protect your privacy. It is your choice if you wish to attend or not. You can stop taking part at any time without giving a reason. If you decide after the session that you wish to withdraw from the study, you will need to contact Yazmin Davila (her contact email and phone number are listed on the first page of this consent). However, due to the nature of group sessions your input will not be able to be removed from the study. What are the benefits of taking part? There may be no direct benefits to yourself, although sometimes talking about your thoughts on how to improve policies (e.g., plans, strategies, actions) and services for women who experience IPV can be positive. The results of the study will help us to take actions on the impacts of IPV on women’s health. Will you be paid for taking part? You will receive a $50 honorarium when you participate in the session. How will your privacy be maintained? We will do all we can to maintain your privacy, but due to the nature of discussion groups we cannot guarantee the privacy of your input in the discussion. As noted above, we will ask participants to respect the privacy of the information discussed at the start and end of the session. Electronic copies of consent forms will be stored in a password protected folder separate from other files at UBC Okanagan’s secure network. Electronic copies of recordings and other research documents during the study will be stored on a university secure network or encrypted, password-protected research computer. Recordings will be used to ensure our notes are accurate. We will delete the recordings as soon as we are able to, following analysis of the data. During the study, as needed, a password protected computer belonging to the research assistant may also be used, but data will be stored on a UBCO secure network. Only those directly involved in the study will have access to any of the research files. Once the study is complete, all files will be stored on the UBC Okanagan secure network or in a UBCO designated research area for 5 years after the results of the study have been published. After this time, files will be securely deleted or shredded. At the end of the study, we will share the findings of the study with you and providers, policymakers, decision-makers and other key groups in the province, and national groups that are interested in the topic. We will also publish the results in research journals or conduct presentations at professional conferences. Results will be presented in a combined form; no data that would allow someone to identify you or your organization will be released in any of these publications or presentations. Who can you contact if you have questions about the study? If you have any questions or concerns about what we are asking you to do, please contact Yazmin Davila. Phone number and email are on the first page of this consent form. Who can you contact if you have complaints or concerns about this study? If you have any concerns about your rights as a research participant and/or your experiences while participating in this study, you may contact the Research Participant Complaint Line in the UBC Office of Research Services at 1-877-822-8598 or the UBC Okanagan Research Services Office at 250-807-8832. Please reference the study number (H21-00169) when contacting the Complaint Line so the staff can better assist you. Consent: Taking part in the session is your choice. You may refuse to participate or withdraw from the study, but your data cannot be removed due to the nature of group discussions. If you decide to withdraw from the study, it will not impact your job or ability to get health services. □ I have received a copy of this consent form for my own records. □ I agree to having the session recorded. Name: Participant Signature Date Printed Name of Participant □ I would like to receive a summary of the results of the study. Email: _____ 195 Appendix L Oral Consent Script/Form for Women Health Equity and Integration for Women Experiencing IPV Hello <name>. Thank you for your interest in taking part in the study. I have emailed you the full consent form and we are going to review it together. Please let me know if you have not received it or if you need a moment to locate the form. This study is being carried out in British Columbia (BC). The goal of the research is to study local and provincial level policy-related to health and social services for women who experience of Intimate Partner Violence (IPV). Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will create actions for improving integration of services and health equity for women in the future. You can take part in the online discussion session to provide your insight. You can take part in the online session if you are 19 years and over, living in BC, have lived experience of IPV, see at least one health and social providers in the community. You must be able to read and understand the consent form. You should be able to communicate in English. Saying yes, I want to participate in the session means you are willing to take part in the discussion with others from your province and across the country. The discussion will take place via computer using UBC licensed Zoom with the servers in Canada. We will share the results of our policy study before the discussion session. The discussion session will be 2 – 2½ hours in length. The discussion will be recorded on flip chart paper, activity handouts, field notes, and will be audio-recorded. The session will be facilitated by Yazmin Davila and one or two research team members. A research assistant, graduate student, or undergraduate student will take notes. They will sign a confidentiality agreement. There will be questions that you are welcome to answer at the session, you can send your answers privately, or not answer at all. It is your choice to attend the discussion session or not. You can stop taking part at any time without giving a reason. If you decide after the session that you wish to withdraw from the study, you will need to contact the research team member. However, due to the nature of group sessions, your input will not be able to be removed from the study. We do not think there are any risks to taking part in this study. The purpose of conducting the discussion session is to develop recommendations to improve integration of health and social services, and health equity for women who experience IPV. Some of the questions that we ask may seem sensitive. You do not have to answer any question if you do not want to. If you have any concerns, please let the research team members know. Their names, emails, and phone numbers are listed in the consent form. There are no direct benefits to yourself, although we think that the results will help to improve health services for women who experience IPV. You will receive a $50 honorarium when you participate in the study. We will do all we can to maintain your privacy, but due to the nature of group sessions, we cannot guarantee the privacy of your input in the discussion. We will ask participants to respect the privacy of the information discussed at the start and end of the session. We will try our best to maintain confidentiality and protect the information you share with us. We will use a password-protected computer and secured university network to store the information. The process is explained in detail on the consent form. At the end of the study, we will share the findings of the study with you and providers, policymakers, decision-makers and other key groups in the province, and national groups that are interested in the topic. Also, the final report will be published in a research paper or presented at professional conferences. Results will be presented in a way that no data that would allow someone to identify you or others. If you have complaints or concerns about the project, please contact the UBC Office of Research Ethics is on the consent form. Can you tell me yes or no if you agree to the following: □ I have received a copy of this consent form for my own records. □ I agree with having the interview audio recorded. □ I will be attending the discussion session with a caregiver to translate. I am providing my consent for their involvement. □ I would like to receive a summary of the results of the study via email. Email: ____________________________________________________________________________ Name and signature of person obtaining oral consent Date Printed Name of Participant: 197 Appendix M Invitation to Participate in a Knowledge Translation Discussion for Contributors (Email Invitation) Health Equity and Integration for Women Experiencing IPV The goal of the research is to study local and provincial level policy-related to health and social services for women who experience intimate partner violence (IPV). This involves policies (e.g., plans, strategies, actions) from public, private, research, not-for-profit, and every type of organization or provider in the community to care for the health and well-being of women who experience IPV. Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will develop recommendations for improving integration of services and health equity for women in the future. This study is being carried out in British Columbia (BC). You can take part in the online discussion session to provide your insight. We would like to invite you to take part in an online discussion to talk about the health and social policies and services to address the need of women who experience IPV. The session will be held on December 3rd at 10:00 am (Kelowna time). You can participate, if you: • Are a policy-maker, decision-maker, manager, or a health and social care provider 19 years and over in BC • Are a member or representative of community organizations delivering services for women who experience IPV in BC • Have worked with women who have experienced IPV • Have designed/delivered/provided health and social services for women who experience IPV People will talk about IPV and some lived experiences may be sensitive for some or may bring up some unpleasant past experiences. Please, be aware, understanding, and respectful of people’s experiences. People may not answer every question. Questions will be asked about policies, health and social services, and specific recommendations for improvement from your perspective and from your organization. You can share more information to answer the questions privately. We will ask people both at the beginning of the session and at the end, not to discuss information shared at the session outside of it. The discussion session will be held online using UBC Zoom. It will take about 2 - 2.5 hours in length. A copy of the consent form is attached with more information on the discussion. If you have questions about the session or would like to receive more information, please contact Yazmin Davila (contact information is listed below). Please also RSVP by <insert date> so we will better know how many people plan to attend. RSVP is not required but would be helpful for the facilitators. Regards, Lead researcher: Nelly D. Oelke, Associate Professor, School of Nursing, University of British Columbia, Okanagan (UBCO). Telephone: 250-807-9880 or email: nelly.oelke@ubc.ca Doctoral Student: G. Yazmin Davila-Lara, School of Nursing, UBCO. Telephone: 250-807-9948 or email: yazmin.davila@alumni.ubc.ca 198 Appendix N Knowledge Translation Discussion Signed Consent Form for Contributors Health Equity and Integration for Women Experiencing IPV Lead researcher: Nelly D. Oelke, Associate Professor, School of Nursing, University of British Columbia, Okanagan (UBCO) Telephone: 250-807-9880 E-mail: nelly.oelke@ubc.ca Doctoral student: G. Yazmin Davila Lara, Graduate Student, School of Nursing, UBCO. Telephone: 250-807-9880 E-mail: yazmin.davila@alumni.ubc.ca Research team members: Colleen Varcoe, Professor, School of Nursing, University of British Columbia, Vancouver (UBCV) E-mail: Colleen.Varcoe@ubc.ca Silvina Mema, Medical Health Officer, Interior Health Authority, Kelowna, BC E-mail: Silvina.Mema@InteriorHealth.ca Funding: There is no funding for this study. This study is being part of a PhD dissertation which will be publicly available on the internet. What is the purpose of this study? The experience of Intimate Partner Violence (IPV) in women is a frequent public health problem in British Columbia (BC). The experiences of IPV have a major impact on physical and mental health in women, which increases the need for them to seek services. The goal of the research is to study local and provincial level policy-related to health and social services for women who experience IPV. This study is being carried out in BC. You can take part in an online discussion session to provide your insight. Who can take part in the discussion session? You can take part in the session if you: • Are a policy-maker, decision-maker, manager, or a health and social care provider 19 years and over in BC • Are a member or representative of community organizations delivering services for women who experience IPV in BC • Have worked with women who have experienced IPV • Have designed/delivered/provided health and social services for women who experience IPV Note: You must be able to speak or read English and understand this consent form. 199 What does taking part involve? You are invited to take part in a virtual discussion session to be held via UBC Zoom for BC. Your Zoom user information will be stored on servers in Canada. We will share the results of our policy study before the discussion session. Throughout an online discussion, we will also talk about the results from the policy analysis, and how and if services (e.g., shelters, food support, legal) have met the needs of women who had lived experience of IPV. Together we will develop recommendations for improving integration of services and health equity for women in the future. The results of the discussion will be combined with the policy analysis results and summarized in a whole report. We anticipate that about 15 - 20 people will take part in the discussion The session will be 2- 2.5 hours in length, and will be audio-recorded and transcribed through UBC Zoom. The session will be facilitated by Yazmin Davila and one or two more research team members. A research assistant, graduate student, or undergraduate student will take notes. They will sign a confidentiality agreement. Are there any risks to taking part in this study? People will talk about IPV and some lived experiences may be sensitive for some or may bring up some unpleasant past experiences. Please, be aware, understanding, and respectful of people’s experiences People may not answer every question. Questions will be asked about policies (e.g., plans, strategies, actions), health and social services, and specific recommendations for improvement from your perspective and from your organization. You can share more information to answer the questions privately. We will ask people both at the beginning of the session and at the end, not to discuss information shared at the session outside of it. You can stop taking part at any time without giving a reason. If you decide after the session that you wish to withdraw from the study, you will need to contact Yazmin Davila (her contact email and phone number are listed on the first page of this consent). However, due to the nature of group sessions your input will not be able to be removed from the study. What are the benefits of taking part? We will develop together recommendations on how to improve policies and services for women who experience IPV. The results of the study will help us to take actions on the impacts of IPV on women’s health. Will you be paid for taking part? There is no honorarium for your participation in the session. How will your privacy be maintained? We will do all we can to maintain your privacy, but due to the nature of discussion groups we cannot guarantee the privacy of your input in the discussion. As noted above, we will ask participants to respect the privacy of the information discussed at the start and end of the session. Electronic copies of consent forms will be stored in a password protected folder separate from other files at UBC Okanagan’s secure network. Electronic copies of recordings and other research documents during the study will be stored on a university secure network or encrypted, password-protected research computer. Recordings will be used to ensure our notes are accurate. We will delete the recordings as soon as we are able to, following analysis of the data. During the study, as needed, a password protected computer belonging to the research assistant may also be used, but data will be stored on a UBCO secure network. Only those directly involved in the study will have access to any of the research files. Once the study is complete, all files will be stored on the UBC Okanagan secure network or in a UBCO designated research area for 5 years after the results of the study have been published. After this time, files will be securely deleted or shredded. 200 At the end of the study, we will share the findings of the study with you and providers, policymakers, decision-makers and other key groups in the province, and national groups that are interested in the topic. We will also publish the results in research journals or conduct presentations at professional conferences. Results will be presented in a combined form; no data that would allow someone to identify you or your organization will be released in any of these publications or presentations. Who can you contact if you have questions about the study? If you have any questions or concerns about what we are asking you to do, please contact Yazmin Davila. Phone number and email are on the first page of this consent form. Who can you contact if you have complaints or concerns about this study? If you have any concerns about your rights as a research participant and/or your experiences while participating in this study, you may contact the Research Participant Complaint Line in the UBC Office of Research Services at 1-877-822-8598 or the UBC Okanagan Research Services Office at 250-807-8832. Please reference the study number (H21-00169) when contacting the Complaint Line so the staff can better assist you. Consent: Taking part in the session is your choice. You may refuse to participate or withdraw from the study, but your data cannot be removed due to the nature of group discussions. If you decide to withdraw from the study, it will not impact your job. □ I have received a copy of this consent form for my own records. □ I agree to having the session recorded. Name: Participant Signature Date Printed Name of Participant □ I would like to receive a summary of the results of the study. Email: _____ 201 Appendix O Knowledge Translation Discussion Agenda and Discussion Questions Health Equity and Integration for Women Experiencing IPV December 3rd, 2021- 10:00 am to 12:00 pm Agenda (for participants) 10:00- 10:10 Welcome and short presentation of key results PhD Student Yazmin Davila Zoom-live 10:10- 10:40 Small group discussion for questions 1 to 2, including brief introductions for all participants at the beginning Facilitators: Dr. Colleen Varcoe, Dr. Nelly Oelke, and Dr. Silvina Mema with PhD Student Yazmin Davila Three zoom-breakout rooms 10:40- 10:50 Break 10:50- 11:10 Report back. Each group shares only a key highlight. Avoiding repetition. Up to 2-3 rounds All participants Zoom-live 11:10- 11:40 Yazmin Davila Three zoom-breakout rooms 11:40- 12:00 Report back, including summary, conclusions, and next steps All participants Zoom-live Discussion Questions: 1)What aspects from the short presentation resonated for you or are important from your perspective? Provide 1-2 highlights. 2)How do current services and supports and the ways that they are delivered impact women’s health and social care? How does it impact health equity and their wellbeing? 3)What is the role of women who experience IPV in the design, planning, and implementation of health and social services? Could you provide 1-2 specific examples? 4)What recommendations for action do you think are needed to improve health and social services, system integration or health equity? Provide 1-2 top priorities 5) Based on the previous answer and the priorities (examples) you identified, what policies and services are needed and how should they be designed and implemented to address women’s health needs? Additional comments Thank you again for taking part. And just a reminder not to share information from the session with others or share who was in attendance. 202 Appendix P Knowledge Translation Discussion Agenda and Discussion Questions Health Equity and Integration for Women Experiencing IPV December 3rd, 2021- 10:00 am to 12:00 pm Agenda (for research team members) Script at the beginning: Welcome to the discussion session and thank you for coming. Our session today will last approximately 2- 2,5 hours. We will be talking about policies (e.g., plans, strategies, actions) and health and social services to address the needs of women who experience Intimate Partner Violence (IPV). To respect people’s privacy, please remember not to share input that will be shared in the session today. Also do not share who has participated in the session. You may use a code name in the Zoom session, and you do not need to turn your camera on. You may also provide your input in the chat box. We will try and track the same. To ensure that we have a precise record of our discussion, we would like to record the session. If you are not okay with recording the session, please let us know now in the chat box or you can let us know directly. If at any time you felt distressed, you could contact Yazmin Davila by chat and let her know. You can choose not to answer any question. There is a list of resources available that will be shared in the chat too. If you, or anyone else is not comfortable recording the session we will only take notes. Otherwise, we will also be taking notes. Before we begin, do you have any questions? [Discuss questions] If any questions (or other questions) arise at any point in this session, you can feel free to ask them at any time. You can see below the agenda proposed: 203 Agenda 10:00- 10:20 Welcome and introductions All participants Zoom-live 10:20- 11:00 Small group discussion Facilitators: Dr. Colleen Varcoe, Dr. Nelly Oelke, and PhD Student Yazmin Davila Three zoom-breakout rooms 11:00- 11:10 Break 11:10- 11:30 Overall discussion All participants Zoom-live 11:30- 12:00 Small group discussion Facilitators: Dr. Colleen Varcoe, Dr. Nelly Oelke, and PhD Student Yazmin Davila Three zoom-breakout rooms 12:00- 12:10 Break 12:10- 12:30 Conclusions and next steps All participants Zoom-live Let’s begin, Discussion Questions: [Interview questions and probes per question:] ___________________________________________________________________________ 1)What aspects from the summary report resonated for you or are important from your perspective? Provide 1-2 highlights. Probes for women • How do the results from the report align with your health experiences? Can you provide 1-2 examples Probes for contributors • What is your opinion about the policy report? • How do the policies identified are related to your work? __________________________________________________________________________________ 2)How do current services and supports and the ways that they are delivered impact women’s health and social care? How does it impact health equity and their wellbeing? Probes for women • Can you tell us about how you yourself have been affected by the implementation (or the lack) of these policies and services over the last few years? Probes for contributors • How system integration and health equity have been designed and implemented to meet the health and social needs of women who experience IPV? Could you provide 1-2 specific examples related to your work? 204 ____________________________________________________________________________ 3)What is the role of women who experience IPV in the design, planning, and implementation of health and social services? Could you provide 1-2 specific examples? Probes for women • How women themselves can be involved in the delivery of health and social services and policies? Could you provide 1-2 examples? Probes for contributors • What is the participation of women in the planning and implementation of health and social services? Could you provide 1-2 specific examples? _____________________________________________________________________________ 4)What recommendations for action do you think are needed to improve health and social services, system integration or health equity? Provide 1-2 top priorities Probes for women • How do health and social services could improve to meet the needs of women who experience IPV? • What need to happen for these services to meet the needs of women? Can you provide 1-2 examples? Probes for contributors • What are the 1-2 main gaps to address the needs of women’s who experience IPV? • How could you or your organization improve the lives of women who experience IPV from you work environment? _____________________________________________________________________________ 5) Based on the previous answer and the priorities (examples) you identified, what and how policies and services are needed to be designed and implemented to address women’s health needs? Probes for women • Can you tell me what and how specific social services (e.g., financial, employment status, housing, child support) need to work to meet the needs of women? Probes for contributors • What are the barriers and facilitators to deliver health and social services based on health equity? • What and how specific social services (e.g., financial, employment status, housing, child support) need to work to meet the needs of women? ____________________________________________________________________________ Additional comments Thank you again for taking part. And just a reminder not to share information from the session with others or share who was in attendance. 205 Appendix Q Summary Report Sent to Participants Prior Knowledge Translation Discussion IMPROVING SERVICES FOR WOMEN EXPERIENCING INTIMATE PARTNER VIOLENCE IN THE SOUTHERN INTERIOR OF BC SUMMARY REPORT June 27, 2022 PhD student: G. Yazmin Davila-Lara. 206 IMPROVING SERVICES FOR WOMEN EXPERIENCING INTIMATE PARTNER VIOLENCE IN THE SOUTHERN INTERIOR OF BC – SUMMARY REPORT Intimate Partner Violence (IPV) in BC is a problem that affects women and their communities. Women who suffer from IPV also are often socially excluded and this affects their health. This report provides a summary of the third phase of a three-phase study. Phase 1 was a review of published scholarly articles and Phase 2 was a review and analysis of BC policy documents about IPV. Phase 3 was an online session to gather women’s and contributors’ views on health and social services for women in the Southern Interior of BC. The event took place on December 3, 2021. Appendix A provides a summary of the first two phases sent to participants before the session. The goal of the session was to invite participants’ reflections on the results of the first two phases and create suggestions for action. Five women with lived experiences of IPV, 12 contributors, and four research team members participated in the session. Women came from Kelowna and West Kelowna and joined the session individually and in groups of two. Most women came from an organization called KANDU, which is an organization supporting people who use substances. Contributors came from different levels of service delivery such as management or point of care levels. Contributors came from Kelowna, West Kelowna, and Vancouver and joined the session individually. The contributors' organizations are included in Table 1. In the session, participants talked about specific areas of care and answered three to five questions. Appendix B shows the agenda and questions discussed in the session. Participants shared experiences and ideas to improve services for women who experience IPV. Women expressed concerns about encounters they had with providers and services, where they had unmet needs. Women’s experiences and needs were recognized as information that needs to be used when services are being planned and delivered. Participants expressed that more collaboration and integration of services would support women to heal and recover. Figure 1 shows the words used most often in the discussion during the 2-hour session. The word experience was used most often. Other words used were integration, understanding, and individual. These words are connected one to another, and together show links among the views shared to improve services. These words were organized into ideas and recommendations. These ideas were further organized into a main theme, experiences should drive service planning and delivery and two subthemes: 1) the importance of understanding women’s needs; and 2) transforming health and social systems. Table 1 Organizations Participants Organizations Interior Health Authority (IH), Kelowna, BC Knowledging All Nations and Developing Unity (KANDU), West Kelowna, BC Multi-Lingual Orientation Service Association for Immigrant Communities (MOSAIC), Vancouver, BC Supporting Survivors of Abuse and Brain Injury through Research (SOAR Project), Kelowna, BC University of British Columbia Okanagan Campus (UBCO) Kelowna, BC University of British Columbia Vancouver Campus (UBCV) Vancouver, BC WAVAW Rape Crisis Centre (WAVAW) Vancouver, BC 207 Figure 1 Words used most often in the meeting Experiences should drive service planning and delivery Participants identified that experiences should be considered as drivers in the planning and delivery of services for IPV. Also, all noted that there is a need to understand the diversity of women’s needs. Finally, they identified improvements for more integrated and equity-based services for women. 1) The Importance of Understanding Women’s Needs Needs are multiple and diverse. All participants recognized that women have diverse experiences and needs and that needs change over time. As such, diverse programs and supports are required to match women’s needs at different points in time. All agreed that the care that women receive should be tailored to address women’s health inequities. Some groups of women such as Indigenous women or women with disabilities experience other barriers (e.g., stigma) that need to be considered when planning services. Build trust to understand and meet women’s needs. Building trusting relationships is important to understanding and improving women's lives. 2) Transforming Health and Social Systems Include Women’s Experiences in Service Planning and Delivery. Participants agreed that understanding women’s experiences enables the design of appropriate care. As such, women’s participation in all levels of service planning and delivery is key. The voices of women should be integrated to improve services. Redesign Systems towards More Integrated and Equity-based Services. Specific recommendations were made for more integrated and equity-based care. Some advocated for system improvements to access health records to better coordinate services. Actions to improve housing systems were also suggested, for example, more second-stage housing to limit homelessness. Long waits and ineffective referrals need to be improved to limit delays in the care. More financial and employment help was needed to limit further economic and social inequities (e.g., poverty). A one-stop model that is women-centered where women could receive care in a single setting was proposed to deliver integrated and equity-based care. To end IPV, community and education programs for men are needed. Figure 2 shows highlights identified in each area. Appendix C presents the main gaps in policy and service planning and delivery of integrated and equity-based care. 208 Figure 2 Highlights by area Finally, participants agreed that there are several steps needed to change services: Appendix A Undertanding women's needs•Women's experiences and needs are multiple and diverse•Providers often do not understand the diverse and complex women's experiences and needs•Because women have multiple needs, multiple care approaches are needed•The care that women receive should be tailored to meet their needs and improve their lives•Some groups of women need specific services to address their needs•Trusting relationships are important to understand and address women’s needsTransforming systems•Women’s experiences and voices are essential to inform improvement of services•Improvements in housing, financial, and job programs are needed to limit further social and financial inequities in the long-term (e.g., homelessness, poverty)•Justice services (e.g., police) need better understandings of women's needs to limit further trauma and harm•Increase education programs for men and the community to change negative behaviours•Use a one stop model of care that is woman-centered and uses trauma and violence-informed careHelp women to provide their views to improve services and how these impact their healthRecognize the impacts of abuse, trauma, and the difficulties of women’s lives over the short and longer termImprove the connection among women’s needs and the supports planned or delivered across servicesOffer IPV-tailored services for womenImprove training on IPV for providers in the justice system (e.g., police, court staff)Tailor services to women’s needs to build trust whether or not they disclose violenceImprove services to include trauma- and violence-informed care with practices and language that do not cause further harm to womenFor more integrated and equity-based services, a formal and intentional process of integrating women’s direction in the design of services and policies should take place 209 Summary This summary shows the main results from the research study in which Canadian literature was reviewed and documents in BC were studied. 1. Review of the literature [Scoping review]: Main results 2. Study of documents [Policy analysis]: Key results from five documents Include women’s voices•Women suffered stigma and discrimination from providers •Services and supports tailored to needs are required•Women value settings with trust and respectUse women's experiences to improve services•Housing and financial supports are needed•IPV impacts women’s needs for services differently•Providers did not understand that women’s lives and needs are complexTransform systems•More access to services not covered by healthcare (e.g., dental)•Policies need to be aligned between different levels of the health system system•Strong partnerships between services are vital•Full evaluation of pain is needed •Supports need to consider women who are not ready to disclose1. Violence against women in relationships (VAWIR) policy (Ministry of Public Safety and Solicitor General et al., 2010)2. Taking action on domestic violence in British Columbia (Ministry of Children and Family Development, 2012)3. British Columbia’s provincial domestic violence plan (Ministry of Children and Family Development, 2014)4. A vision for a violence free BC (Government of British Columbia, 2015)5. Best practice approaches, child protection and violence against women (Ministry of Children and Family Development, 2017)•Public and private services came together to address IPV•A macro level response to address IPV was identified across sectors•Coordination and integration were discussed as ways to improve services•Multiple agencies identified IPV as a complex issue•New legislation impacted the way that domestic violence was managed •Groups of women such as Indigenous, immigrant, and refugee women, women with disabilities and from the LGBTQ community were considered within the policy actions 210 Overview of the project Background: Women who experience intimate partner violence (IPV) tend to experience worse health no matter what ethnicity, economic status, or social contexts they have (Clifford et al., 2007). The use of specific approaches (e.g., trauma and violence-informed, harm reduction) impact health experiences. This study will build upon health system integration1 and health equity2 as approaches that can meet the needs of women who experience marginalization and IPV. Results: Review of Literature: This phased review focused on health equity and health system integration in women who experience marginalization and IPV in Canada. Eight studies met the inclusion criteria. An overview of the studies included is presented in Supplement 1; and Supplement 2 provides a summary of the articles. Authors in Canada studied intersections of women’s lives such as: social context of participants, current service use, barriers and strengths of services, abuse history, and overall health status. Results were organized into three themes (see Table 1). Study of Documents: For this phase, five publicly available documents related to IPV were examined with respect to the ways in which they support or deter integration of services and health equity for women. A specific Framework (Morestin, 2012) was used to extract and combine data. Figure 1 presents an overview of documents and key actions to improve women’s lives. Table 2 shows the main strategies planned to address IPV per document. 1 Health system integration referred to the “tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care” (Valentijn et al., 2013, p. 4). 2 Health equity was considered as the absence of systematic and avoidable obstacles in health between individuals and groups that impact the possibility of being as healthy as possible. Examples of barriers and obstacles include poverty or discrimination (Braveman et al., 2017). Phase 3: Online Metting•Objective 3. Develop recommendations for actions to support health equity through system integration for women who experience marginalization and IPV in the Southern Interior of BC.Phase 2: Study of documents•Objective 2: Identify how policies and structures enhance or limit system integration and health equity for women who experience marginalization and IPV in BC.Phase 1: Review of literature•Objective 1: Identify how system integration and health equity have been designed and implemented to meet the needs of women who experience marginalization and IPV in Canada. 211 Table 1 Main Themes Identified and Key Results Themes Key results Include women’s voices • Women experienced stigma and discrimination • Supports should consider specific care approaches (e.g., trauma- and violence-informed, harm reduction) to offer services in a trusted environment • Services need a balance between specific care approaches and women’s needs • Partnerships among victim’s services was an effective action to increase service access • Participants “valued having time with the nurses, being listened to, and not being judged” (Varcoe et al., 2019, p. 18) Use women's experiences to improve services • Interventions such as new housing models are needed • “Strategies to enhance access to primary health care services, and to create a system of more integrated, accessible services, are required” (Ford-Gilboe et al., 2015, p. 1) • The experiences of IPV impacted women’s needs in different ways • For women, tailoring services should be based on individual needs • Providers did not understand the complexity of women’s lives • Common barriers to women’s wellbeing included: limited opportunities for income generation and lack of harm reduction policies Transform systems • IPV-related policies should support gender equality, limiting substance use related stigma, and protect women from violence when homeless • Indigenous women need high levels of support due to poverty and systemic racism • Resources need to improve service availability for dental and counselling • Policy alignment, clear goals, and specific actions are important to integration of services • Providers in the justice system need to use specific models of care • Comprehensive and effective pain assessment and management are needed Figure 1 Overview of the Policy Documents Studied and Key Actions Violence against women in relationships (VAWIR) policy (2010)Recognized Indigenous women, Immigrants, and women living with disabilities at a greater risk of experiencing more types of abuse and more severe violence than women not pertaining to these groupsTaking action on domestic violence in BC (2012)Planned to support immigrant and refugee women, women with disabilities, and Indigenous womenBC Provincial domestic violence plan (2014)Recognized the need for a diversity perspective to be inclusive of women’s needs Considered the need to involve men in addressing violenceAcknowledged the need for an Indigenous specific strategy A vision for a violence free BC (2015) Recognized the effects of policies and practices on women’s experiences of violenceOffered two programs to work with perpetrators Best practice approaches, child protection and violence against women (2017)Identified that the well-being of children depended on the safety of the mother Support women through learning collaborative decision-making 212 Table 2 Main Strategies and Actions to Address IPV Source Purpose Specific actions Violence against women in relationships (VAWIR) policy (2010) To set out “the protocols, roles and responsibilities of service providers across the justice and child welfare systems that respond to domestic violence” (p.2) • Considered a broad definition of Violence Against Women in Relationships, including a set of rules to identify women at a high-risk of experiencing severe violence • Focused on the justice and child welfare response, but emphasized collaboration and coordination among services • Recommended an integrated and cross-departmental response was for high-risk cases Taking action on domestic violence in BC (2012) To set “a coordinated approach to addressing domestic violence across the child and family serving systems in BC” (p.4) • Divided actions into immediate (June-December 2012), short-term (January-December 2013), and long-term (January 2014 on) • Included actions for the coordination and collaboration section work between the Ministry of Health and Ministry of Children and Family Development to develop protocols, screening tools, risk assessments, information sharing, and referral processes for providers within both ministries BC Provincial domestic violence plan (2014) To “increase safety for individuals and communities by strengthening the systemic response to domestic violence” (p.8) • Took VAWIR policy to level up a 3-year project • Included actions such as the creation of the website www.domesticviolencebc.ca with information and resources for victims • Created the VictimLink BC/Domestic Violence Helpline as a toll-free, province-wide helpline to connect victims with services A vision for a violence free BC (2015) To create “a province where all women have the supports they need to help prevent violence, escape from violent situations, and recover if they have been victims of violence” (p.2) • Included services and supports such as than 500 victim service and counselling, outreach, victim assistance, and shelter programs were planned for women • Contemplated a trauma-informed, holistic, collaborative and coordinated, evidence-informed, long-term and sustainable, culturally safe, relevant and responsive approach • Implemented specialized responses to sexual assault victims across BC • Set third-party reporting protocols in the justice system to help report sexual violence Best practice approaches, child protection and violence against women (2017) To “promote an integrated response that builds on the strengths between women’s and child welfare services” (p.6) • Promoted an integrated response to mothers impacted by abuse (and their children) • A coordinated departmental approach was designed • Included guidance for providers such as prompts to guide the delivery of services • In case of abuse to mothers, supportive services should be offered to improve her skills to continue to care safely for her child(ren) • Focused on a women-centered approach towards women’s empowerment and safety 213 Conclusions: In Canada, there have been efforts to address the needs of women who experience marginalization and IPV. The literature showed that the diverse voices of women need to be incorporated to design effective strategies to end/limit violence against them. Also, services and providers need to understand the high level of complexity of women’s lives and needs in the long-term to co-transform systems. Additionally, the government of BC, including multiple health and social organizations have recognized IPV as a complex health problem and have designed specific policies and actions to address IPV for the past 10 years. These policies have started to build a systemic strategy to strength IPV related services where coordination and integration of supports have been used to meet women’s needs. 214 References: Braveman P., Arkin E., Orleans T., Proctor D. & Plough A. (2017). Report. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation. Clifford, M., Porteous, T. & Varcoe, C. (2007). Critical Elements of an Effective Response to Violence Against Women. Briefing Document. ISSUE: Addressing Gaps in Services for Marginalized Women. BC Association of Specialized Victim Assistance & Counselling Programs. B.C./Yukon Society of Transition Houses. BC Institute Against Family Violence. Ford-Gilboe, M., Varcoe, C., Noh, M., Wuest, J., Hammerton, J., Alhalal, E., & Burnett, C. (2015). Patterns and Predictors of Service Use Among Women Who Have Separated from an Abusive Partner. Journal of family violence, 30(4), 419–431. Available from: https://doi.org/10.1007/s10896-015-9688-8 Government of British Columbia. (2015). A vision for a violence free BC: Addressing violence against women in British Columbia. http://cdhpi.ca/sites/cdhpi.ca/files/a_vision_for_a_violence_free_bc.pdf Haag, H., Sokoloff, S., MacGregor, N., Broekstra, S., Cullen, N., & Colantonio, A. (2019). Battered and brain injured: Assessing knowledge of traumatic brain injury among intimate partner violence service providers. Journal of Women's Health (Larchmont, N.Y. 2002), 28(7), 99-996. https://doi.org/10.1089/jwh.2018.7299 Hovey, A., & Scott, S. (2019). All Women Are Welcome: Reducing Barriers to Women’s Shelters with Harm Reduction. Springer Publishing Company. Partner Abuse. Volume 10, Number 4, p. 409-26. Available from: http://dx.doi.org/10.1891/1946-6560.10.4.409 Levac, D., Colquhoun, H., & O'Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science: IS, 5(1), 69-69. https://doi.org/10.1186/1748-5908-5-69 Mantler, T., Jackson, K. T., & Walsh, E. J. (2019). Critical discourse analysis of policies impacting the intersection of health and experiences of intimate partner violence for rural women in Ontario, Canada. Rural and Remote Health, 20(1), 5185-5185. https://doi.org/10.22605/RRH5185 Mantler, T. & Wolfe, B. (2018). Evaluation of Trauma-Informed Integrated Health Models of Care for Women: A Qualitative Case Study Approach. Springer Publishing Company. Partner Abuse, Volume 9, Number 2, p. 118-36. Available from: http://dx.doi.org/10.1891/1946-6560.9.2.118 Mantler, T., & Wolfe, B. (2017). A rural shelter in Ontario adapting to address the changing needs of women who have experienced intimate partner violence: A qualitative case study. Rural and Remote Health, 17(1), 3987-3987. Available from: https://doi.org/10.22605/RRH3987 Ministry of Children and Family Development. (2012). Taking action on domestic violence in British Columbia. Government of British Columbia. https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/domestic-violence/podv/taking_action_on_domestic_violence_in_bc_report Ministry of Children and Family Development. (2014). British Columbia’s provincial domestic violence plan. Government of British Columbia. https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/domestic-violence/podv/provincial_domestic_violence_plan.pdf Ministry of Children and Family Development. (2017). Best practice approaches, child protection and violence against women. Government of British Columbia. https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/public-safety/protecting-children/best_practice_approaches_policy.pdf Ministry of Public Safety and Solicitor General, Ministry of Attorney General, & Ministry of Children and Family Development. (2010). Violence against women in relationships policy. Government of British Columbia. https://www2.gov.bc.ca/assets/gov/law-crime-and-justice/criminal-justice/victims-of-crime/vs-info-for-professionals/info-resources/vawir.pdf 215 Morestin, F. (2012). A framework for analyzing public policies: Practical guide. National Collaborating Centre for Healthy Public Policy, Institute national de santé publique Québec. http://www.ncchpp.ca/docs/Guide_framework_analyzing_policies_En.pdf Torchalla, I., Linden, I. A., Strehlau, V., Neilson, E. K., & Krausz, M. (2015). “Like a lots happened with my whole childhood”: Violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside. Harm Reduction Journal, 12, Article 1. https://doi.org/10.1186/1477-7517-12-1 Torchalla, I., Linden, I. A., Strehlau, V., Neilson, E. K., & Krausz, M. (2017). Erratum to: "like a lots happened with my whole childhood": Violence, trauma, and addiction in pregnant and postpartum women from Vancouver's downtown eastside. Harm Reduction Journal, 14(1), 65-65. Available from: https://doi.org/10.1186/s12954-017-0191-9 Valentijn, P. P., Schepman, S. M., Opheij, W., & Bruijnzeels, M. A. (2013). Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care, 13(March), e010. https://doi.org/10.1192/bjp.bp.105.016006 Varcoe, C., Browne, A. J., Ford‐Gilboe, M., Dion Stout, M., McKenzie, H., Price, R., Bungay, V., Smye, V., Inyallie, J., Day, L., Khan, K., Heino, A., & Merritt‐Gray, M. (2019). Reclaiming our spirits: Development and pilot testing of a health promotion intervention for indigenous women who have experienced intimate partner violence. Research in Nursing & Health, 40(3), 237–254. https://doi.org/10.1002/nur.21795 216 Supplement 1 Overview of Selected Records Characteristic Output Province of origin • Ontario (n=5) (Haag et al., 2019; Hovey & Scott, 2019; Mantler & Wolfe, 2017; 2018; Mantler et al., 2019) • British Columbia (n=2) (Torchalla et al., 2015; Varcoe et al., 2019) • British Columbia, Ontario, and New Brunswick (n=1) (Ford-Gilboe et al., 2015) Year of publication • 2019 (n=4) (Haag et al., 2019; Hovey & Scott, 2019; Mantler et al., 2019; Varcoe et al., 2019) • 2018 (n=1) (Mantler & Wolfe, 2018) • 2017 (n=1) (Mantler & Wolfe, 2017) • 2015 (n=2) (Ford-Gilboe et al., 2015; Torchalla et al., 2015) Study design • Qualitative (7) o Interview (n=4) (Mantler & Wolfe, 2017; 2018; Torchalla et al., 2015; Hovey & Scott, 2019) o Survey (n=2) (Haag et al., 2019; Ford-Gilboe et al., 2015) o Critical discourse analysis (n=1) (Mantler et al., 2019) • Mixed methods (1) o Tailored approach which involved an Elder-led group and interviews (n=1) (Varcoe et al., 2019) Topics discussed in relation to IPV • Substance use (n=2) (Torchalla et al., 2015; Hovey & Scott, 2019) • Maternal/perinatal care (n=1) (Torchalla et al., 2015) • Indigenous women (n=1) (Varcoe et al., 2019) • Trauma (n=4) (Haag et al., 2019; Mantler & Wolfe, 2018; Torchalla et al., 2015; Varcoe et al., 2019) • Brain injury (n=1) (Haag et al., 2019) 217 Supplement 2 Methodological Summary Source Purpose Study characteristics and data collection approaches Ford-Gilboe et al., 2015 Analyze patterns of access to services in health, social, violence-specific, and legal sectors among Canadian women who had separated from an abusive partner A longitudinal survey of 309 Canadian women Haag et al., 2019 1) Explore service providers’ knowledge of traumatic brain injury (TBI) and its impact; 2) Identify existing TBI-specific IPV services, and barriers and facilitators; and 3) Develop recommendations, and create a network Phase one: 68 agencies providing IPV services were invited to complete an online survey Phase two: 22 participants (stakeholders, women) attended a workshop to disseminate knowledge and develop a network Hovey & Scott, 2019 Examine women’s experiences with a harm reduction service at a Canadian rural violence against women shelter 25 women participated in an on-site semi-structured interview Mantler & Wolfe, 2017 Examine how a rural Canadian women’s shelter role was changing to meet the needs of women experiencing IPV, and how the shelter was adapting to achieve the changing role Semi-structured interviews were conducted to six service providers and four women (staying in or utilizing services) Mantler & Wolfe, 2018 1) Examine the acceptability and perceived impacts of two models of trauma-informed social and primary care services; and 2) Identify gaps and recommendations for improving the quality of services offered to women Participants came from two models of care: facility- and system-level integration. There were three groups: a) administrators (n=4); b) service providers (n=10); and c) women utilizing services (n=25) Mantler et al., 2019 Examine the degree of alignment among provincial women’s shelters and hospital policies on the delivery and access to services for women who have experienced IPV in rural Ontario Policy analysis of three documents and their strategies: 1) the ODVAP, 2) the rural women’s shelter policy, and 3) the hospital policy Torchalla et al., 2015 Explore themes and perspectives of trauma and gender-based violence in women who experience marginalization and struggled with substance use during pregnancy and early motherhood 31 women accessing harm reduction services for pregnancy and postpartum care completed a quantitative questionnaire Only 27 women were interviewed due to data saturation Varcoe et al., 2019 Test the efficacy of an intervention known as Reclaiming Our Spirits in improving quality of life and health of Indigenous women who experience IPV 152 Indigenous women completed a self-report measure of primary and secondary outcomes at three points: preintervention, postintervention, and six months later
Thesis/Dissertation
eng
Interdisciplinary Studies
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Oelke, Nelly
Health system integration and equity-based services to support women who experience marginalization and IPV
Text