Benefits and qualities of groups in human services Final

Exploring Intimate Partner Violence and Sexual Health Needs in the Southwestern United States: Perspectives from Health

and Human Services Workers Eva Margarita Moya, Silvia María Chávez-Baray, Omar Martínez, and Aurora Aguirre-Polanco

This study explored intimate partner violence (IPV) and sexual and reproductive health (SRH) in the southwestern United States, focused on health and human services professionals (HHSPs) and community health workers (CHWs) in El Paso, Texas. Understanding provid- ers’ perspectives about IPV and SRH is an integral component of clinical and service care. Two focus groups were conducted with HHSPs and CHWs directly involved in health and human services delivery (N = 24). Participants discussed risks, protective factors, challenges, interventions, and programs to address IPV and SRH. Lack of specialized professional train- ing and educational programs about IPV and SRH were identified as the principal barriers to addressing the needs of IPV victims/survivors and perpetrators. The findings suggested that interventions should be culturally and linguistically appropriate and focused on a broad range of IPV and SRH issues and professional skills building. The information gathered from the focus groups informed the adaptation of two modules to improve IPV and sexual health. Subsequently, CHWs received training from the newly adapted program. This promising program is designed to meet the SRH needs of women, men, and survivors/victims of IPV and builds on the strong roles of health professionals, CHWs, and social workers.

KEY WORDS: health workers; intimate partner violence; reproductive health; sexuality

I ntimate partner violence (IPV) is defined as a pattern of abusive and coercive behaviors in intimate relationships. It remains a major public health concern in the United States and is often character- ized by an escalation in more severe violence across episodes, often becoming chronic, with potentially dangerous consequences ( Signorelli, Arcidiacono, Musumeci, Nuovo, & Aguglia, 2014). Gendered vio- lence violates basic human rights guaranteed by the Declaration on the Elimination of Violence against Women ( Devries et al., 2013; Pan American Health Organization, 2013; C. Watts & Zimmerman, 2002). According to the World Health Organization ( WHO, 2014), sexual health is the state of physical, emotional, mental, and social well-being related to sexuality. Sexuality encompasses sex, gender, identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. The organization also defines reproduc­ tive health as a state of complete physical, mental, and social well-being, in all matters relating to the repro- ductive system and to its functions and processes ( WHO, 2014). Documenting the prevalence and

magnitude of this hidden and unacknowledged epi- demic to guide policies and programs and monitor progress has been difficult ( Devries et al., 2013). IPV is a serious phenomenon affecting women in devel- oped and underdeveloped countries ( Devries et al., 2013; Renzetti, Edleson, & Kennedy, 2012). Accord- ing to the U.S. Department of Justice, in 2011 the rate of IPV against women was 4.7 victimizations per 1,000 females age 12 or older ( Catalano, 2013). More than 2 million adults in the United States are exposed yearly, resulting in psychological harm, physical harm, or both ( Texas Council on Family Violence [TCFV], 2012). The consequences can be lethal. Nationally, IPV homicide is responsible for 40 percent to 50 percent of female homicides ( Catalano, 2013; Glass et al., 2009; Neuman & Wozniak, 2011) and has been associated with injury and physical and mental health concerns, including depression and suicidal behaviors, disabilities, and homicide death ( Bloom et al., 2009; WHO, 2013). In Texas, 114 women were killed by their male partners during 2012 ( TCFV, 2012). Most of the victims were from 20 to 59 years old ( Catalano,

e29doi: 10.1093/hsw/hlv080 © 2015 National Association of Social Workers

2013). In addition, a high percentage of the murdered women (78 percent) were in a relationship, as girl- friends or wives, with the perpetrator; most of the women were killed at home (74 percent) ( TCFV, 2012). Addressing IPV prevention, infectious disease detection, wellness education, SRH, substance abuse prevention and treatment, and access to mental health services is essential in addressing women’s health ( Lapeyrouse et al., 2012).

Several factors contribute to IPV: (a) individual risk factors, including low self-esteem, depression, emo- tional dependence and insecurity, being a victim of physical or psychological abuse; (b) relationship factors such as marital conflict and marital instability, includ- ing divorce or separation; (c) community factors such as poverty and low social capital—lack of institutions and community’s social support; and (d) societal factors such as traditional rigid gender norms ( Ellsberg, Jansen, Heise, Watts, & García-Moreno, 2008; González- Guarda, Florom-Smith, & Thomas, 2011; González- Guarda, Vasquez, Urrutia, Villarruel, & Peragallo, 2011; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008). In addition, migration status, language, and migrants’ perceptions of quality of services offered in the United States, lack of knowledge, and dual mar- ginalization of migrant women are barriers to access- ing IPV services and support networks ( Desdaud-Ayala, Moya, & Chávez-Baray, 2012). Migrant women who are undocumented may fear being reported and, there- fore, are less likely than their documented counterparts to seek care. The social context of migrant women is one of high vulnerability ( Bloom et al., 2009; Glass et al., 2009; McDonald, Mojarro, Sutton, & Ventura, 2013; Moore, Frohwirth, & Miller, 2010; Neuman & Wozniak, 2011; WHO, 2010).

IPV is one of the many components of sexual health. Sexual health has been defined as a continuum of indicators of gynecology and reproductive health. Specifically, sexual health has been defined as the absence of specific diseases such as sexually transmit- ted infections (STIs), unwanted pregnancy, pain dur- ing menses or intercourse, menstrual irregularity, endometriosis, or vaginal bleeding. Sexual well-being includes the role of sexual expression to enhance life and personal relations through mutually pleasurable sexual relationships and reproductive choices ( Coker, 2007). Despite the advances in sexual health knowl- edge, sexual wellness promotion, and IPV prevention and care for women ( Caal, Guzman, Berger, Ramos, & Golub, 2013; Cashman, Eng, Siman, & Rhodes, 2011), no prevention intervention program presently

exists targeting IPV and sexual and reproductive health (SRH) in El Paso, Texas.

Women’s health is generally worse in Texas than in other states, and Latinas fare even worse in many key health indicators. They are the most likely among Texas women in any racial or ethnic group to report being in fair or poor health or sexual health. Texas has the highest percentage of uninsured adults in the country at 27 percent of the state’s population ( Henry J. Kaiser Family Foundation, 2014). Numerous bar- riers to health care exist for residents of El Paso and of colonias (unincorporated and underdeveloped areas outside of the city limits) in particular. The Texas– Mexico border is designated as a medically under- served area by the federal government. El Paso women—urban, rural, Mexican, immigrant, unin- sured, and poor—are largely unable to afford private health insurance; consequently, they tend to forgo preventive care and seek medical attention only in emergencies ( Center for Reproductive Rights, 2013).

This study builds on three previous community- based research projects that evaluated the SRH needs of Latinas affected by IPV ( Moya, Chávez-Baray, & Finley, 2012; Moya, Chávez-Baray, & Martínez, 2013, 2014). We wanted to further explore IPV and SRH from health care providers’ perspectives and inform the adaptation of two modules, one on IPV and one on SRH, to an existing educational program for health providers and community health workers (CHWs). Health and human services visits provide a window of opportunity for health professionals, social workers, and CHWs to address IPV and co- ercive behaviors and provide comprehensive SRH information.

METHOD We used a qualitative research approach to assess CHWs and health professionals’ perceptions of IPV and SRH ( Downe-Wamboldt, 1992; Liamputtong, 2011; Maxwell, 2013; J. H. Watts & Psaila, 2013). A team composed of two investigators, a consultant, and a research assistant conducted two focus groups: one with CHWs and one with health and human services professionals (HHSPs). The focus group methodology was well suited to explore people’s subjective expe- riences, perspectives, and attitudes about IPV and SRH type ( Krueger, 1988). The study used a guided focus group style that consisted of engagement ques- tions, exploration questions, and exit questions ( Liamputtong, 2011). The focus groups were con- ducted between April and May 2013 in El Paso, Texas.

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Focus group questions were designed to solicit infor- mation concerning IPV and women’s access to SRH services. The study used a convenience sample tech- nique to recruit HHSPs and CHWs.

Recruitment and Data Collection The study was approved by the University of Texas at El Paso Institutional Review Board. We recruited 24 participants (N = 24) from health and human ser- vices organizations and community-based clinics who met the following criteria: (a) 18 years of age or older and (b) experienced health professionals or CHWs in SRH. Prior to participation in the focus groups, all participants provided informed consent. Participa- tion was entirely voluntary, and each individual re- ceived a $20 gift card as appreciation for their time.

The focus groups were conducted at the university and were facilitated by the principal investigator and a co-investigator. A focus group with HHSPs was con- ducted in English and Spanish, and the CHWs focus group was conducted in Spanish. The focus groups were recorded, the audiotapes were transcribed, and translated transcripts were generated for analysis. The first focus group of 12 experienced CHWs engaged in a dynamic discussion about IPV and SRH. The second focus group consisted of 12 HHSPs with pre- vious experience on issues of IPV and SRH.

We developed a bilingual focus group guide for each of the groups. We explored the following themes: (a) meaning of IPV and SRH, (b) context and motivations for IPV, (c) the role of culture and norms in IPV and SRH risks and protection, (d) the role of CHWs and HHSPs in IPV and SRH, (e) other issues related to SRH and IPV, and (f ) recommenda- tions to address IPV and SRH. We encouraged par- ticipants to talk to one another, ask questions, exchange ideas, and provide recommendations based on their clinical experiences and perspectives from working with women ( Kitzinger, 1994).

Data Analysis A latent content analysis method was used, focusing on interpreting the underlying meaning of text. Con- tent analysis is a flexible and practical method for ana- lyzing text data ( Downe-Wamboldt, 1992). After reading the transcripts, an experienced research team generated and interpreted codes and themes using constant comparative method and written summaries to verify the emerging findings ( Glaser & Strauss, 1968; Hammond, 2012; Lincoln & Guba, 1985; Silverman, 2012). Categorization of codes was conducted, and a

final concept mapping of categories was created to reflect the interrelationship of beliefs, knowledge, and recommendations provided by participants about IPV and SRH.

As a result of providers’ perspectives and previous research conducted by our research team with women on IPV and SRH ( Hong, Fongkaew, Senaratana, & Tonmukayakul, 2010; Moya et  al., 2012, 2013, 2014), we identified two guides on IPV and SRH and incorporated participants’ perspectives and rec- ommendations to serve as a source of methodologi- cal guidance, and provided structural support to guide an existing CHW training program. Other sexual health program development studies have followed the same procedures ( Hong et al., 2010). Description of the guides selected can be found in the Discussion section.

RESULTS Participant Characteristics We recruited a total of 24 participants for the study (four men and 20 women), 12 CHWs (one man and 11 women), and 12 HHSPs (three men and nine women). Table 1 provides a summary of the project sample demographics. CHWs have specific skills, qualities, and knowledge to carry out health-related and social services activities. CHWs serve as cultural brokers between their own community and the for- mal health and human services system and can play a critical role in health promotion and wellness in their communities ( WestRasmus, Pineda-Reyes, Tamez, & Westfall, 2012). Most of the CHW participants in our study were involved in community service from an early age. All of them expressed a desire to increase their skills and knowledge to intervene on IPV issues in the community. CHWs in our study were engaged in health promotion and education (for example, diabetes, HIV services provision, drug and alcohol abuse, SRH education, IPV), human rights, and ac- cess to health and housing services. The HHSPs in the study were engaged in different health-related roles and responsibilities, including developing health programs, social work, coaching and training other health personnel in health topics, providing social services, case management, legal counsel, and par- ticipating in coalitions to advance health.

Qualitative Findings SRH. When talking about SRH, CHWs stated that physical, mental, and spiritual health begins with education and carries across the life span. For in-

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stance, they indicated that women who plan to bear a child have to be prepared (receive orientation and health exams) to cope with both their and the baby’s demands for health care before, during, and after pregnancy. CHWs believed that SRH education begins in the family environment and that CHWs’ educational experiences on contraception and pre- ventive measures help to mitigate the burden of un- planned pregnancies and prevent STIs. A CHW stated,

Reproductive health is knowing how to nurture children, every child is a “mundo” (world) and he or she can be productive or not, therefore we (parents) have to recognize that we are forming the community, and we need to know how to do it. (47-year-old female CHW)

* * *

Socially, we (males) learn early on in life that males are not responsible for unwanted or un- planned pregnancies. Most men see pregnancy and children’s nurture as the female’s responsibil- ity. (45-year-old male HHSP)

CHWs explained that education in SRH should focus on gender and address the needs of both women and men. They suggested the need to in- clude trainings on men’s SRH. One of the partici- pants explained that, in today’s society,

reproductive health isn’t a priority for men, nor are there programs tailored for their needs. (36-year-old male CHW)

* * *

To break some of the taboos associated with human sexuality, we (health professionals) need to create social spaces and opportunities for boys and men to learn about SRH. (38-year-old female HHSP)

Both HHSPs and CHWs said that it was difficult to talk about SRH and that the Latino community traditionally does not address the topic openly and comprehensively among family members, especially children and youths. The two groups reiterated the need to have culturally and linguistically competent HHSPs trained in IPV and SRH. Families, especially

Table 1: Sociodemographic Characteristics of Participants

Characteristic

CHWs (n = 2) HHSPs (n = 12)

n (%) M (SD) n (%) M (SD)

Gender Male 1 (10) 3 (27) Female 11 (90) 9 (63) Age (in years) 50.6 (9.3)a 47.7 (9.9)b

Annual income ($) 27,500 46,750 Education level Partial high school 1 (9) 0 (0) High school/GED 2 (18) 0 (0) Partial college 3 (27) 2 (17) College graduate 4 (36) 1 (8) Partial graduate 0 (0) 1 (8) Graduate school degree 1 (9) 8 (67) Race/ethnicity Hispanic 12 (100) 10 (82) White 0 (0) 2 (16) Employment status Full-time work 9 (43) 10 (63) Part-time work 1 (5) 2 (13) Student 1 (5) 2 (13) Volunteer/other 10 (48) 2 (13)

Notes: CHWs = community health workers, HHSPs = health and human services professionals. aRange of 32 to 63 years. bRange of 31 to 60 years.

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children, need to have access to human sexuality education early in life.

A CHW stated,

I was invited to deliver a sexuality education program for parents in various settings . . . there were people from 15 to 30 years and elderly too. . . . I saw a lot of conflict when we discussed the topic of talking about sexuality and relation- ships with our children. . . . Parents said it is a difficult topic, “What should I say?” . . . I think that we as a community are not prepared to help our children understand these topics (sexuality, HIV, and STIs). . . . These topics are being avoided, when we do not talk about them, we put them away. (37-year-old female CHW)

HHSPs also believed that youths need to be in- formed about STIs and unplanned pregnancies. In particular, the issue of STIs is a taboo for young Latinos. One of the providers explained: “It’s an underestimated issue, it’s a taboo among young His- panics” (52-year-old female HHSP).

Another participant discussed the needs of vul- nerable groups, like people with disabilities.

Sexuality education is not only a priority for children and youths. Individuals with special needs are sexual beings and need sexuality edu- cation. Their rights need to be respected. We need professionals who are trained to work with the needs of the disabled communities; they continue to be isolated and underserved. (58-year-old female HHSP)

Intersection of IPV, Social Norms, and Stressors. CHWs discussed their perspectives on IPV, the definition and types of abuse, and the victim/survi- vor characteristics. They mentioned that violence affects all family members. Girls and women con- tinue to be the most vulnerable group and, as a result of IPV, end up having lower socioeconomic status. Latino immigrants face even greater challenges and sometimes tolerate the abuse because they fear being deported and separated from their children.

CHWs identified four levels of violence: (1) at the personal level, violence is learned primarily at home and in school settings; (2) at the interpersonal/rela- tionship level, conflicts in partner relationships may lead to IPV, and economic stress and life challenges can also lead to violence; (3) at the community level,

mass media foster violence and can influence the community’s behaviors toward an objectification of  women; and (4) at the societal/cultural level, “male violence and aggression” were identified as machismo.

A participant explained,

Domestic violence or rape isn’t the problem, it’s a symptom of a bigger problem . . . it’s an op- pressive culture, where (violence) is used as a tool. . . . People use violence as a way to oppress a particular type of person, so I become abusive not because I’m prone to violence, but because there’s a need to exert my superiority over someone else, and I use violence as a tool to accomplish this. (36-year-old male CHW)

* * *

As males, we learn that violence against women is a mechanism to control, lead, and be respected by the family. If your spouse does not obey you, others will make fun of you and will call you by different names like “mandilón” (submissive man that obeys women, “whipped”). (39-year- old male HHSP)

Barriers and Opportunities for IPV and SRH Ser- vices. Both groups recognized the daily challenges of women’s lives, marked by poverty and geograph- ical isolation, and that for some women fear and insecurity regarding their immigration status con- strained their ability to obtain timely IPV services and SRH care. As noted by the participants, these stressors and barriers to care are interrelated. HHSPs and CHWs highlighted the need to screen victims/ survivors for health risk and needs and to provide comprehensive mental and physical health services. The provision of individual and family therapy ser- vices, as well as protective orders, were identified by the CHWs and the HHSPs as a top priority. Other comprehensive services identified by both groups include shelters and centers that offer orientation, case management, and legal counsel and advocacy services. A CHW in a rural community described how gender violence is a barrier to women’s SRH:

To convince women that they are the owner of their bodies and that they have the right to have health screenings without their partners’ consent is vital. (50-year-old female CHW)

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An HHSP provided an example of how women’s health continues to be dependent on gender power and inequality. He stated,

As a male, and as a husband, . . . my wife’s re- productive health impacts me, and affects my life; it also affects the health of my family. So bringing men into the conversation, to make them active participants in SRH, is vital. I need to be included. (39-year-old male HHSP)

The HHSPs recommended three solutions to stop violence: (1) specialized services and resources for all IPV victims/survivors, to train them to be- come empowered and confront their reality and overcome the obstacles; (2) financial resources for centers, victims/survivors, children and youths, ag- gressors, and volunteers to create educational ma- terials and programs tailored to the population’s needs; (3) culturally and linguistically competent professionals like CHWs, social workers, therapists, mental health specialists, and employment coun- selors for victims/survivors, their children, and aggressors.

HHSPs identified needs related to specialized medical and mental health care, including counseling to address the psychological and behavioral conse- quences of IPV; and legal services, especially to ad- dress irregular immigration status, and for victims/ survivors, to help them navigate the health and human services system. Another important aspect discussed was the need to have culturally and linguis- tically competent professionals and services in the community for military personnel; Native Americans living on reservations; immigrants; the lesbian, gay, bisexual, transgender, questioning, and intersex (LG- BTQI) population; and individuals with disabilities.

To address the SRH needs of IPV victims/survi- vors, both groups suggested training on SRH topics to deliver culturally and linguistically competent services to teenagers, youths, and parents to increase the intervention’s impact. To improve SRH in their communities, participants identified the use of a peer-based approach as a viable strategy to address the SRH needs of vulnerable groups.

One of the opportunities cited by both groups of participants was the 2010 Patient Protection and Affordable Care Act (ACA) and how it could address IPV and SRH needs of their communities. They indicated that, although the ACA is going to in- crease access to mental and health care services, they

are concerned about the questionable accessibility and quality of services being provided to special groups (for example, people with disabilities, im- migrants, and LGBTQI populations). They sug- gested that the ACA should focus on improving access and quality of services being delivered to vulnerable populations. The ACA will support the health care workforce development as a whole and is an opportunity to integrate CHWs as an essential part of the health care workforce. They believe that the law could support the implementation of sanc- tions for professional malpractice, especially against vulnerable populations, and is an opportunity to reform the health insurance market.

Empowerment was mentioned as an important strategy to address IPV:

Women need to be proactive . . . they need empowerment to be motivated to recover their well-being. (46-year-old female HHSP)

CHWs agreed that education can serve as an em- powerment mechanism to increase self-efficacy and self-advocacy:

Women need to understand who they are, where they’re coming from, and where they want to go, being able to self-advocate what they want or need. (51-year-old female CHW)

Participants from both groups agreed that mass media interventions used by community-based or- ganizations and institutions are needed to bring awareness and address IPV and SRH. The effective practices and lessons learned from programs that achieved great success in addressing the needs of victims of IPV, including SRH, in other parts of the country can be adapted to meet the needs of the El Paso community. CHWs and HHSPs agreed that men should also be an integral part of programs and interventions and that men could help to hold ag- gressors accountable for their actions.

The last theme centered on the roles and training of CHWs, health professionals, and social workers. HHSPs believed that CHWs are the most appropri- ate agents to provide education on IPV and SRH in the community. CHWs emphasized the impor- tance of ethics, and ensuring confidentiality in the IPV and SRH training. CHWs also identified strat- egies to promote education on IPV in the com- munity, such as “pláticas en casas” or home talks.

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CHWs and HHSPs indicated that SRH educa- tion programs will help bring social change by ad- dressing factors that contribute to IPV, promoting equity, and reducing oppression and discrimination. They pointed out that the education provided by CHWs should focus on an individual’s needs, values, and preferences for health care. CHWs and HHSPs presented ideas about the need for public awareness campaigns (for example, posters in public spaces and schools, Photovoice exhibitions, community pre- sentations, and health fairs) to promote implemen- tation of the program in the community. Policies that ensure accessibility, availability, and affordability of SRH services are needed for all. CHWs and HHSPs also mentioned that social workers, health professionals, decision makers, employers, and the community at large need to be aware of the rele- vance and importance of programs developed on IPV and SRH in the community.

DISCUSSION Our findings suggest that there is a need in com- munities along the U.S.–Mexican border region for SRH education programs and that SRH education can be provided through CHWs and other health professionals, including social workers specialized in services related to IPV and SRH. HHSPs and CHWs highlighted the need to promote SRH to men and women across the life span in a culturally and lin- guistically competent manner. Participants also sug- gested the need to explore SRH through the intersection of IPV, social norms, and stressors, and taking into consideration the impact of IPV on SRH.

A salient collateral finding of the study was that the aggressors were identified as primarily men and that no reference was mentioned about how women could also be aggressors. In addition, the participants referenced that most aggressors are Hispanics and that machismo prevails in the Latino culture. Nevertheless, in our previous research ( Moya et al., 2013) on IPV, the majority of aggressors were non-Hispanic men. In addition, despite previous research connecting the two, there was no reference made to the association between depression and aggression in men.

As a result of the study, we identified, adapted, and translated two monolingual guides to address IPV and SRH on the basis of the HHSPs’ and CHWs’ perspectives and previous published work on IPV and SRH ( Downe-Wamboldt, 1992; Moya et al., 2012, 2013, 2014). One of the outcomes of

the study included piloting these two guides with a group of 23 IPV victims/survivors in training by Familias Triunfadoras, Inc., a community-based organization in San Elizario, Texas. The training enabled the participants to effectively serve as spe- cialized CHWs, opinion leaders, and community advocates on IPV and SRH.

Adaptation of the training modules was per- formed by using qualitative methods. The SRH guide for migrant women in the United States, originally developed in Spanish by INMUJERES and Programa de Investigación en Migración y Salud ( Instituto Nacional de las Mujeres, 2006), was used. In 2013, we secured authorization from the creators of the two manuals (kits) to adapt and use the guides to meet the needs of women in the U.S.– Mexican border region. After a careful review, we also selected the New York State Office for the Pre- vention of Domestic Violence (NYSOPDV) Safety and Support Guide for victims/survivors as our primary resource tool for cultural and linguistic ad- aptation ( NYSOPDV, 2013). In 2013, we received authorization from the NYSOPDV to adapt the guide for victims/survivors of IPV in El Paso, Texas.

The study participants indicated that training mod- ules that build on effective participatory educational approaches to reach and affect community members are needed. The participants agreed that social work- ers, CHWs, and health educators can reach large numbers of individuals and serve as a potential re- source to reduce and eliminate health disparities among vulnerable and hard-to-reach groups as cited in the literature ( Cupertino et  al., 2013; Duran, Cuchi, Centro de la Juventud Latinoamericana, & National Council of La Raza, 1997; Otiniano, Carroll-Scott, Toy, & Wallace, 2012; Twombly, Holtz, & Stringer, 2012). There was a consensus that CHWs can serve as cultural and linguistic brokers between their communities and the formal health care services ( Vollmer Dahlke, Cho, Gines, St. John, & Ory, 2014; WestRasmus et al., 2012).

Although we acknowledge the significance and the potential impact of our project in addressing IPV and SRH, more research is needed to implement research on a larger scale and continue refinement and adaptation for other vulnerable populations affected by IPV and SRH.

One limitation of the study is that convenience sampling was used and included a relatively small sample size; therefore, the findings cannot be gen- eralized to other CHWs and HHSPs. Nevertheless,

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the study’s findings may be used to inform the de- sign of other IPV and SRH interventions and pro- grams beyond the U.S.–Mexican border region. Additional research on IPV and SRH for health professionals, victims/survivors, and aggressors is needed to address what they perceive as risks and protective factors that influence health-seeking be- haviors and practices.

CONCLUSION The findings of this study do more than identify the needs and limitations of SRH policy; they identify opportunities to address the rights to health care and promote equity and access to quality services. There is a salient need for educational programs and inter- ventions in the areas of IPV and SRH for health professionals, CHWs, and the community at large. The two modules adapted through this study can serve as curricula and training tools for social work- ers, psychologists, educators, health professionals, CHWs, and students to increase awareness, improve access to services, and mitigate the impacts of IPV on SRH. CHWs have the capacity, skills, and abil- ities to work in communities where other health professionals have not been able to serve. IPV and SRH programs need to be culturally and linguistically competent, evidence-based, and built on successful practices based on community needs. Collaborative work between comm unity, educational, and academic institutions is important to improve IPV education, SRH, and community well-being.

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Eva Margarita Moya, PhD, LMSW, is assistant professor and Silvia María Chávez-Baray, PhD, is a lecturer, Social Work, College of Health Sciences, University of Texas at El Paso. Omar Martínez, JD, MS, MPH, is assistant professor, School of Social Work, College of Public Health, Temple University, Philadelphia. Aurora Aguirre-Polanco, MPH, is a doctoral student, College of Health Sciences, University of Texas at El Paso. Address correspondence to Eva Margarita Moya, Social Work, College of Health Sciences, University of Texas at El Paso, 500 W. University, El Paso, TX 79968; e­mail: [email protected]. This study was supported by a grant from the National Institutes of Health/National Institute on Minority Health and Health Disparities (I P20 MD002287­05; principal investigator [PI]: Elias Provencio­Vasquez, PhD) to the University of Texas at El Paso College of Health Sciences. The authors thank study participants and community partners for their time, contributions, and support. Dr. Martínez is supported by a National Institute of Mental Health training grant (T32­MH19139 Behavioral Sciences Research in HIV Infection; PI: Theo Sandfort, PhD) at the HIV Center for Clinical and Behavioral Studies (P30­ MH43520; center director: Robert H. Remien, PhD).

Original manuscript received September 24, 2014 Final revision received June 21, 2015 Accepted July 10, 2015 Advance Access Publication December 6, 2015

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