Examining the Domestic Violence Crisis in Ventura County in the Wake of the COVID-19 Pandemic.

BACKGROUND: Domestic violence (DV) worsened during COVID-19 and Family Justice Centers (FJCs) were, even more so than before, a critical part of providing services to DV victims. This study characterizes the clinical and sociodemographic features of the clients that come to the Ventura County FJC (VCFJC) and examines the effect of COVID-19, thus informing awareness of services available to victims of DV.
METHODS: This was a retrospective cohort study utilizing the VCFJC database from 2019 to 2021. All client data normally collected was studied. A comparison of pre-COVID and post-COVID data was also conducted.
RESULTS: There were 3488 client entries. Clients were mostly female (79% [2755]; n = 3488), aged 25-40 (31.73% [1106]; n = 3448), white/Caucasian (44.42% [1531]; n = 3448) or Hispanic/Latinx (42.41% [1462]; n = 3448). Clients most often requested restraining orders (72.41% [2496]; n = 3448), and most commonly reported DV [physical] (47.90% [1651]; n = 3448). Most health-insured clients were covered by MediCal (45.06% [1231]; n = 2732). Pre- and post-COVID analysis showed the highest increases in DV [physical] (odds ratio = 1.26, P < .0007) and stalking/harassment (odds ratio = 2.45, P < .0007), and decreases in all Initial Service Request categories except one. DISCUSSION: In serving clients affected by DV, FJCs are an important service for health care providers to be aware of. Post-COVID, clients reported DV and stalking/harassment at much higher percentages, which is consistent with national studies on the pandemic. The most alarming finding was the steep decrease in Initial Service Requests.
Conclusion: This study shows the importance of collaboration and awareness of services, especially in a world of COVID-19.

Key Take aways

Domestic violence (DV) in the home has an overall cost to society—especially to the health of society—leading to potentially adverse physical and mental health outcomes, and Family Justice Centers (FJCs) have been a key player in combating DV since they were founded in 1989.

Very few studies have been done on FJC databases in any capacity, and with the COVID-19 pandemic increasing the prevalence of DV, and research indicating that FJCs have made demonstrably positive impacts on the communities they serve, it is imperative to analyze who seeks out services for DV.

Increased awareness of services available to patients will improve overall health care, and we hope this study will increase knowledge of how intertwined FJCs and health care services are.

Introduction

Domestic violence (DV) is a public health issue that crosses families, communities, and populations.[1,2] One in 4 women and nearly 1 in 10 men have experienced intimate partner violence (IPV), sexual violence, physical violence, and/or stalking by an intimate partner during their lifetimes.[3] Furthermore, approximately 41% of female IPV survivors and 14% of male IPV survivors experience physical injury related to IPV.[4,5] During COVID-19 and the confinement measures, these conditions may stimulate smoldering violence in families. The pandemic has also led to “intimate terrorism” with an increase in intimate partner homicide.[2]

Violence in the home is costly to the health of society. This may potentially lead to adverse physical and mental health outcomes, including a higher risk of chronic disease, substance use, depression, post-traumatic stress disorder, and risky sexual behaviors.[6]

The Family Justice Center (FJC) movement began in 1989 to provide diverse, culturally competent services for victims of DV and family trauma.[6] FJCs use a “wraparound” service delivery model and seek to marshal all available resources in a community into a coordinated, centralized system so that victims are served and prioritized by addressing important social determinants of health in a fashion consistent with trauma-informed care.[7] Trauma-informed care understands and considers the pervasive nature of trauma and promotes environments of healing and recovery rather than practices and services that may inadvertently re-traumatize.[8] There are now over 100 FJCs and multi-agency models across the United States, with many more in development. FJCs have demonstrated their positive impact on collaborative efforts, thereby increasing hope and access to services for survivors and their children.[9,10]

There have been many studies done to characterize nationwide databases and describe the clinical and sociodemographic features of the DV population.[11,12] However, very few studies have been performed on specific FJC databases.[13] With the COVID-19 pandemic increasing the prevalence of DV, and research indicating that FJCs have made demonstrably positive impacts on the communities they serve, it is imperative to analyze who seeks out services for DV.[14] This information can allow for increased collaboration between sister services such as health care professionals and mental health counseling—a pre-existing model of collaboration core to FJCs between nonprofits, county governments, and law enforcement agencies. This model has been successful in leveraging funding and providing high-quality services from community-based organizations (CBOs).[15]

DV and IPV remain under-reported, under-recognized, and under-addressed by health professionals. A patient who is suffering from a suspected physical injury due to a firearm or assaultive or abusive conduct is reportable.[16] Increased awareness of services available to patients will improve overall health care, and we hope this study will increase knowledge of how intertwined FJCs and health care services are.

This study will focus on the Ventura County Family Justice Center (VCFJC) and describe the clinical and sociodemographic features of the population they serve. The VCFJC client database will give valuable insights into how the COVID-19 pandemic affected the population they serve, as the VCFJC opened in March 2019, and lockdown orders in Ventura County began in March 2020.[17]

Methods

Study Design

This was a retrospective cohort study utilizing the VCFJC database from its inception—March 2019 to December 2021. This database contained upwards of 3000 client entries. All new client entries were included in this study. This data can be accessed by some VCFJC staff members and the de-identified data can be provided upon request for approved purposes. This study was granted expedited approval by the Ventura County District Attorney’s Office and the Ventura County Medical Center Institutional Review Board, and considered exempt from the need for informed consent.

When a client comes to the VCFJC, they are greeted by a Navigator who works with the client to review their rights to confidentiality and privileged conversations, assess their needs, complete the intake process, discuss available services, and establish a service plan. The navigator will provide a warm handoff to the service providers based on the clients’ service plan. Once the client has met with all service providers within their service plan, the navigator will schedule other referrals.

The form completed in the intake process collects client demographic information, the purpose of the visit and primary experiences that brought them to the VCFJC, information about their offender and their children, and many other types of information about their circumstances. These include whether they have called law enforcement, sought medical care, gone to the emergency room (ER), have health insurance, who they were referred by, and what services they choose to receive. In entries where categories were not clear, consistent categories were made with the help of VCFJC staff.

Statistical Analysis

Statistical analysis was carried out using JMP (John’s Macintosh Project) [JMP 16] to produce unbiased standard errors and construct 95% confidence intervals around categories gleaned from the VCFJC raw data. All records were included in the analysis to ensure accurate calculations. Final percentages were verified through internal calculations of VCFJC data. Differences were considered statistically significant when the confidence intervals did not overlap. Statistical significance was set to P < .05 for all analyses. According to VCFJC procedures, all clients complete an intake form with a navigator, so the likelihood of missing data is low.

For the pre-/post-COVID analysis, a generalized linear model was run with binomial distribution and logit link function. From this, we found odds ratios for each category pre-/post-COVID in Initial Services and Primary Experience. We also used the Bonferroni correction to ensure P-values were scaled for the number of tests we ran in each category (Initial Services and Primary Experience).

Results

Based on the VCFJC client database, there were 3488 new client intake packets from March 2019 to December 2021. There were 1608 client intake packets from pre-COVID (March 2019 to March 2020), and 1880 client intake packets from post-COVID (March 2020 to December 2021).

The demographic characteristics of the clients are presented in Table 1. Clients were mostly female (79% [2755]; n = 3488). The two most common age ranges were 25-40 (31.73% [1106]; n = 3488) and 41-59 (30.32% [1058]; n = 3488). English was the primary language of most clients (84.15% [2935]; n = 3488). Most clients were white/Caucasian (44.42% [1549]; n = 3488) or Hispanic/Latinx (42.41% [1479]; n = 3488). Most clients did not report a special population on the intake packet, but the highest category out of those provided was limited English proficiency (7.08% [246]; n = 3488). Of these, 46.87% [1634] (n = 3488) had minor children. Table 2 shows the clients’ history.

Table 1.

Demographic Characteristics of Ventura County Family Justice Center Clients from 2019 to 2021 (N = 3488).

Variable	N	Percent (%)
Gender
Female	2756	79.01
Male	718	20.57
Other	15	.42
Primary language
English	2935	84.15
Other	35	1.01
Spanish or Mixteco	518	14.84
Race/ethnicity
American Indian or Alaska Native	8	.24
Asian	98	2.81
Black or African American	64	1.83
Hispanic/Latinx	1479	42.41
Multiple ethnicities	117	3.35
Native Hawaiian or Pacific Islander	13	.37
Other	160	4.59
White/Caucasian	1549	44.42
Age range
0-17	40	1.14
18-24	314	9.00
25-40	1107	31.73
41-59	1057	30.32
60+	592	16.97
Other	378	10.85
Identified population
Cognitive, physical, or mental disability	158	4.54
Deaf or hard of hearing	94	2.68
Homeless	59	1.70
Immigrant refugee asylum seeker	71	2.05
LGBTQ+	21	.61
Limited English proficiency	247	7.08
Military: Spouse-active duty-Veteran	107	3.05
Minor children
No	1852	53.10
Yes	1635	46.87

Note. LGBTQ+ is Lesbian, Gay, Bisexual, Transgender, Queer, + other includes did not provide.

Table 2.

Client Reasons for Accessing Ventura County Family Justice Center Services 2019-2021.

Variable	N	Percent (%)
Initial services sought
Restraining order assistance	2526	72.41
Advocate or counselor	1415	40.57
Safety planning	723	20.73
Civil legal services	392	11.24
Shelter, housing, and basic needs	80	2.28
Other	342	9.81
Primary experience
Adult physical assault	409	11.73
Adult sexual assault	78	2.23
Child abuse	169	4.84
Dependent adult abuse	27	.78
Domestic violence (physical)	1671	47.90
Elder abuse	335	9.60
Stalking/harassment (DV or other)	1562	44.78
Other	399	11.44
Law enforcement called
No	1004	28.79
Yes	2484	71.21
Client’s relationship with offender
Acquaintance or other	453	13.00
Dating	1395	40.00
Other	105	3.00
Other family or household member	942	27.00
Spouse	593	17.00
Referred by
Coalition	7	.21
District attorney	635	18.20
Family	67	1.92
Friends	43	1.22
Interface	13	.37
Law enforcement	1491	42.74
Medical professional	15	.43
Other	893	25.60
Self	325	9.31

Clients that came to the VCFJC were significantly more likely to request restraining order assistance (72.41% [2525]; n = 3488), followed by advocate/counselor, safety planning, civil legal services, then shelter, housing, and basic needs. The common Primary Experience reported was DV—physical (47.90% [1670]; n = 3488) and stalking/harassment—DV or other (44.78% [1561]; n = 3488). Most of the client’s offender was someone they previously or currently were dating (40.00% [1395]; n = 3488). 71.21% [2484] (n = 3488) had called law enforcement at least once. Most clients were referred to the VCFJC through law enforcement (42.74% [1490]; n = 3488).

Table 3 shows clients’ health insurance and treatment information. Most clients reported health insurance coverage (79.24% [2764]; n = 3488). Most clients were covered by MediCal (45.06% [1245]; n = 2764), followed by Blue Cross Blue Shield (17.86% [494]; n = 2764), MediCare (9.67% [267]; n = 2764), and Kaiser (9.54% [264]; n = 2764). Of these, 14.53% [506] (n = 2764) sought medical assistance, and 10.80% [377] (n = 2764) were treated in the emergency room (ER) or the hospital. Out of the clients that sought medical care, a greater proportion had health insurance than the general client population (86.08% [435]; n = 506), as did people that went to the ER or hospital (85.22% [320]; n = 377).

Table 3.

Ventura County Family Justice Center Client Medical Information 2019-2021.

Variable	N	Percent (%)
Health insurance coverage
No	724	20.76
Yes	2764	79.24
Sought medical assistance
Clients reporting medical assistance	507	14.53
Clients that did not	2981	85.47
Treated in ER or hospital
Clients reporting ER or hospital visit	377	10.80
Clients that do not	3111	89.20
Health insurance
Blue Cross Blue Shield	494	17.86
County insurance	11	.40
Covered California	54	1.95
Kaiser	264	9.54
MediCal	1245	45.06
MediCare	267	9.67
Other insurance (not known)	288	10.43
Other private insurance	32	1.14
Signa	35	1.28
Tricare/VA	28	1.01
United health care	46	1.68
Health insurance coverage of people that sought medical care
No	70.43	13.92
Yes	435.6	86.08
Health insurance coverage of people that went to the ER
No	55.57	14.78
Yes	320.4	85.22

Note: Reported numbers for each variable depend on client responses.

Pre-COVID and post-COVID analysis was done with Initial Services and Primary Experiences. Table 4 shows the pre-/post-COVID analysis of Primary Experiences. Table 5 shows the pre-/post-COVID analysis of Initial Services. Both of these data points were collected consistently throughout operations of the VCFJC and give valuable insights about the effect of COVID-19. For Primary Experience, there were significant decreases in the chance of Adult Physical Assault and Child Abuse from pre- to post-COVID, indicated by an odds ratio of less than 1. However, the most significant changes were the increases in DV (physical) and stalking/harassment from pre- to post-COVID. There is a 26% chance of increased DV (odds ratio = 1.26, [Cl] 1.18-1.35 P < .0007) and a 145% chance of increased stalking/harassment (odds ratio = 2.45, [Cl] 2.27-2.64 P < .0007). The change was not significant for Adult Sexual Assault, Child Abuse, or Dependent Adult Abuse.

Table 4.

Client Primary Reason for Seeking Ventura County Family Justice Center Services Pre- and Post-COVID.

Primary Experience	Odds Ratio (OR)	Confidence Interval		P-Value
		Lower	Upper
Adult physical assault	.35	.30	.40	<.0007[a]
Adult sexual assault	.74	.58	.93	.076
Child abuse	.81	.69	.95	.057
Domestic violence	1.26	1.18	1.35	<.0007[a]
Dependent adult abuse	.57	.37	.89	.09
Stalking/harassment	2.45	2.27	2.64	<.0007[a]
Other	1.57	1.40	1.77	<.0007[a]

aSignificance level set at less than .05.

Table 5.

Initial Services Sought Out by Ventura County Family Justice Center Clients Pre- and Post-COVID.

Initial Services	Odds Ratio (OR)	Confidence Interval		P-Value
		Lower	Upper
Restraining order	.85	.79	.92	<.0006[a]
Advocate or counselor	.26	.24	.29	<.0006[a]
Safety planning	.19	.16	.22	<.0006[a]
Civil legal services	.53	.47	.60	<.0006[a]
Shelter, housing, and basic needs	1.51	1.18	1.94	.0066[a]
Other	.72	.64	.81	<.0006[a]

aSignificance level set at less than .05.

For pre- and post-COVID analysis, it is important to note the difference in how the data was collected. The intake forms had some significant edits and the categories were reassigned. Because of the different categories between pre- and post-COVID, the increase may be inflated.

For Initial Services, all categories except one had a significant decrease in chance from pre- to post-COVID, indicated by an odds ratio of less than 1 (restraining order, advocate or counselor, safety planning, civil legal services, and other). The only category with a significant increase in change was shelter, housing, and basic needs (odds ratio = 1.51 [Cl] 1.18-1.94 P = .0088), and the category with the most significant decrease in change was the safety planning category (odds ratio = .185 [Cl] .16-.22 P < .0001).

Discussion

DV is extremely pervasive in our society, and despite the severe physical and psychological injury caused by DV, little attention is paid to DV as a health issue. Lack of knowledge on adequately managing cases of DV, such as appropriate ways to help survivors, leads to it remaining an under-addressed issue.[18] DV is extremely relevant to the health care professional because it corrodes the physical and mental health of those affected, which means that being aware of the services available and who seeks those services is crucial, which is precisely what this study does. In addition, within the first 15 years of the founding of the first FJC in San Diego, California, there was a reduction of nearly 95% in DV homicides.[10] FJCs are an essential part of addressing DV, and this study shows who seeks services at the VCFJC.

Of these, 79.24% of clients reported health insurance, and 45.06% of those clients were covered by MediCal. This means that those clients are 138% below the poverty line.[19] When a client comes to the FJC, it is likely their sole source of services. 71.21% of clients have previously called law enforcement, and the highest percentage of clients also found out about the JFC through law enforcement (42.74%), compared to any other source of referral. This shows the state of crisis a client may be in when finally being made aware of a place to seek services. Awareness of services is often the key to finding care—which is also shown in the people that sought medical care or went to the ER—they were significantly more likely to have health insurance than the general client population.

Additionally, COVID-19 had a significant impact on Primary Experience and Initial Services sought by clients. These two variables were chosen because they delineate the reason why someone sought services and how the interventions they requested changed based on COVID-19. DV cases went up significantly after COVID-19 (odds ratio = 1.26) as did stalking and harassment incidents (odds ratio = 2.45). This is consistent with national studies acknowledging DV’s recognition as the “Shadow Pandemic” by the United Nations.[20] A concerning issue was the decline of Initial Service Requests in every category except shelter, housing, and basic needs. This may be because clients were not able to seek out as many services due to limited in-person interaction stemming from the pandemic. Owing to the stay-at-home orders, almost all client intakes were conducted remotely, so the awareness of all services available at the FJC was likely not as widespread. Future research should be conducted on additional ways nonprofits, such as those organizations that partner with FJCs, can continue to serve even if they cannot be on site. Another important note is that the Initial Services are what the client requested upfront, and the Primary Experiences are what they describe as the reason for their visit, highlighting the noteworthiness of critical social determinants of health that truly affect a victim’s life. The Initial Service Requests made by clients may represent only a portion of the services or referrals received.

Limitations

Data collection methods changed with appropriate modification from the inception of the VCFJC. Clients were not always completing similar forms from year to year, but data collection at the VCFJC was kept consistent as best as possible. The navigator or advocate may have guided clients through the process non-uniformly due to the human element aspect, despite similar training sessions. Victims’ self-reporting of the number of times contact was made with law enforcement or sought medical care could not be verified.

Conclusion

This study underscores the importance of FJCs working in concert with the health care system to address life-altering social determinants of health. It also highlights the increase in stalking and harassment brought on by the COVID-19 pandemic. Further research is needed to enable the empowerment of victims.