VIOLENCE AGAINST WOMEN: EVALUATING HEALTH CARE INTERVENTIONS

Release Date:  February 16, 2000

RFA:  HS-00-006
 
Agency for Healthcare Research and Quality (formerly AHCPR)
 
Letter of Intent Receipt Date:  March 24, 2000  
Application Receipt Date:       April 27, 2000

PURPOSE

The Agency for Healthcare Research and Quality (AHRQ), formerly known as the 
Agency for Health Care Policy and Research (AHCPR), invites grant applications 
to conduct research on the outcomes, effectiveness and cost effectiveness of 
programs for early identification and treatment of domestic violence against 
women.  The goals of this RFA are to develop new knowledge in the prevention 
of domestic violence, improve the identification of female patients at risk, 
and to evaluate outcomes and effectiveness of health care interventions 
designed to treat domestic violence victims.

The AHRQ encourages partnerships between health plans, service providers, 
researchers, and community-specific programs.  The research may encompass 
important aspects of the health care response to domestic violence including 
adoption and implementation of protocols and practice guidelines, routine 
screening for domestic violence, on-site capacity to provide treatment and 
safety planning, and follow-up of victims.

The evaluation is encouraged to follow patients over time and to measure 
whether the intervention improves the health and safety of victims, predicts 
or improves health care utilization patterns, prevents or reduces the 
occurrence of domestic violence, or helps us develop better techniques to 
detect women at risk.  The evaluation may use an experimental or quasi-
experimental design and include development and testing of performance 
measurement tools and outcomes related to domestic violence.

HEALTHY PEOPLE 2010
 
The Public Health Service (PHS) is committed to achieving the health promotion 
and disease prevention objectives of "Healthy People 2010," a PHS-led national 
activity for setting health improvement priorities for the United States.  
AHRQ encourages applicants to submit grant applications with relevance to the 
specific objectives of this initiative.  Potential applicants may obtain a 
copy of "Healthy People 2010" at http://odphp.osophs.dhhs.gov/pubs/hp2000 .

ELIGIBILITY REQUIREMENTS
 

Applications may be submitted by domestic or foreign, public or private 
nonprofit organizations, including universities, clinics, units of State and 
local governments, and eligible agencies of the Federal government.  For the 
purpose of this RFA, AHRQ, by statute, can make grants only to non-profit 
organizations; however, for-profit organizations may participate in grant 
projects as members of consortia or as subcontractors.  Organizations 
described in section 501(c)4 of the Internal Revenue Code that engage in 
lobbying are not eligible.

AHRQ encourages investigators who are women, members of minority groups and 
persons with disabilities to apply as Principal Investigators.  

MECHANISM OF SUPPORT
 
This RFA will use the RO1 mechanism.  Responsibility for the planning, 
direction, and execution of the proposed project will be solely that of the 
applicant.  

AHRQ is interested in development of longitudinal studies that will follow 
patients over time.  The initial funding period will be for projects of 3 to 5 
years.  The anticipated award date is September 29, 2000. 
 
This RFA is a one-time solicitation.  Future unsolicited applications (new and 
revised) may be resubmitted to the Agency but will compete with all other 
investigator-initiated applications and be reviewed according to customary 
peer review procedures.  

FUNDS AVAILABLE
 
AHRQ expects to award up to $1 million total costs (direct plus facilities and 
administrative (F&A) costs) in Fiscal Year (FY) 2000 to support the first year 
of approximately one to three projects under this RFA.  The actual number of 
applications funded is dependent on the number of high quality applications 
and their individual budget requirements; it is not the intent of AHRQ that 
the awards be equal in size. 

Although this program is provided for in the financial plans of AHRQ, awards 
pursuant to this RFA are contingent upon the availability of funds for this 
purpose.  

Funding beyond the initial budget period will depend upon annual progress 
reviews by AHRQ and the availability of funds.  

RESEARCH OBJECTIVES 

Background 

Domestic violence is defined as a pattern of assaultive and coercive behavior 
that adults use against their intimate partner.  Domestic violence is a public 
health problem affecting millions of women and their families each year.  It 
is the second leading cause of injuries and death among women of childbearing 
age (Grisso, 1991) and the leading cause of maternal mortality (Fildes, 1992) 
in at least two major cities.  Domestic violence is prevalent among all racial 
and ethnic minority groups and is not exclusive to one socio-economic strata.

The National Violence Against Women (NVAW) Survey in 1998 revealed that 25 
percent of surveyed women said they were raped and/or physically assaulted by 
an intimate partner in their life (Tjaden,1998).   The Survey estimated 
approximately 1.5 million women are raped or physically assaulted by an 
intimate partner annually in the United States.  Approximately one-third of 
the victims sustain an injury.  Further, in about one-third of all such injury 
victimizations, the victim receives some type of medical care. 

Domestic violence is a powerful predictor of increased health care 
utilization. (Bergman et al, 1991; Koss and Koss, 1991; Felitti, 1991).  
Domestic violence has physical and emotional consequences for victims and 
their children.  The consequences include acute injuries as well as chronic 
injury, chronic stress and fear, and lack of control over health care or 
support systems (Chalk and King, 1998).  These consequences are manifested in 
a range of medical, obstetric, gynecological, and mental health problems.  
Direct health care costs to victims of domestic violence is estimated to be in 
the range of 1.8 billion dollars per year (Miller et al, 1993).  One large 
health plan showed victims of intimate partner violence against women cost 
approximately 92 percent more than a random sample of general female enrollees 
(Wisner et al, 1999).

The health care system encounters the consequences of domestic violence in 
everyday clinical practice.  Current efforts of domestic violence 
interventions in health care have generated standards of care and major 
initiatives to increase provider awareness, establish and distribute clinical 
guidelines and to offer strategies for improving institutional responses to 
domestic violence (Wisner et al, 1999).  Comprehensive innovative intervention 
programs in health care are increasing in number.  In 1995, the Joint 
Commission on the Accreditation of Health Care Organizations (JCAHO) expanded 
its guidelines on emergency departments and hospital-
sponsored ambulatory care centers to encourage the development of staff 
education and protocols for the acute management of domestic violence 
(Oakbrook, 1998).  In 1998, the Institute of Medicine published a report on 
Violence in Families: Assessing Prevention and Treatment Programs (Chalk et 
al, 1998).  The report characterized what is known about intervention efforts 
and developed guiding principles for the development of future evaluations of 
family violence interventions.  The report concluded that scientific research 
does not provide clear guidance for determining the comparative effectiveness 
of specific efforts to prevent or treat family violence.  Given the important 
role health care systems can play in identifying patients at risk, preventing 
recurrences, and responding to the needs of domestic violence victims, the 
opportunity to evaluate the effectiveness of these interventions is critical.

Important aspects of the health care response to domestic violence include 
institutional adoption and implementation of model protocols and practice 
guidelines, routine screening for domestic violence, and on-site capacity to 
provide safety assessment and planning, medical documentation, identification 
of community resources, assessment and treatment of medical and mental health 
problems and appropriate follow-up.


AHRQ is interested in understanding the key components of effective 
identification and intervention programs in health care systems.  AHRQ is also 
interested in development of longitudinal studies that will fully assess the 
impact of the intervention programs with immediate and long-term outcomes, 
multiple time periods, both self-report and observational measures, and 
different levels of outcomes.  A combination of quantitative and qualitative 
data measuring the impact of domestic violence intervention strategies could 
be included.  Core questions of greatest interest are:

1)  Assessment of effectiveness: Does the intervention improve a woman=s 
health and safety and sense of safety?  Does the intervention improve 
detection of women at risk?  Does the intervention prevent or reduce the 
recurrence of domestic violence?  Does the effectiveness of the intervention 
vary by subgroup (racial or ethnic background, socioeconomic status, or 
community of residence e.g., inner-city and rural areas)?

2)  Assessment of health care utilization and cost: Does the intervention 
predict or improve health care utilization patterns?  Does the type or cost of 
services used by victims change following treatment interventions?   Is the 
intervention cost-effective?  (Types of analysis which are sought include cost 
analyses distinguishing between direct and indirect service costs of the 
program on the health care services used by victims of abuse; the impact of 
domestic violence on the use of physical, mental, and social services by 
victims; cost implications for the core health care programs; the costs and 
benefits associated with integrated service records and more comprehensive 
record management, especially in managed care settings; the extent to which 
episodes and histories of violence can be tracked).  

Related areas also of interest include:

3)  Assessing improvement in provider behavior: Has provider behavior, 
knowledge, and attitude improved?  Has the number of eligible women screened, 
identified, and receiving interventions increased?  Has the documentation and 
case management improved?  To what extent is provider behavior influenced by 
patient characteristics including race or ethnicity, socioeconomic status or 
community of residence (e.g., inner-city and rural areas)?

4)  Assessment of community linkages: Has the intervention improved linkages 
between individual health services, social support networks, community 
resources, and more comprehensive prevention efforts?  What linkages between 
screening efforts and treatment work best?

Research Methods

The studies are encouraged to have an experimental or quasi-experimental 
longitudinal design, including measurable outcomes and a comparison group.   
Study design must include provisions for following the use of health care 
services for abuse victims for a period of at least 3 years, and a plan to 
establish capacity to follow victims over a longer period of time.

SPECIAL REQUIREMENTS 


Applicants are expected to develop collaborative partnerships between academic 
researchers, health plans and service providers, and community specific 
programs responding to domestic violence, with each partner contributing to 
the substantive operation of the proposal.  The nature of the partnership, 
including the contribution of each and financial agreements shall be 
explained.  If the grantee is a health care system that is proposing to 
establish referral linkages with domestic violence or social service providers 
in the community, then both programmatic and financial reimbursement 
provisions shall be clearly outlined.  

If more than one project is funded, it is AHRQ=s expectation that projects 
will use common measures to increase the usefulness of study findings.  All 
funded grantees will be expected to work together to discuss common data 
elements and measures to the maximum extent feasible.  To this end, the 
investigators will have an initial meeting and subsequent annual one-day 
meetings convened by AHRQ in Rockville, MD.  All applicants should include 
annual travel costs for one researcher in the budget allowance. 

Evidence of Satisfactory Progress

While it is the intent of AHRQ to fund applications for the maximum period 
applied for, after two years, the grantee may undergo an external peer review 
to provide evidence of satisfactory progress for funding beyond a three year 
period.  Interim progress measures may include progress in accrual of 
sufficient numbers of domestic violence victims necessary to proceed with a 
valid study; development of record-keeping systems that protect patient safety 
and confidentiality while providing research data on the types and extent of 
abuse suffered by the patient, and on the cost and use of physical and mental 
health care services over time.

Data Privacy

Pursuant to section 903(c) of the Public Health Service Act (42 USC 299a-
1(c)), information obtained in the course of any AHRQ-study that identifies an 
individual or entity must be treated as confidential in accordance with any 
promises made or implied regarding the use and purposes of the data 
collection.  Applicants must describe in the Human Subjects section of the 
application procedures for ensuring the confidentiality of such identifying 
information.  The description of the procedures should include a discussion of 
who will be permitted access to the information, both raw data and machine 
readable files, and how personal identifiers and other identifying or 
identifiable data will be safeguarded.

The grantee should ensure that computer systems containing confidential data 
have a level and scope of security that equals or exceeds those established by 
the Office of Management and Budget (OMB) in OMB Circular No. A-130, Appendix 
III - Security of Federal Automated Information Systems.  The National 
Institute of Standards and Technology (NIST) has published several 
implementation guides for this circular.  They are: An Introduction to 
Computer Security: The NIST Handbook; Generally Accepted Principals and 
Practices for Securing Information Technology Systems; and Guide for 
Developing Security Plans for Information Technology Systems.  The circular 
and guides are available on the web at
http://csrc.nist.gov/publications/nistpubs/800-12/handbook.pdf.    

The application of these standards to subcontractors and vendors should be 
addressed as necessary.


Important legal rights and requirements applicable to AHRQ grantees are set 
out or referenced in the Agency=s grants regulations at 42 CFR 67, Subpart A.

Rights in Data

AHRQ grantees may copyright or seek patents, as appropriate, for final and 
interim products and materials including, but not limited to, methodological 
tools, measures, software with documentation, literature searches, and 
analyses, which are developed in whole or in part with AHRQ funds.  Such 
copyrights and patents are subject to a Federal government license to use and 
permit others to use these products and materials for AHRQ purposes.  In 
accordance with its legislative dissemination mandate, AHRQ purposes may 
include, subject to statutory confidentiality protections, making research 
materials, data bases, and algorithms available for verification or 
replication by other researchers; and subject to AHRQ budget constraints, 
final products may be made available to the health care community and the 
public by AHRQ, or its agents, if such distribution would significantly 
increase access to a product and thereby produce public health benefits.  
Ordinarily, to accomplish distribution, AHRQ publicizes research findings but 
relies on grantees to publish in peer-reviewed journals and to market grant-
supported products.

Important legal rights and requirements applicable to AHRQ grantees are set 
out or referenced in the AHRQ=s grants regulation at 42 CFR Part 67, Subpart A 
(Available in libraries and from the GPO=s website 
http://www.access.gpo.gov/nara/cfr/index.html).

INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY POPULATIONS

It is the policy of AHRQ that women and members of minority groups be included 
in all AHRQ-
supported research projects involving human subjects, unless a clear and 
compelling rationale and justification are provided that inclusion is 
inappropriate with respect to the health of the subjects or the purpose of the 
research.  In addition to these populations, AHRQ is also interested in 
supporting research that includes other priority populations, e.g., rural, 
inner-city, or elderly. 

All investigators proposing research involving human subjects should read the 
"NIH Guidelines on the Inclusion of Women and Minorities as Subjects in 
Clinical Research," which have been published in the Federal Register of March 
28, 1994 and in the NIH Guide for Grants and Contracts of March 18, 1994 .  To 
the extent possible, AHRQ requires adherence to these NIH Guidelines.

Investigators may obtain copies from the above sources or from the AHRQ 
contractor, listed under INQUIRIES, or from the NIH Guide Website 
http://grants.nih.gov/grants/guide/index.html.


AHRQ also encourages investigators to consider including children in study 
populations, as appropriate.  AHRQ announced in the NIH Guide of May 9, 1997, 
that it is developing a policy and implementation plan on the inclusion of 
children in health services research.   This Notice is available through the 
AHRQ Website http://www.ahrq.gov (Funding Opportunities) and InstantFAX (see 
instructions under INQUIRIES).

AHRQ Program staff may also provide additional information concerning these 
policies (see INQUIRIES).

LETTER OF INTENT

Prospective applicants are asked to submit, by March 24, 2000, a letter of 
intent that includes a descriptive title of the proposed research, the name, 
address, and telephone number of the Principal Investigator, the identities of 
other key personnel and participating institutions, and the number and title 
of the RFA in response to which the application may be submitted.  

Although a letter of intent is not required, is not binding, and does not 
enter into the review consideration of any subsequent application, the 
information allows AHRQ staff to estimate the potential review workload and 
avoid conflict of interest in the review.  AHRQ will not provide responses to 
letters of intent.

The Letter of Intent is to be sent to Charlotte A. Mullican, M.P.H. (see 
address under INQUIRIES)

APPLICATION PROCEDURES
 
The research grant application form PHS 398 (rev. 4/98) is to be used in 
applying for these grants.  State and local government applicants may use PHS 
5161-1, Application for Federal Assistance (rev. 5/96), and follow those 
requirements for copy submission.  

Application kits are available at most institutional offices of sponsored 
research.  They may also be obtained from the Division of Extramural Outreach 
and Information Resources, National Institutes of Health, 6701 Rockledge 
Drive, MSC 7910, Bethesda, MD 20892-7910, telephone (301) 435-0714, E-mail: 
grantsInfo@nih.gov.

AHRQ applicants are encouraged to obtain application materials from the AHRQ 
Publications Clearinghouse  (see INQUIRIES).

The RFA label and line 2 of the application form PHS 398 (rev. 4/98) should 
both indicate RFA number.  The RFA label must be affixed to the bottom of the 
face page.  Failure to use this label could result in delayed processing of 
the application such that it may not reach the review committee in time for 
review.  In addition, the RFA title and number must also be typed on line 2 of 
the face page and the YES box must be marked.  The sample RFA label available 
at http://grants.nih.gov/grants/funding/phs398/label-bk.pdf has been modified 
to allow for this change.  Please note this is in pdf format.


Applicants are encouraged to read all PHS Form 398 instructions prior to 
preparing an application in response to this RFA.

The PHS 398 type size requirements (p.6) will be enforced rigorously and non-
compliant applications returned.

Submit a signed, typewritten original of the application, including the 
Checklist, and three signed, photocopies, in one package to:
 
Center for Scientific Review
National Institutes of Health
6701 Rockledge Drive, Room 1040 - MSC 7710
Bethesda, MD  20892-7710
                         (20817 for express/courier service)
 
At the time of submission, two additional copies of the application, labeled 
AAdvanced Copy (s)@ must also be sent to:

Charlotte A. Mullican, M.P.H.
Center for Outcomes and Effectiveness Research
Agency for Healthcare Research and Quality
6010 Executive Blvd., Suite 336
Rockville, MD  20852
Telephone:  (301) 594-0382
FAX: (301) 594-3211
Email: cmullica@AHRQ.gov

Applications must be received by April 27, 2000.  An application received 
after the deadline may be acceptable if it carries a legible proof-of-mailing 
date, assigned by the carrier, and the proof-of-
mailing is not later than 1 week prior to the deadline date. If an application 
is received after that date, it will be returned to the applicant without 
review.  

Application Preparation (for Using HCFA Data) 

For applications that propose to use Medicare or Medicaid data that are 
individually identifiable, applicants should state explicitly in the Research 
Design and Methods section of the Research Plan (form PHS 398) the specific 
files, time periods, and cohorts proposed for the research.  In consultation 
with the Health Care Financing Administration (HCFA), AHRQ will use this 
information to develop a cost estimate for obtaining the data.   To avoid 
double counting, applicants should not include the cost of the data in the 
budget. 

Applicants should be aware that for individually identifiable Medicare and 
Medicaid data, Principal Investigators and their grantee institutions will be 
required to enter into a Data Use Agreement (DUA) with HCFA to protect the 
confidentiality of data in accordance with standards set out in OMB Circular 
A-130, Appendix IIIBSecurity of Federal Automated Information Systems.  The 
use of the data is restricted to the purposes and time period specified in the 
DUA.  At the end of this time period, the grantee is required to return the 
data to HCFA or certify that the data have been destroyed.  

Grantees must also comply with the confidentiality requirements of Section 
903(c) of the PHS Act.  See the Data Privacy section for details on these 
requirements as well as references to Circular A-130 and its implementation 
guides from the National Institute of Standards and Technology.

In developing research plans, applicants should allow time for refining, 
approving, and processing their data requests.  Requests may take 6 months 
from the time they are submitted to complete.  Applications proposing to 
contact beneficiaries or their provider require the approval of the HCFA 
Administrator and may require meeting(s) with HCFA staff.

HCFA data are provided on IBM mainframe tapes using the record and data 
formats commonly employed on these computers.  Applicants should either have 
the capability to process these tapes and formats or plan to make arrangements 
to securely convert them to other media and formats.

Questions regarding HCFA data should be directed to the AHRQ program official 
listed under INQUIRIES.

REVIEW CONSIDERATIONS
 
Upon receipt, applications will be reviewed for completeness and 
responsiveness.  Incomplete applications will be returned to the applicant 
without further consideration.  If the application is not responsive to the 
RFA, AHRQ Referral staff may contact the applicant to determine whether to 
return the application to the applicant or hold it for review in competition 
with unsolicited applications at the next review cycle.  Applications that are 
complete and responsive to the RFA will be evaluated for scientific and 
technical merit by an appropriate peer review group convened by AHRQ in 
accordance with the review criteria stated below.

As part of the merit review, all applications will receive a written critique, 
and also may undergo a process in which only those applications deemed to have 
the highest scientific merit will be discussed and assigned a priority score. 
 
General Review Criteria
 
The criteria to be used in the evaluation of grant applications are listed 
below.

The goals of AHRQ-supported research are to enhance the quality, 
appropriateness, and effectiveness of health care services, and access to such 
services.  The reviewers will comment on the following aspects of the 
application in their written critiques in order to judge the likelihood that 
the proposed research will have a substantial impact on the pursuit of these 
goals.  Each of these criteria will be addressed and considered by the 
reviewers in assigning the overall score, weighting them as appropriate for 
each application.  Note that the application does not need to be strong in all 
categories to be judged likely to have a major scientific impact and thus 
deserve a high priority score.  For example, an investigator may propose to 
carry out important work that by its nature is not innovative but is essential 
to move a field forward.
 

1.  Significance.  Does this study address an important problem? If the aims 
of the application are achieved, how will scientific knowledge be advanced?  
What will be the effect of these studies on the concepts or methods that drive 
this field?
 
2.  Approach.  Are the conceptual framework, design, methods, and analyses 
adequately developed, well-integrated, and appropriate to the aims of the 
project?  Are the proposed data sources appropriate and adequate?  Does the 
applicant acknowledge potential problem areas and consider alternative 
tactics?
 
3.  Innovation.  Does the project employ novel concepts, approaches or method? 
 Are the aims original and innovative? Does the project challenge existing 
paradigms or develop new methodologies or technologies?
 
4.  Investigator.  Is the investigator appropriately trained and well suited 
to carry out this work?  Is the work proposed appropriate to the experience 
level of the principal investigator and other researchers (if any)?  Is the 
project (or work plan) well organized?
 
5.  Environment.  Does the scientific environment in which the work will be 
done contribute to the probability of success?  Do the proposed experiments 
take advantage of unique features of the scientific environment or employ 
useful collaborative arrangements? Is there evidence of institutional support?

The initial review group will also examine: the appropriateness of proposed 
project budget and duration; the adequacy of plans to include both genders, 
children, and minorities and their subgroups as appropriate for the scientific 
goals of the research and plans for the recruitment and retention of subjects; 
the provisions for the protection of human subjects; and the safety of the 
research environment.

The review group will also examine the extent of the collaborative 
partnerships developed between academic researchers, community-specific 
programs, health plans and service providers.

AWARD CRITERIA
 
Applications will compete for available funds with all other applications 
under this RFA.  The following will be considered in making funding decisions: 
1) quality of the proposed project as determined by peer review; 2) 
availability of funds; 3) program balance with respect to types of health care 
insurance and organizational delivery system features, enrollee versus 
community studies, populations studied, geography including rural/urban mix, 
regional representation, and targeting understudied areas with unmet 
evaluation needs; 4) compatibility with other awardees with respect to 
cooperative activities; and 5) policy relevance. 


INQUIRIES
 
Copies of the RFA are available from:

AHRQ Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907-8547
Telephone: 1-800- 358-9295

The RFA is also available on AHRQ=s Web site, http://www.ahrq.gov, and through 
AHRQ InstantFAX at (301) 594-2800.  To use InstantFAX, you must call from a 
facsimile (FAX) machine with a telephone handset.  Follow the voice prompt to 
obtain a copy of the table of contents, which has the document order number 
(not the same as the RFA number).  The RFA will be sent at the end of the 
ordering process.  AHRQ InstantFAX operates 24 hours a day, 7 days a week.  
For comments or problems concerning AHRQ, please call (301) 594-6344.

AHRQ welcomes the opportunity to clarify any issues or questions from 
potential applicants who have read the RFA.  Written and telephone inquiries 
concerning this RFA are encouraged.   Inquiries regarding programmatic issues, 
including information on the inclusion of women, minorities, and children in 
study populations should be directed to:
 
Charlotte A. Mullican, M.P.H.
Center for Outcomes and Effectiveness Research
Agency for Healthcare Research and Quality
6010 Executive Blvd., Suite 336
Rockville, MD  20852
Telephone:  (301) 594-0382
FAX: (301) 594-3211
Email: cmullica@AHRQ.gov

Direct inquiries regarding fiscal and eligibility matters to:
 
Joan Metcalfe
Grants Management Specialist
Agency for Healthcare Research and Quality
2101 East Jefferson Street, Suite 601
Rockville, MD  20852
Telephone: (301) 594-1841
FAX: (301) 594-3210
Email: jmetcalf@AHRQ.gov
 
AUTHORITY AND REGULATIONS
 
This program is described in the Catalog of Federal Domestic Assistance No. 
93.226.  Awards are made under authorization of Title IX of the Public Health 
Service Act (42 USC 299-299c-6).  Awards are administered under the PHS Grants 
Policy Statement and Federal Regulations 42 CFR 67, Subpart A,  and 45 CFR 
Parts 74 and 92.  This program is not subject to the intergovernmental review 
requirements of Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a 
smoke-free workplace and promote the non-use of all tobacco products.  In 
addition, Public Law 103-227, the Pro-
Children Act of 1994, prohibits smoking in certain facilities (or in some 
cases, any portion of a facility) in which regular or routine education, 
library, day care, health care or early childhood development services are 
provided to children.  This is consistent with the PHS mission to protect and 
advance the physical and mental health of the American people.

REFERENCES

Bergman B, Brismar B, 1991.  A 5-year Follow-up Study of 117 Battered Women, 
American Journal of Public Health, 81 (11):1486-1489.

Chalk R, King PA editors, 1998.  Health Care Interventions (Chapter 6); 
Violence in Families: Assessing Prevention and Treatment Programs; National 
Research Council and Institute of Medicine, 223-224.

Felitti VJ, 1991.  Long-Term Consequences of Incest, Rape and Molestation.  
Southern Medical Journal, 84:328-331.

Fildes J, Reed L, Jones N, Martin M, Barrett J, 1992.  Trauma: The Leading 
Cause of 
Maternal Death. J. Trauma, 32:643.

Grisso JA, Wishner AR, Schwarz DF, Weene BA, 1991.  A Population-Based Study 
of Injuries in Inner-City Women. Am J Epidemiol, 134:59.

Koss MP, Koss PG, Woodruff WJ, 1991.  Deleterious Effects of Criminal 
Victimization on Women=s Health and Medical Utilization.  Archives of Internal 
Medicine, 151:342-347.

Miller TR, Cohen MA, Rossman SB, 1993. Victim costs of violent crime and 
resulting injuries. Health Affairs, 12:186.

Oakbrook IL, 1998.  Joint Commission on Accreditation Manual for Hospitals: 
The Official Handbook.

Tjaden P, Thoennes N, 1998.  Prevalence, Incidence, and Consequences of 
Violence Against 
Women: Findings From the National Violence Against Women Survey; National 
Institute of Justice/Center for Disease Control Research in Brief.  November.

Wisner CL, Gilmer TP, Saltzman LE, Zink TM, 1999.  Intimate Partner Violence 
Against Women: Do Victims Cost Health Plans More?  Journal of Family Practice, 
48:439-443.


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