 All right, folks, I think we should get started. Thank you so much for coming out today on this beautiful day, actually, it's kind of a treat. So I'm Sheetal Wildman. I'm Associate Director of the Health Justice Institute. And delighted to be with you here today in the beautiful sunny Magma, the traditional and unceded territory of the Magma people. We are grateful for the wisdom of the Magma elders and their teachings, and we acknowledge the ongoing legacies of colonial violence, including in our institutions devoted to promoting health and education. We recognize, too, that African Nova Scotians are distinct people whose histories, legacies, and contributions have enriched that part of Magma Nghi, known as Nova Scotia, for over 400 years. Today's speaker is Professor Alexa Jakubovic. She's an assistant professor in community health and epidemiology here at Hellhousie and is cross-appointed in gender and women's studies. Dr. Jakubovic is also an affiliate scientist at Nova Scotia Health. She holds a PhD in evidence-based social intervention and policy evaluation from the University of Oxford. Dr. Jakubovic's research focuses on what causes and can prevent interpersonal violence, and especially intimate partner and sexualized violence. This includes investigations of the social and structural determinants of violence and its health impacts, as well as the design and evaluation of interventions that account for these determinants. So issues and questions, inquiries that affect all of us here in Nova Scotia and beyond, and we're so grateful to have, really, from our own backyard, Dr. Jakubovic with us here today to share her work. So without further ado, welcome. Thank you. Thank you. Okay, thank you so much for having me. And I'm really looking forward to this conversation. You'll notice right away on my title slide, I have preliminary results. You'll see as I'm presenting, this is very new data. So I'm really excited to be having a first conversation, actually, with these particular set of data, and I'll be very interested to hear your questions and any feedback and comments you have. So what we're gonna be focusing on today is how the health system is responding to violence against women in Nova Scotia. So I'm gonna start by giving a little bit of background around intimate partner violence in Canada. Intimate partner violence, or IPV, is the most common form of violence against women. In 2019, there were over 100,000 victims, the police reported IPV, 79% of whom were women. Between 2014 and 2019, there were 497 victims of intimate partner homicide, 80% of whom were women. Women who are indigenous or visible minorities are at a particularly high risk for IPV and intimate partner homicide. And while we can see that the vast majority of victims of this violence and fatal violence in particular are women, we also know that sexual and gender minorities are disproportionately affected by IPV. So we can see just by looking at these statistics in Canada, these numbers are similarly reflected around the world, that taking a gender-based approach to preventing intimate partner violence is very important. The numbers are even more dramatically gendered when we look at sexualized violence. I'm gonna also provide a little bit of context around IPV in Nova Scotia. Of course, if you've been reading the news, you're well familiar that this has really been a major political and public issue in Nova Scotia since the pandemic started. But Nova Scotia is the home to the greatest number of women who self-report experiencing IPV among all Canadian provinces. We currently have the highest provincial rate of homicide, which is the killing of women with a sex or gender motive. And Nova Scotia is the site, of course, of the country's worst mass killing, which was rooted in misogyny and IPV. So given where there are some in our series and where we are today, I wanna take a moment really to provide some background around the role of law and policy in understanding how it determines violence. Typically, in public health and in healthcare, we think about the social determinants of violence. So the biological, behavioral, psychosocial, or material factors that impact the distribution of health and wellbeing in society. But it's actually really important to take a step back and think about what are the causes of the social determinants of health in and of themselves. And this is where law and policy fits in under the structural determinants of health, including the socioeconomic and political context and the distribution of resources, power, and prestige in society. And when we understand law and policy in this way, we can see that there are two primary pathways that they can influence whether violence occurs. That's by influencing behavior that leads to violence, but it's also by influencing systems and how they respond to violence and then how this impacts people's access to support and then whether they're able to get out of higher situations. So the work that I'm gonna share today is more focused around this secondary pathway, looking at systems responses. But when we're thinking about recommendations from this work, we can take a step back and think a little bit more about that primary pathway as well. So of course, when we think about how law and policy can impact violence, COVID-19 is a very important example. We know that since March 2020, the rates of domestic and sexualized violence increased as a result of the pandemic. And this is in line with increases we've seen in previous public health emergencies. In part, this is because of policies like physical distancing and lockdown, which were very important to promoting public health but have the unfortunate consequence of impacting people who are at risk of experiencing violence or who were experiencing violence and ended up having to physically isolate with their users and having very little means of escaping that violence. At the same time, there have been a number of other recent events across the country over the same time period that has brought new public and political attention to these issues. That includes the national action plans and gender-based violence, which was announced in Nova Scotia November 2022. It also includes the Mass Casualty Commission and its recommendations and most recently, the Desmond Vitality Inquiry. In addition, you'll see in that top left corner a photo from the Redford County Inquest. This was an inquest that occurred in Ontario into the homicide of three women killed by their ex-instrument partner that has led to over 70 municipalities across the province declaring intimate partner violence against women and epidemic. So with all of these new events, judicial events, new policy initiatives, and of course, the impact of the COVID-19 pandemic, we have seen an increase in the number of initiatives, policies and interventions that have been implemented to respond to domestic and sexualized violence. But we don't really know a lot about how they're working, what is happening and how well they are meeting the needs of the survivors. And that's where my research project comes into play. In particular, I'm leading the Interprovincial Bonds Against Women Project or the IPV project, which is conducting surveys and interviews with Bonds Against Women or BAW survivors and the staff who support them across Nova Scotia, New Frontswick and Ontario. And our goal is first to investigate how and why supportive services for BAW survivors have adapted since March 2020 and how all these data patients are meeting the needs of survivors, including those facing different forms of marginalization, whether that's racism, whether that's being a caregiver, a solo caregiver, children, whether that's disability, immigration status, et cetera. So we're looking across a variety of different social factors. And then we aim to take that knowledge and to develop contextualized best practice recommendations for service delivery and policy, both in the midst of the COVID-19 pandemic and looking in the post-pandemic world. And when we say contextualized, we mean based on the relevance to different jurisdictions and population groups. And as we develop these recommendations, we're thinking about service organizations, pro-sector partners, funders, and all levels of government. So in the remainder of my talk, I'm going to go over the methods of the project and then we're gonna talk about our results and specifically what we have learned about the health needs and outcomes of VAW survivors since March 2020 and what the current capacity of the health system is to address these needs. And then we'll have some time to talk about next steps and then have some discussion. So the research team for this project is based at Dell Housing and includes partners from UNB, U of T, and then several hospitals in Ontario. A critical piece of the project is that we have an inter-provincial advisory group, which is made up of violence against women organizations, and provincial government representatives from across our three provinces. And in addition, we have the health advisory group specific to Nova Scotia. So our overall project is supported by the Canadian Institutes of Health Research and we have a specific health arm to the study that's funded by Nova Scotia Health. And so that piece includes a health system advisory group with representation from across NSH, ILUK, provincial government, and community health organizations like the Health Association of African Canadians. So there's two stages of data collection to this project. The first was a short online survey and that was delivered across Nova Scotia from Brunswick and Ontario to survivors who have access or wanted to access BW services since March 2020, as well as direct support of leadership staff working on those services. And then the second piece to our survey was a survey they went out to healthcare providers and decision makers in government, healthcare, public health, or community health organizations in Nova Scotia. The next round of data collection is in-depth virtual interviews and focus groups to really dig in deeper to the results that we found in our survey. And this is gonna be conducted with a subset of participants who've completed the survey to indicate they want to be followed up with. We're in the fortunate situation of having hundreds and hundreds of people who wanna be followed up with so we will only be selecting a purposive sample based on different socio-demographic characteristics and also what type of work they're doing or what type of services they've accessed and where they've accessed those services or where they're working. This is also an integrated knowledge translation project. So as we collect our data, we feed it back to community, policy, and practice partners, which is also why I'm able to so rapidly share this information with you all today. In terms of how we recruited our participants, we circulated our emails and posters through professional associations and networks. We emailed and called organizations and contacts and we attended meetings and events to share more about the project. In addition, for our VAW surveys, we also used social media and some in-person data collection with organizations and new friends like who really needed more tech support for their clients. For our health survey, we used registries to contact professionals and programs within priority areas. And specifically what that meant was going through the registry for all licensed health professional groups in the province who are more likely to see patients or clients who've experienced violence. And then when those people were in medical professions like nurses or physicians going through priority program areas. So this was, it's very nicely and neatly summarized in this slide, it was months and months of work by five different team members. So a huge amount of work went into survey recruitment. The first VAW survey ran from November 2022 to November 2023. And then shortly after that, our health survey was open for three months and just closed on Monday. So again, you can see the speed at which we have been analyzing these data. I wanna take a moment to talk about data quality because I feel like this is very underappreciated when people present or share online research. Data quality is a huge issue, especially now for proliferation of online research. And so you should always be skeptical when someone just presents online results and doesn't talk about this at all. We knew that we were at high risk for survey fraud with our online research. And especially with our VAW survey being advertised on social media, we took a number of different steps to prevent fraudsters or bots from infiltrating the survey, which included downloading all the data as it came in and having multiple people screen the data. It was fortunate we did this because we were hit by over 4,000 survey bots early in data collection, which we were able to address immediately, but still an issue we had to manage. And through that, we developed an even more rigorous validation protocol which involved three screeners who went through every single survey response. So again, be skeptical when someone just presents you online research results and doesn't mention this and feel free to ask them about their data quality assessment. So across our three included provinces, we have had over 2,300 participants representing 160 municipalities and over 200 organizations. So I'm gonna tell you a little bit about where our participants come from. And I'll talk about all three participant groups, but from here on in, we're gonna focus more on our VAW survivors and the health professionals who took our surveys. So we had 465 VAW staff participants, 75% approximately were direct support and then the remaining quarter were leadership. And we see for both participant groups, about two thirds a little bit over for direct support were coming from Ontario and then the remaining third split between Nova Scotia and New Brunswick. We had 191 survivor participants. This is a little bit closer to 50-50 between Nova Scotia and Ontario with a smaller proportion from New Brunswick. And that really reflects challenges that researchers across New Brunswick have been facing and engaging funds against women organizations and why we did that extra in-person data collection. This, that could be a whole talk in and of itself talking about that experience. We do have a significant number of our participants who work only in or live only or are accessing services only in rural and remote areas. Many more are accessing across rural and urban but this subset of our sample allows us to dig a little deeper at the challenges that might be experienced by people only living, working and accessing services within rural and remote. For our health survey, we had over 1,600 surveys that were at least partially completed and we had an 81% completion rate with over 1,300 fully completed surveys and we are able to analyze all of the available data with the survey, which is really fantastic. We have representation from all the different health zones. Of course, the most common being the central zone but we see representation from all other health zones as well and in very good numbers. And again, with our health survey, we have participants who are only servicing or focusing on rural and remote areas in their work. This is just a map to show you how representative the survey was across the province. We have representation from 85 communities and 50% of the sample are from outside HRM. So a little bit about the demographics of our sample. So for survivors, we have about 27% identifying as an ethnic or racialized minority and 14% identifying as indigenous. The remaining 59% identified as white and actually these numbers are not mutually exclusive so people can identify across different racial categories and 21% are born outside of Canada. In terms of gender identity, we do see most of the sample identify cis women, 5% identified as gender minority and just a birth order identified as a sexual minority. In terms of age and socioeconomic factors, the average or the median age was 37. Just under 15% have an education above a bachelor's degree and a third of the sample have high school education or less. Most of the sample have children living with them and we'll talk a little bit more about that. And then 35% have household income less than 20,000. So quite a socioeconomically marginalized group. Our health professional sample, as expected, summing up quickly, wider, less, more of them were born in Canada. The vast majority of notice and relevance are women and especially cis women. A smaller number are identifying as sexual minority and they tend to be a bit older and they have higher education. Okay, so getting into results. What have we learned about the health needs and outcomes of the AW survivors since March 2020? So 70% of our survivor participants were single at the time of the survey. This is expected. We know that separation is the highest risk period for women to experience violence and severe violence. And of course, being that this is largely a service access population, many of our participants had left abusive relationships. Of note, they haven't all only experienced IPV. Many of them have experienced violence from different people in their lives. Among those who are currently in a relationship, one in two of our participants began seeing their partner after March 2020. So this is interesting because sometimes we see in samples of survivors, they've been in relationships for decades. In this case, this is a very kind of fluctuating relational sample. 91% of survivors reported that their partners were men and 9% reported they were women or gender diverse. So going back to the piece around children, 55% of survivor participants had children living with them, an average of two children, but 70% of those who have children living with them are living along with their children. So really speaking to the caregiving burden among this population. And again, this has relevance to the services that survivors were able to access. So for instance, you can't always easily get into shelter when you have children living with you. And of course, this also impacts people's health needs and their psychosocial well-being, which we're gonna talk about very shortly. In terms of where survivors are living, 20% were living in a place that they or their partner owns. 80% of the remaining participants were either in shelter, 16%, 65% were renting or living with someone who is renting. And importantly, of those who were renting, one in two were living in social housing, rentier to income or otherwise subsidized housing. Again, this is really important. There's been a lot of discussion in the media lately around people experiencing homelessness. Women often get excluded from these conversations because women's experiences of homelessness and housing precarity is much less visible. Intimate partner violence is the most common reason for women to experience homelessness. So when we think about the needs both health and social needs of violence against women survivors, we need to be thinking about housing and including them in these conversations as well. So we asked participants to tell us about the impact of the pandemic on their ability to meet their financial obligations like rent as well as utilities and groceries. And 78% of our participants indicated the pandemic has had a moderate or major impact on their financial ability. I also wanna share our data around experiences of intimate partner violence, intimate partner violence has severe consequences for women's health as I'm sure people can imagine. It can lead to injury. It can lead to mental health problems and it can also lead to chronic pain and disease among other conditions. So understanding the extent to which people are experiencing violence is directly related to their health needs. What I'm gonna show you are items from the Composite Abuse Scale, which is a standardized scale for measuring experiences of intimate partner violence and measures physical, psychological, and financial violence. And so the items you see are gonna be color coded based on the type of violence they're measuring and the items are gonna be ordered in terms of the most commonly reported as being experienced since March, 2020 to the least commonly. It's an overwhelming amount of data but what I wanna highlight here is when you look at that top number 66% and you look at that bottom number 19%. Those are still very high numbers. This is a very high proportion of our sample who's experiencing almost every single type of violence that we measure. When you look at that last item, confined or locked in a room or other space, that's a very severe form of abuse and also one we could imagine would have been exacerbated by the pandemic. So of course, these experiences of violence are absolutely impacting the health needs of survivors and those seeking services. And when we look across the violence we see that three quarters of our participants had experienced any IPV since March, 2020 alone and 60% had experienced any IPV in just the last 12 months. So in light of all of this, when survivors reported on their health status they reported very poor health. Just under a third of our survivors rated their health as fair or poor which is the bottom of the five point scale. Almost three quarters reported often are always experiencing a disabling condition most commonly emotional, psychological or learning related. And over half reported that their health was worse during the pandemic and over a third reported using more alcohol or other substances. And of note, this is a population with very high rates of alcohol or substance use. So over a third scored at the high end of an alcohol use disorder scale indicating hazardous drinking. Over a quarter are using illicit drugs. 9% have an opioid prescription, 7% are injecting drugs and 6% experienced an overdose just since March, 2020. So again, of course, all of these things are having the impact on survivors' mental health. This is a comparison in the symptoms survivors reported experiencing in the two weeks prior to taking the survey and at the height of the pandemic. So blue is in the last two weeks, purple is at the height of the pandemic and we have scores for anxiety symptoms and depressive symptoms. And you can see that the purple bars are higher which indicates that anxiety and depression was worse at the height of the pandemic. But you can also see that line that cuts across which is the clinical cutoff to examine for potential clinical diagnosis for anxiety or depression. And regardless of whether we're looking at in the last two weeks or at the height of the pandemic survivors are almost at that threshold or surpassing that threshold at both time points. Likewise, when we look at their total scores on the scale those are divided into none, mild, moderate and severe. We can see that in the last two weeks survivors are sitting well into the moderate range. And when we look at the height of the pandemic they're getting into that severe category. So in light of survivors health needs we see a large proportion of our sample that we're trying to access both BAW services and healthcare services. These are the most common supports that our participants reported trying to access since March 2020. Again, just hitting home with that housing piece I wanna emphasize this was the most commonly reported support or service that survivors wanted to access but we're not able to. 23% wanted housing support and 26% wanted permanent supportive housing. We also see high rates of healthcare service usage. So these are services that participants accessed and then those that they said they wanted to but were unable to access. And we can see that the top three services survivors access were also those they most commonly wanted to but weren't able to access. This is mental health and addictions to family physician and sexual assault aftercare. In light of what we know in the population and what we see in our sample that many of survivors don't have access to family physician. We also saw very high rates of emergency department usage. So 37% of survivors over one third access an emergency department just in March 2020. And this is a quote that I think really highlights the challenges that survivors have faced in trying to access healthcare service. Services is from one of our participants who shared I've gone to the ER when on the darker end of suicidal thoughts to sit for 45 minutes without even being greeted. At a range was saying a sexual assault nurse examiner to go in for an exam and X-rays to ensure there was no internal damage from being sexually assaulted. It took weeks before I could commit to going. When I went, the triage nurses wouldn't go get the same who was just around the corner. They wanted me to sit in a path waiting room. I explained my situation visibly shaking into stress and I ended up leaving not getting any of the tests I needed done. Now I share this because obviously this very powerfully demonstrates what it is like once you are able to get into a healthcare service what it is like once you're actually there for many survivors. It is a re-traumatizing experience. I don't share this to put the blame on individual healthcare providers or really sit the problem there. Really, this is a systemic issue and we're gonna move into what is the current capacity of the health system to address this with the goal of thinking about how we can address these issues from a systemic and structural approach. So finally just reflecting all that we've seen in the survivor data. We asked both survivors and BW staff to indicate what are the most common outcomes that survivors or their clients are experiencing since the pandemic started. The top three outcomes were all negative outcomes despite there being both negative and positive outcomes on the list and they were survivors feeling a lower sense of power experiencing a stalling or reversal in feeling and increased difficulty in navigating available services and resources. Okay, so now I'm gonna move into what is the current capacity of the health system to address these needs. Again, I wanna contextualize the data I'm gonna share in terms of who participated. So of our over 1,600 participants, we have 64% coming from Nova Scotia Health and then the remainder coming from the IWK, Provincial Government and Community Organizations and Private Clinics. Now, I mentioned the survey was open to anyone working at these different organizations but we did also do targeted reach outs to program areas where we knew people are more likely to see patients who've experienced violence. And so we see that reflected in our participants. So most of our participants coming from mental health and addictions and primary health care as well as maternity and child health care services and emergency and critical care. We see smaller numbers for community health and those involved in sexual domestic violence response like sexual assault versus examiners and those working at sexual and reproductive health care services. But this is also reflected of the fact that these are much smaller organizations and services. So actually we see very high response rates from these groups, which is what we had hoped for. Also, this is where some of our remaining participants come from in terms of their areas of work. And while these were some of the areas we targeted, the ones on the left were kind of like the highest priority for us, but we're still very happy to see participation from long-term care, children's health, general public health programs, surgery, rehab, restorative and chronic pain services, patient safety and dietetics and nutrition. And we also have 18 senior leadership from Nova Scotia Health, IWK and Provincial Government. In terms of the rules that our health survey participants hold within the health system, the vast majority are engaging directly with patients, community members or clients, so 86%. A third are managing or leading people who are providing direct support and then 9% are doing neither of these direct support rules and they're working more in the space of policy, research and program development. 80% of the sample has clinical training, the majority of which were nurses, we also have quite a bit of representationalist, 200 physicians, over 150 social workers and then we also have psychologists, occupational therapists, counselors, healthcare assistants and many more. We have a number of people who indicate other training areas and we're rapidly cleaning that data so we can share some of the other rules involved with that includes, for instance, speech language pathologists, community pharmacists, dentists, dental hygienists and dental assistants and more. So we ask participants, actually before I kind of get into this data, I now just want to contextualize that sample and kind of help with the interpretation of these findings. So I'm sure some of you are thinking to yourself, it's a convenience sample, is it representative, is it a random sample? How much faith do we put into these numbers? And even if you aren't thinking that, now you're thinking it. So I want to think about, how can we understand the data that we're seeing? So if you see a survey on domestic and sexualized violence, it is more likely that you're going to participate if you care about these issues, if you're working around these issues, if you're committed to doing the work to respond to these issues. So we would expect that when we're looking at these data, we're going to see higher levels of knowledge, more preparedness to respond, and people who are doing more in the health system around these issues. So in a sense, we then can think that this is kind of on the higher end in terms of knowledge, experience, and practice, and capability to respond to these violence. So to this violence. So what we would imagine then, what we would see generally in the health system is much lower knowledge. We would expect to see less preparedness to respond to people who are doing less. So I say that because I think that will help you understand the import of some of our findings. So we ask people, how much do you know about the prevalence of domestic and sexualized violence in Nova Scotia? 61% said none or a little bit. We ask how much do you know about your role in responding to or preventing domestic and sexualized violence, and half reported none, a little, or it's not applicable to my work? We then asked people to rate their level of agreement with the statement, I know which organizations and resources to refer to if issues of domestic or sexualized violence come up in my work. And 40% said they weren't sure or they strongly disagreed. Now, we asked six knowledge testing questions around domestic and sexualized violence. And our participants did quite well on these knowledge testing questions. So the median score was four out of six. But I want to highlight the questions that people most commonly got wrong. The first is, to our false, policies that promote public health can exacerbate the occurrence of domestic or sexualized violence. Now, just in the examples I gave around COVID-19, physical distancing and lockdown, are policies that promoted public health but exacerbated domestic or sexualized violence. And 27% of our participants got this right, and nearly three quarters got this wrong. Now, I will say this is a question we came up with ourselves. The rest of the questions I'm going to share are standardized questions that have been evaluated in other studies. We will dig in and interviews how people interpreted this and why they got it wrong. But I will say that we actually were about to take this question out of the survey because we thought it was too easy for people. So I think it's really interesting, it's the question that people did the worst on. This is really impactful, though. What is the strongest single risk factor for becoming a victim of intimate partner homicide? The correct answer is female. Only 50% or just over 50% of the sample got this right. This, I'm surprised and I'm not surprised, but it is shocking as a researcher in this field, the rate of intimate partner homicide is six times higher among females and males. It's not even a comparison in terms of the magnitude of risk factor. So this is a really important one that unfortunately, almost half of the sample did not answer correctly. Now, in line with their overall good performance on knowledge-testing questions, we also see that our participants scored quite well in terms of victim understanding. So this comes from the physician writing this to respond scale, which we adapted to our survey as others have done in the past with different health professionals, and essentially higher scores on a scale from one to seven indicate better preparedness to respond. So this victim understanding scale is getting at victim blaming attitudes. So the fact that people are scoring quite highly on this scale suggests that they're not holding victim blaming attitudes, which is very good. However, when we look at the other sub-scales here, workplace issues and preparation, we see much lower scores. And this is really indicating that people don't feel supported by their workplace to respond to domestic and sexualized violence, and that they themselves don't have the skills to respond to this violence. And in light of that, we can look at the number or the proportion of our sample who reported that addressing domestic or sexualized violence was part of their teams or teams objectives or goals. And that was just over a third. So two thirds of the sample said that it's not part of their objectives or goals, or they're not sure. In particular, 21% said they don't know, and 44% said addressing violence is not part of their goals. This is really important because this variable in terms of whether people are working in a team or an organization that's addressing violence is correlated with the amount of training they have in terms of what practices they're implementing and in terms of their awareness of referrals and resources both in the community and at their work site. So it's very much going hand in hand in terms of how people are responding to violence. When people said that it wasn't part of their goals, they most commonly indicated because it's not relevant to their work, but also people commonly indicated there was a lack of awareness or education and a lack of leadership support on these issues. Now, three quarters of the sample have had at least some training on domestic or sexualized violence, but most commonly, this is very minimal. So it was classroom training from a professional degree. We know this is typically about one to three hours in a four-year program. Attending a lecture or talk, probably like what you're all doing today, or reading your institution's protocol. For 57% who said that they had had training, most of this was done before March, 2020. So on the one hand, we can look at this in a positive way, 43% have received training since the pandemic, probably because all of the different initiatives and by virtue of being newer to the health workforce, but at the same time, 57% have not received training in at least the last four years, 15% have not received training in more than 10 years. And then just under a third of those who directly see patients or clients or managed teams who do, are also screening for domestic or sexualized violence. 54% are screening all new patients, so taking a universal approach, and 36% are screening only those with abuse indicators taking a case-finding approach. Now, when you put all the numbers together and you think about the concerns that people have in terms of the capacity and support from their organization, the out-of-date training, this over one-third who are using abuse indicators in their work is a little bit concerning. Now, in terms of the abuse that people are seeing in their work, regardless of whether violence is part of their work, whether they reported screening, 43% of our participants reported they had seen at least one case of abuse in just the last six months. 12% reported they saw six or more cases in six months. Now, critically, of this 43% that saw at least one case of abuse, one and two said that addressing violence is not part of their team's objectives or they didn't know if they were, again, indicating that lack of organizational support and directives, and 40% had never had any training on domestic or sexualized violence. In terms of the barriers and facilitators to responding to violence, participants who screen or have seen recent cases of abuse indicated the most common challenges since March 2020 are an increased workload or staffing shortages and a decreased availability of supports to refer patients or clients to. Again, really speaking to that lack of systemic and organizational support. The most common opportunities, however, a glimmer of hope here, so more awareness amongst themselves or their team about domestic or sexualized violence being an issue among their patients. In addition, in line with what we've seen in a few studies that have come out around COVID-19, we see that visitor restrictions were a new opportunity that made it easier to ask patients about potential cases of violence. Now, of those who are screening for abuse or have seen recent cases, 42% indicated that they do not have adequate referral resources at their work site and 40% reported they don't have adequate knowledge of referral resources in the community. So again, speaking to that lack of organizational support about what to do when violence comes up. One of my last set of results, so 22% were involved in designing or implementing policies, programs or directives to prevent the spread of COVID-19. And as we've discussed, we know that these policies did impact violence against women and this is in line with what we've seen in previous public health emergencies. So it shouldn't really be a surprise. We asked participants who were involved in policies, programs or directives, whether they accounted for the needs of violence against women survivors when designing or implementing these policies or programs. And 45% said no and 45% said they don't know, which means that 10% did. And what I just wanna note here that's interesting is we also asked what approach people took in designing and implementing policies and the most common responses were a trauma-informed approach, equity-based and patient or people-centered. So in some ways that suggests that there is receptiveness to thinking about violence against women and gender-based violence and how it intersects with these policies, but there's a disconnect. And this is an area I would like to dig in deeper with our participants in interviews. So very finally, I wanted to include these results because part of the Desmond Fatality Inquiry recommendations are around monitoring and evaluation and how potential violence gets reported and who that gets shared with. So we wanted to look at what do people report that they're collecting on or have access to in terms of patient experiences? So we asked if people have any data on any form of domestic or sexualized violence. We gave them a list of six into the partner violence, domestic violence, sexual violence, child abuse, elder abuse for human trafficking. And 32% just under one-third said that they have access to or collect data on any of these different forms of violence. Among those who are collecting or have access to this data, the vast majority of cases, this data cannot be easily aggregated, which means that it's, in a lot of cases, it's paper-based or it's single files with notes done that are not systematically reported. And what that means is that we cannot easily, based on this data, look at how many patients or clients are at risk for experiencing violence or are experiencing violence. Who's most at risk? When we are implementing our programs or interventions, how do we evaluate whether we're making a difference in these patients' lives and in the care they're receiving? So there is a huge need when it comes to monitoring and evaluation that I don't even think the Desmond Fatality Inquiry Report fully captured the state of this data. So very quickly, I'll talk about some of our next steps and then we can have some time for discussion. So of course, there's much more data analysis that's underway. I'm happy to hear what your questions are and what you would like to know more about. I might not have all the answers right away, but it's certainly going to guide our next steps. We're also beginning a second round of data collection, which is focus groups and interviews with that subset of participants. And that's really going to allow us to offer additional explanation and context around our findings. And that's going to be starting this spring. In addition, moving towards a more action space for this research program, we've received an additional four-year grant from CI, CHARC, Indian Institutes of Health Research to partner with the IWP on strengthening their response to violence against women and the organizations they partner with across the health system as well. And you can follow along with these developments at our website, www.bauresearch.com. So just to wrap up, there has been tremendous change in the lives of the AW survivors as well as in health and social service sectors since March 2020. Our data provided unique snapshot of the state of health and well-being among the AW survivors across provinces and insight into the current capacity of the health system to respond to these needs in Nova Scotia. While, of course, there is room to further interrogate our findings, there is a clear need for more training and expertise within the health system, improve knowledge of internal and community resources, and stronger organizational directives and protocols, and indeed stronger directives and accountability at all levels of government as well. So we must take this opportunity with all this new public and political tension on these issues to determine and advocate for the nuanced structural changes that are necessary to improve the lives of AW survivors and the staff who support them. So thank you. And of course, I want to acknowledge all of our participants, AW survivors, and the AW staff and health staff who have shared their experiences and their expertise while participating in this project. Thank you. That's a question. And so feel free. So I know it doesn't inquiry in some of the other projects. There's been a lot of pressure around information sharing. I'm wondering if your research here or otherwise has kind of had any sign of whether or not that might actually help or whether some benefits are associated with that? That's a great question. So I mean, part of the answer is what is the information we're sharing and do we actually have it? What does it look like? But the second part of it is when we think about collecting that information, do we have the training and safeguards in place to do so? So that's where we can look not so much nationally but we can look internationally at really strong examples of how to properly identify, manage disclosure and take note of disclosure within the health system. And there are a number of different protocols and safeguards that need to be put in place. So it isn't simply a matter of just implementing screening and interventions, having people answer the question, writing it in the file and then leaving it at that. That's not helpful to patients and it actually can cause a lot of harm because you end up having people disclose really serious and traumatic experiences and then not necessarily getting the support that they need from it. So one of the most promising healthcare models that we see internationally is taking this work out of the hands of general healthcare professionals and instead embedding domestic violence and sexual violence experts within the health system. That is the model that Nova Scotia is currently testing but the test is with five domestic violence consultants and then the sexual assault nurse examiner program which I don't know off the top of my head but it's less than a hundred. So we're testing it which is great and really important but we know that it's not actually enough to meet current capacity. So hopefully that gives you some insight into that but that's again, how to properly respond and document. That's a whole other, probably our in and of itself. I was just curious how you access the health profession. Was that through college or through health? Both. So our advisory group includes leadership from Nova Scotia Health and from the IWK as well as provincial government and community health organizations. So they were a big part of championing the project and getting us in connect with different team leads and managers and leadership across the organizations but on top of that we also went through the public registries for all licensed healthcare professionals in the province that would be most relevant to this work and then individually contact with them either by email or calling. So there wasn't a general call out to a professional program, notes from college? There was, yeah. So we also had professional associations circulate. That's right, yeah. I'm very curious about the thoughts. It's actually something that I have, I'm sure many people in this room are very familiar with that but I wasn't. And so one question I have is do you have a read on how those thoughts, if you hadn't been doing all filtering you've done, how those thoughts might have affected your study? Oh my gosh, they would have completely, firstly, I mean it's nontensical data. Okay, that's what I'm sure it's gonna be. So there's the thoughts but actually what you need to be more wary of are the actual people who are taking your survey in a fraudulent manner. So you'll see when you're monitoring the data, a hundred responses come in one right after the other of one person filling in the survey but it's a real person and that's when it's harder to identify his survey is not valid. And so the bots are easy to detect because they come in daches, they take two seconds to do the survey. So you have to have safeguards in place like measuring how long a survey takes, whether there's consistency across the different survey responses but in general you can usually quickly identify the bots. If you've included them in your sample you would just have a bunch of noise in your data and you'd report the results and it wouldn't really make a whole lot of sense. Could I ask them just behind that, is there some kind of intentionality behind that in terms of the people who release the bots, if they tend to go after particular studies to destroy them or is that? Yeah, well it's the honor area in part. So there was the VAW surveys had a cash honor area for each participant. Usually surveys have a draw, our health survey had a draw. So that makes it a little less attractive. So when there's a cash honorarium, if you sit and you take the survey a hundred times in 20 minutes, that's a good amount of cash in a short amount of time. But I think there is a nefarious component to it just in talking with other women's health researchers across different provinces. I do think that our projects get targeted when people are filling it in, especially the fraudsters. We see things like what about the men and comments around gender and things like that that make it obvious that there is another motive. I think the primary motive is the money but there is I think a more nefarious component to it as well. So the question is, when you did the old survey, when you looked at CPS, did you correlate the numbers, did CPS offer you provincial-wide numbers around their own experience in such domestic violence? Can you clarify a little bit when you- Yeah, so the Department of Community Services has to go and visit people who experience domestic violence when they know of it. So they would add hard numbers. Right. Did you look at those hard numbers and compare those to the numbers that you were getting inside your survey? In terms of like a number- Is there a correlation? Are they seeing many more higher people who aren't people receiving healthcare services? Right. All of those. So there would be, I would expect in some rural areas that the numbers of people experiencing domestic violence who aren't seeing healthcare professionals, there might be a skew. And I'd be curious about what that skew is. Yeah. Yeah, there is. Yeah, so we do have, I guess, to answer your question a little bit differently. So this isn't our survivor example, are people who, by virtue of the participant criteria, are all people who've experienced violence. So we're not measuring, we're not comparing them to people who haven't experienced violence and looking at the differences in their characteristics. We know that they've all experienced violence. But we do know that our survivor participants have had, many of them have had connections with CPS. And so we can look at those experiences and given the high rates of solo caregiving in our sample, that is a focus of a lot of the open-ended responses is around either having children removed from custody or fighting for custody. And in experience with another study that I led in Ontario, a smaller study where we've already done our interviews, this was a major focus of conversation, was around trial protection and the experience in protecting children. And in any of the jurisdictions that you're working in, was CPS considered as a health physician or were they considered as a legal listening? Yeah, they would've participated in the BAW staff survey. So we do have participants from CPS in the BAW staff survey. Yeah, we tried to distinguish, when we were thinking about the participants for the health survey, we wanted to take a broad public health approach, but at the same time, we knew we very could easily get into the position of everything is public health. So everyone's eligible. And so we did wanna try to draw boundaries there and one of the boundaries we did draw, although we did not actively exclude people, we didn't actively recruit from DCS funded services for the health survey, for the BAW survey we did. Oh yeah, well, so we have people who participated from DCS on the BAW staff survey, but for me the health survey, it's only, I think maybe one or two people who did because of that intentional. Because there is a correlation between the mandatory aspect of having to be involved in protected services. Yes, and actually one of, yeah, one of our knowledge testing questions in the health survey was whether people are aware of their mandatory reporting requirements around children and domestic violence. You know there's domestic violence with a patient. There is a mandatory reporting requirement in place. Whenever there's a child involved and 85% or so of the sample got that answer, correct? Which is good, but at the same time, there's a lot of nuance actually in terms of what you really do when a patient reveals violence and you know that there's children in the home and there's a lot of fray area around what you should do and how you should go about managing that situation. Thank you. Yeah. Go to him. I'm curious if you were surprised that a partner from all the research that you've done in the area on thinking about some of the work in other jurisdictions and how the media works. We know we have a high, many of the highest rates here in the solution, so I'm just curious. So, I mean, in some ways we were surprised in some ways we were. So our survivor results just around how dramatic the health needs of survivors are. I think that's just shocking in a way in and of itself to see. It is as far as we know, one of the first if not the only quantitative snapshot of survivors health needs since March 2020 in Canada. So it does kind of demonstrate what those needs are in a way that we haven't yet seen. But it is very much in line with what we are seeing from qualitative research that's being done across the country and from other quantity to studies from around the world. So it's in line with the research. It's not totally out of left field but those numbers are always surprising. With the health survey, again, in some ways we're not that surprised because what research does exist on preparedness to respond and knowledge does tend to suggest that the health system lacks capacity that there hasn't been appropriate training and there are a number of systemic and structural reasons for this. But again, just given thinking about our sample being a more committed sample to these issues working in priority practice areas where we know there's gonna be higher rates of domestic or sexualized violence. It is still, I think, a little bit shocking to see those numbers in light of that in that context. The sort of system. Yeah. Yeah. Did she have a question? Yeah, this might be just another overview that this study didn't go down yet. But you noted that there is a small percentage of people that identify as a sexual minority. Wondering, was there any data collected or will it be made in a different study about what their relationships look like? So violence in heterosexual relationships versus home sexual relationships or how that relationship's gonna look. And then a sub-study that is specifically looking at kind of these diverse sexual relationships in that, is there violence disproportionately in certain relationships in that minority as well? Yeah, so I think that's something that we are gonna explore more in the qualitative stage of the project because it really allows for more opportunity to have these deeper nuanced conversations. So we know in our data that it's about 25% of survivors identified as a sexual minority. And then of those currently relationships, it's about 10% who are, their partner is a woman or gender diverse. So we know that we have that representation to explore that further in interviews. So that'll be one of the demographics that we consider when we're purposefully recruiting people. But in this data, there was only 10% that were, that didn't have a male group. Of the 30% who are currently in a relationship, 10% were with someone who's a woman or gender diverse. That's not a whole about the violence in some places. This is just what the conversation says. Yes, some of them might be experiencing violence from their partner, some of them might not be. Yeah, yeah. And then there's the 70% who are currently in a relationship but may have been in lesbian relationships in the past or other forms of relationships as well, that we can explore. It wasn't about, it wasn't about the relationship of the client or the client. No, yeah, exactly, yeah. So like a lot of these specifics and nuances are things that as researchers, we always want to capture everything. But when we're putting the survey together, we have to think about how to make it feasible for our participants. And so some of these things we just have to say like, okay, this is better explored when we can have conversations with people rather than trying to like map out all these details as interesting as they are. But we do know generally speaking, that while we know the majority of victims of intimate partner violence and sexualized violence are women who experience violence from men, we do know as I mentioned, the start sexual and gender minorities are disproportionately affected. And also that the risk factors in ways that this violence gets used differs depending on whether it's a heterosexual versus lesbian, gay or otherwise relationship. So there are different dynamics at play. Again, bigger conversation, but it has led to some research that suggests that there might actually be different measures that are needed for different forms of violence. Yeah, so, yeah. I'm surprised and but terrifying. You mentioned on your last slide the need for more nuanced, structured solutions on positive victims of violence and sexual changes. It sounds like the way in which violence is disclosed and documented in the lives of some women in the area where there might be an opportunity for structural change, but others might be able to do that. So, well, firstly, the nuance piece with our data. One of the strengths of the data is that we can look at different program areas, different organizations, different work roles and really start to understand. And what I focused on here today is our quantitative data, but it was a mixed method survey. So we also have qualitative data. So we have a lot of rich data, even just from the survey around where people are coming from, what they're doing for work and then what the barriers to responding to this violence are. And that can really help us develop more nuanced recommendations. But yeah, I think the recommendations come down to, A, in terms of substantive focus, better training, better documentation. I think a huge one is monitoring and evaluation in our data systems. So the training end of things, what goes into it, but then also the technical side of things as we move more towards electronic records, what does setting up a record look like to safely report violence? And then also the systems collaboration piece, better connections between the health system, the VAW sector and cross-sectional partners that do this work. There is some of that happening. So there's a relatively new coordination table for managing cases that are high risk for intimate partner homicide that just in the formation of this table for the first time includes the health system, which has never been included before. So that kind of systemic change is needed, but there's still a lot of structural pieces that go into that. How do you share data potentially across different systems and sectors? There's data privacy piece and all that, yeah, to get into. So there's a number of different ways we can imagine taking approach at the system or structural level. And one of the benefits of what we wanna do is our survey data that maybe hasn't happened in some of the larger judicial inquiries is digging down deeper in terms of what are people who are actually working in these different areas reporting they do or don't have access to a college amount? Hi, I already knew there was a systematic review in the UK that said that health care professionals were less comfortable inquiring about sexual or violence against women than women were comfortable to receive those questions. What do you think that is? Okay, so say that one more time. So when we were asked, are you comfortable being asked about violence against women? Let's say 60% said yes. But then when we changed the health care professionals, let's say 50% said they were actually comfortable inquiring about any indication that there was violence. Why do you think that is? I think that health professionals don't know how to have these conversations in a lot of cases. And we've seen that they don't always have the training and they don't know what to do when they ask a question and someone discloses. If you don't know the resources or referral options available, what do you do when somebody tells you that they're experiencing violence and what's your responsibility? Does that help? Yeah, it's not interesting because on the one hand, women are talking about violence against themselves, which is incredibly vulnerable. And the other hand, you have a health care professional who's trained to work through their emotional biases and ask questions that have been occultant and seems to me that that discrepancy isn't correct. I mean, when we look at the training that our sample experienced, a one hour lecture over the course of a four year degree or attending a talk like this or reading two page protocol is not really going to be sufficient for actually knowing what to do when someone is sitting in front of you and telling you some very serious things that are happening in their lives. None of those things that I just mentioned are going to prepare you to know what organizations are available that you can call, what are the numbers within the health system of the DV consultant or sexual assault nurse examiner, et cetera. And then on top of it, just imagine all the pressures that the health system is currently under and health professionals are under in terms of work load and staffing shortages. So it's a major systemic issue and that we can't sort of put at the individual level. It's really a problem at starting at education but then moving once people are into the workforce as well. Is there a follow up? Do you have a follow up question? Oh, yeah. I just want to give you an example. So I work in the sense of women and one time the religious community doctor came up to visit us and she didn't know where to send me if she'd seen people clearly like broken jaws, high soft drinks. Remove. Did not know and was afraid to find out more about the situation because one of the things that this inquiry talks about is health care system. People want to know how to, should know how to make a warm handoff, right? You don't just give somebody a card and call this place. They want to be able to give a better warm handoff so that that person feels safe and access and safe. Right? So this particular emergency room doctor was like, she's found us in the bubble. Can you just say something? I don't know what to do, where do I send people? Can I just send people to writing house in the calendar like, yes, absolutely, right? There is a, you know, of course, under resource, under staff, under funding but just really not a whole lot of training and awareness. And this was an emergency room doctor who lived as a colleague in Ontario being shot by their partner while on duty, right? Yeah, we have participants in our sample who were, you know, on the phone with someone who was shot during the mass shooting, shot and killed. So it's personally touching the lives of people working in the health system and professionally among their patients and clients. So there is a real need for determining a better training and education strategy. And then I think also really building the capacity of embedded advocates within the system as well. Oh, one last question? Yeah. I think it's pretty quick. I'm wondering what the first point of contact is for survivors in rural settings. I mean, you find that it's too pushed towards like rural clinics or something. Is that expected? Do you have a few resources that we find? For sure. So we know that health services are often one of the first and only formal services that survivors access, especially if, because they have like immediate health consequences that they face. So in a lot of cases, it will be a health clinic or a health organization. Also in rural settings, a lot of the women's resource centers in the province are providing health programming. So that is a common point of contact when there is one. So I'm sorry to do this. I'm looking at the call and it's about a minute after, 20 after. So I think we're going to have to just wind up. So let me just say a couple of words before I ask you to join me in thanking Professor Nikiswitch for this wonderful, wonderful, harrowing, disturbing portrait of our communities here in Nova Scotia and across Canada. I just wanted to, I was looking back at the MCC report and they characterize gender-based intimate partner violence and family violence as a public health emergency that warrants a meaningful whole of society response. And it highlights the need for community-based systems that reflect the needs, especially of marginalized survivors, but of survivors. And so what are those needs? It seems like such a basic question. And how can a health system respond appropriately? And how can it go beyond a health system? I mean, I think this is one of the great merits of this big study you're doing. I know it's preliminary. You're giving us a really early snapshot of what kind of potential we have to learn about how whole communities or a whole of government responses and beyond government responses might react. Last thing I'll just say, looking back at that report, again, because we feel that the depth of connection to the tragic consequences of intimate partner violence. But beyond that, I was reminded at how the mass casualty perpetrator had also exploited low-income black women through his denturist professional work. There was a college involved that should, where was the college? Where was community services referring people to that denturist disbook? Where are community systems of trust, building trust, so that people can share information and share concerns where those are live? And I have to, my very last piece is about community nonprofits. I really hope that the work you do will help us understand the potential within those nonprofit organizations that do build trust and create relationships over time. The great potential of those organizations to be partners with the health system and with public health priorities. Because if there was one thing I heard over and over in the MCC process, it was organizations including, oh my God, beautiful indigenous service organizations working hand to mouth and losing their funding every year, a couple of years because it's program-based funding. So when I think about needs and support needs, I hope somehow we may have a window into services or supports that folks have accessed or tried to access. Can we help evaluate those services that nonprofits are providing? Because every couple of years you have to support the fact that you've made a difference and then you lose your funding and you start from scratch. Just working with people at the McModalegal Support Network this week about losing their funding over and over. Sorry to make it a polemic, but I'm feeling that. I'm feeling it's a moment for a bit of a polemic, but it's even more a moment for gratitude to you. Before I do that, finally, I wanna announce our next lecture coming up on March 8th. Please come, Professor Jeffrey Anseless, who is a Canada Research Chair in Critical Studies and Indigenous Health at the Ontario Institute for Studies in Education at U of T. We'll be sharing a talk that is titled so provocatively and I think very appropriately moving from today's talk. It's called World Ending and Mending, An Indigenous Feminist Perspective on Suicide, Climate Change, and Health Justice, as if we couldn't get any bigger in our aspirations in our Health Justice series. So please join me in thanking and I'm so curious to hear more and more from you as this unfolds in thanking Professor Yukubovich. Thank you. Thank you.