Creating Healing-Centered Care for Intimate Partner Violence Survivors with Dr. Maya Ragavan

The Division of General Academic Pediatrics | CHP.edu

Intimate Partner Violence | American Academic of Pediatrics

IPV: Short Animated Video Series | American Academy of Pediatrics

Stress and Violence at Home During Challenging Times | HealthyChildren.org

Intimate Partner Violence: The Role of the Pediatrician | AAP Publications

Intimate Partner Violence | Centers for Disease Control and Prevention

Casa San José Pittsburgh

Futures Without Violence

Women’s Center & Shelter of Greater Pittsburgh

Crisis Center North

Center for Victims Pittsburgh

Pittsburgh Action Against Rape

Pennsylvania Coalition Against Domestic Violence

National Domestic Violence Hotline

Life Changing Is … Looking Out for Those Who Need It with Dr. Maya Ragavan | UPMC.com

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Allison Williams: Hi, I'm Alli Williams, a pediatric hospitalist here at UPMC Children's Hospital of Pittsburgh.

Dr. Sameer Agnihotri: I'm Sameer Agnihotri, an assistant professor in the Department of Neurological Surgery.

Dr. Williams: And thanks for listening to That's Pediatrics. Today, we are so thrilled to have Dr. Maya Ragavan here from the Division of General Academic Pediatrics. Not only is she a fabulous clinician, but she is also a wonderful researcher who has a focus on intimate partner violence and is here to talk to us today about some of her research and some of her clinical experiences. Thanks so much for being here.

So to roll into it, we always like to start out with just a fun question and it seems like you've lived in many different areas. So what's your favorite thing about Pittsburgh?

Dr. Maya Ragavan: So I think my favorite thing about Pittsburgh is the community partners that I've worked with here. And so I have lived in Pittsburgh mainly during the pandemic, so it's been a little bit hard. I moved here in 2019 and I have been so blessed to work with incredible community-based organizations. So one of the organizations I work with a lot is Casa San Jose. They're a wonderful group of people who support the Latino communities here in Pittsburgh and other immigrant and refugee organizations and other organizations in Pittsburgh.

And just the work that they do really inspires me and just how welcoming that they've been to connect me with community partnered-research. Research has been wonderful. And then I absolutely love my colleagues here. I mean, it's a great group in the Division of General Academic Pediatrics, and I work a lot with adolescent medicine, so I feel really lucky. So I just love the connection. I love the community here. I think it's really, really fun to be here because of that reason.

Dr. Agnihotri: That's awesome. Do you know what things drew you to Pittsburgh and especially Children's Hospital and UPMC and-

Dr. Ragavan: Yeah, yeah. So thank you, that's a great question. I will be honest. I came here for the one and only Dr. Liz Miller. I wanted to work with her because she is amazing researcher, a brilliant, innovative person, and I've always wanted to work with her. And so I really came here because I wanted to work with her. And there were other people when I came, I did my interview here like Dr. Diego Chaves-Gnecco that I met. And I just thought were incredible. Dr. Debra Bogen, there's so many wonderful people here.

So I really came here for the people. I came here to work with these people and I am so glad I did. I don't have any family in Pittsburgh. I have one friend here, but other than that, really I came here to work with the people in my division and more broadly at the Children's Hospital. And I'm really, really happy that I came here. I really love working here, so-

Dr. Williams: And now I bet you have more than one friend, right? I mean-

Dr. Ragavan: I do have more than one friend. I have more than one friend here. I know. It's great.

Dr. Williams: I feel like Pittsburgh is a great community in which you can really easily acclimate to. I also had the same experience that you did where I moved here for another than training and I just feel like it's a great environment. And so is the Children's Hospital of Pittsburgh. But not only is Liz Miller, Dr. Liz Miller, a powerhouse, you are too. You have done some very impressive things even in your short career here at UPMC Children's Hospital of Pittsburgh. Can you talk to us a little bit about your clinical passions?

Dr. Ragavan: Yeah, absolutely. So my clinical passion I think is really providing healing centered care for families. And so I'm a general pediatrician. I became a general pediatrician for so many reasons. But I think the biggest is because I love building relationships with families. I think it's so fun to see a kid grow up and be part of their life for all of that time. I love the continuity aspect of it. And so I love supporting families.

I love providing holistic care. So really thinking about ways that community and structural level factors impact care. And then really holding up a strength-based lens. So really thinking how can I as a pediatrician support you and your strengths and build relational health and support your strengths. And so that's what I love. And then I'm really passionate about this idea of becoming more trustworthy. So I think one of the things that I've been reflecting on a lot is, we often talk about trust in medicine and we often ask families to trust us.

And I think we really think it's important to flip the script a little bit and say, "What can I do to earn your trust?" So for many folks, especially folks for marginalized communities, there's really no reason for them to trust us. There's been much harm that has been done historically and in the current day. And so I'm really interested in how can I as a healthcare provider and how can the healthcare systems that I work for become more trustworthy? So I'm really passionate about that idea, teaching that idea, and then of uplifting that idea as well.

Dr. Williams: You also have not only great clinical interest, but some research interests as well. Have your research interest overlapped with that clinical interest at all in looking at how to help minorities in the community have faith in the healthcare system?

Dr. Ragavan: Yeah, no, thank you. That's a great question. So I think my broad research interests or my research focus is on community-partnered work. And I think, so I would say absolutely because I think what community-partnered work does in its essence is, it thinks about how do we uplift and amplify the voices of communities and really include them in co-creation of science. And so I think it's one thing to say, "Okay, we'll work with a community partner to help us recruit," but that's not really dismantling power inequities. That's still me as a researcher coming up with the idea and you as a community partner leveraging your own social capital to allow me to complete my study.

And that's not what community-partnered research is. Community-partnered research is co-creating science together. So as an example, I just finished a study with multiple immigrant and refugee communities in Pittsburgh where we were doing focus groups in multiple languages to understand the COVID-19 vaccination experience of non-English speaking immigrant and refugee communities.

And the reason that we decided to do this study together is because many community-based organizations and myself as well as many others, were trying to support vaccine access for the COVID-19 vaccine at the beginning of the rollout. And were noticing that a lot of the ways that people could register for the vaccine were in English. And so non-English speaking communities really just didn't have great access. And so that idea of let's preserve this history, let's understand the experiences of non-English speaking immigrant and refugee communities. That came not just from me, but it came from all of us together.

And we wrote a pilot grant together. We did this project together. We are publishing hopefully soon together. And that is community-partnered research really from start to finish co-creating science. And so that's what I'm really passionate about. And I think that very well aligns with this idea of how can we become more trustworthy? And a lot of it is really leaning on the expertise and the wisdom of communities.

And I think the other thing that Dr. Miller talks a lot about, and I also want to just uplift a lot, is this idea of not being extractive in our work and making sure we're compensating community partners for their time. And so one of the things that I think is really important is also making sure that while we're centering the voices of community organizations, leveraging their wisdom and social capital, that we're also equitably compensating them. So I think that's the essence of the research that I do and that I love, and it spans multiple topic areas, which we can talk about. But that's my passion in research is focused on community-partnered work from that lens.

Dr. Agnihotri: Great. And can you talk a little bit about your research? Any studies that you're conducting or any things in the field that you'd like to share with us?

Dr. Ragavan: Yeah, yeah. So my work with that community-partnered lens, I focus a lot on partner violence prevention. And really there's two big areas with that. The first is how do we create healing centered spaces in pediatric healthcare settings to support survivors of partner violence, whether it's a parent or caregiver or an adolescent. And then the other area that I'm really passionate about is, how do we engage parents and caregivers and trusted adults in supporting adolescents in dating violence prevention?

And so one of the things, so I can talk a little bit about both of those, but one of the things that we were working on, and so this includes folks from PITT as well as from Futures Without Violence, which is a national domestic violence, a national gender-based violence equity group. It is a social policy group in the American Academy of Pediatrics and the Centers for Disease Controls.

We were trying to understand the experiences of intimate partner violence survivors during the pandemic and really trying to understand what was their lived experience during the pandemic, what were some of the challenges that they went through? And what we found was, I think really important for folks for healthcare providers to know. So intimate partner violence survivors were experiencing a lot of isolation during the pandemic. I mean, we were all experiencing so much isolation, but they were experiencing of compounding isolation because one of the fundamental pieces about IPV is power and control and isolation.

And so partners who are using violence, who are using the pandemic to isolate folks even further cutting off their cell phone service, taking away their stimulus checks, not allowing them to seek healthcare, things like that. And so really understanding the ways that COVID was actually being used to control and manipulate and isolate survivors, so that came out a lot from our study.

And the other thing that came out was really how survivors from marginalized communities or who had one or more marginalized identities were experiencing even more challenges. So as an example, some of the folks we spoke with worked with immigrant survivors of IPV, and they were talking about how a lot of immigrant survivors were not able to access the same resources that folks were, that not immigrants that have documentation here were able to access. So they were experiencing even more challenges of rooted in structural inequities.

And so that came out a lot from our study. And I think the other thing that I want to highlight that came out from this study was the importance of collaborating with victim services agencies. So folks talked a lot about how domestic violence agencies, so an example in Pittsburgh for example, is the Women's Center and Shelter really were doing so much work during the pandemic. They were moving all of their services to virtual, they were creating text line and chat line. They were partnering with grocery stores to try to support survivors.

So I just want to really uplift the work that they do and remind us all as healthcare providers, that victim services agencies and domestic violence advocates are really important part of our healthcare system. So it's really important that we collaborate with them to serve our patients.

Dr. Williams: I think that is so important to have all of this research and to work with these community partners to identify what some of the many challenges are with intimate partner violence survivors, especially in light of the COVID pandemic. I mean, like you mentioned, it was fearful and isolating for everyone, but for this particular group of individuals, it must have been even more so, which it sounds like your study really highlighted.

Dr. Ragavan: Yeah, absolutely. There were so many challenges and there was a lot of talk about resilience too, a lot of self-care, community care, the way that communities were coming together to support survivors, which is also really uplifting to hear. And so it was really important to also hear about the resilience that came through in this work as well.

Dr. Williams: I bet with your research and identifying some of these challenges that they experience is you also have a lot of experience with not necessarily solutions, but ways to bridge and try to fix might not be the best word, I don't know if we can fix everything, right? But to make these challenges easier, what are some things that we could do as healthcare providers to overcome some of the language barriers that you've been talking about? Do you have any tips or tricks that we could use?

Dr. Ragavan: Yes, absolutely. And sorry, can we... To clarify language barriers for non-English speaking folks, or do you mean to support domestic violence survivors?

Dr. Williams: I would say, I mean in all honesty. I guess both, right? Because if you're bringing up both-

Dr. Ragavan: Sure.

Dr. Williams: ... I was thinking more language barriers with non-English speakers, but I mean there most certainly is language barriers with even just having these discussions with patients too. It's challenging for a lot of us, especially those for healthcare providers who haven't been trained.

Dr. Ragavan: Yeah, yeah. No, it's such important questions and I can answer both briefly. So in terms of supporting non-English speaking communities, I think the most important thing is using interpreters. And so we all have access to in-person, well, we all have access to the CyraCom System. I think there needs to be more access to in-person interpreters as well. And as a reminder, it's not just at the provider level.

So sometimes, the provider level or the clinician level, we'll use an interpreter. But from start to finish, every moment that one of our patients is interacting with us from when they pick up the phone to make an appointment or when they enter the front door to when they leave, they should be able to access services in their language. We also need to make sure that we're asking people about their language in a really thoughtful way.

And so making sure that we're not only asking people their language preferences based on our own assumptions, but rather we're asking that universally. And I do want to highlight here, one of my colleagues who's doing a lot of work at the Children's Hospital, who I'm sure you all know Mariace, and just uplift her work because she's an amazing force and has done a lot of work for us to make sure we have better language, equitable services. And so I think that's important.

And in terms of supporting IPV survivors, I'll just list a couple suggestions. The first is I don't recommend – a lot of Dr. Miller's work has been in this – screening. I recommend providing everybody with some universal education and resources around IPV because there's so many reasons why a survivor may not want to tell us about this incredibly traumatic thing happening. So I recommend providing everybody resources. If somebody discloses they're experiencing IPV, the first thing to do is just center yourself for a moment.

Because it's very stressful how they say, I have not been inpatient in a while. But how they say if there's a code, check your own heart rate first. I think it's really similar. Just make sure your nonverbal expression that you're in a calm place. And then what survivors say they want doctors to do, healthcare providers to do, is listen to them and not try to fix this. This isn't something that can be fixed all the time. This is something where we need to create a space where we're listening in a non-judgmental way. So that's also what I recommend.

And then just make sure that you have resources to our local community-based organizations. Like I was saying, we're lucky here in Pittsburgh. We've got the Women's Center and Shelter, Crisis Center North, the Center for Victims, Pittsburgh Action Against Rape. And if we have someone that's not from Pittsburgh, the Pennsylvania Coalition against Domestic Violence has resources.

So just make sure who your resources are and help survivors connect with them. I never recommend pushing resources on people. So if a survivor says," I don't want that," I don't recommend saying, "Oh no, definitely take it." So you never know the safety level and survivors know how to keep themselves safe. But definitely making sure they know about resources is helpful.

Dr. Agnihotri: So for the healthcare providers, are there regional conferences, national conferences where different organizations can convene to share ideas on how to approach some of these topics and what to look out for?

Dr. Ragavan: That's such a great question. Let me think. So if folks are really interested in partner violence prevention, so Futures Without Violence has a National Health and Domestic Violence conference, which is biannual. So every other year, that's a great conference if people want that focus. And it's nice because it's multidisciplinary. There is going to be a workshop at the AAP conference that my colleague and I are running on partner violence if people are going to be there and are interested.

And there are always, there's an upcoming, actually tomorrow there's a conference on social media and partner violence. So there's always a lot of great conferences that happen on both topics on language equity and on partner violence. But definitely if anyone's interested in, they're going to be AP conference in October, excuse me, in San Diego, there will definitely be workshops there as well.

Dr. Williams: Do you have any other resources that healthcare providers can use to become more comfortable with these topics? As many of us don't have nearly as much training or any training at all in these topics. Are there any like CME courses that you've done before, any websites that other providers could use to become more familiar with these topics?

Dr. Ragavan: Yeah, yeah. Great question. So the American Academy of Pediatrics as a new IPV website, it's got a lot of information on it and I think that they're working on adding in as part of the research that I was talking about, the COVID research, we've also created some videos for pediatrician so that's going to be up on that website soon so that's a great place to start. The AAP, American Academy of Pediatrics also has an IPV policy statement, which is excellent.

It's just about to get redone a little bit. But even the one that isn't from 2010 that's going to be updated is great to look at healthychildren.org, which I know we all use has something for parents on stress and domestic violence and COVID, that is helpful. Let's see, what other resources are helpful? The National Domestic Violence Hotline has a lot of great resources as well. And then the Women's Center and Shelter, their medical advocate is so generous with her time and will often come and give talks to different divisions.

So she's spoken at our division before. Excellent. Very practical presentation on how to support survivors. And so if folks want to make that connection, they could always reach out to me if they want to talk on domestic violence and, sorry, I use domestic violence and intimate partner violence interchangeably here. And yeah, I think that those are some good resources to start.

Dr. Williams: That's awesome. Thank you so much for sharing all of that information with us 'cause I know that it is fascinating for me to hear all of your work. It is also overwhelming for me to hear all of this because this is a topic that I think a lot of us are uncomfortable with because they're difficult conversations and difficult experiences to even think about.

Dr. Agnihotri: It's very important.

Dr. Williams: Yeah. Oh, it's absolutely important. Do you have any other social media or websites that folks should know about for you personally or your division for more information about your research in particular?

Dr. Ragavan: Yeah, absolutely. And just to comment on what you just said, usually when I start talks about partner violence, the first thing I say is take a deep breath and take care of yourself. This is very, very difficult to hear-

Dr. Williams: Right.

Dr. Ragavan: ... and partner about me. I didn't say this earlier. Partner violence is incredibly pervasive. A lot of statistics are one in three, which means many of the folks listening may have experienced it themselves, may have friends, loved ones ,family who've experienced partner violence. So absolutely, if you're interested in diving more into this space, excuse me, please just know that it can be really hard. This is a hard thing to talk about and it's okay to take the time you need to process all of this.

And in terms of websites, so my website through that, through pediatrics has some information about my work. I do have a Twitter handle that I'm trying to use more frequently now, which is Mi Ragavan, and I'm working on building up some more stuff as well. And then some of the work that I've done, you will be able to see on the IPV website through at AAP. But I think that those are a good place to start or just email me. I'd love to talk with you.

Dr. Williams: We are so thankful that you're able-

Dr. Agnihotri: Thank you so much.

Dr. Williams: ... to come and talk with us about this and we're also really thankful that you took the dive into come to the Pittsburgh community even during the midst of the pandemic. So thank you so much for joining us today. Thank you so much for sharing your experiences with us and your research, and thanks for listening to that pediatrics.

Dr. Ragavan: Great. Thank you so much.

Dr. Agnihotri: Awesome.

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