COLUMBUS, Ohio -- Sometimes, the impacts of physical abuse run deeper than a scar, and researchers in Ohio are digging deeper into cognitive injuries caused by domestic violence.

Working with researchers from Ohio State University, the Ohio Domestic Violence Network's CARE project discovered that a majority of survivors have lived through extensive violence directed at the head, neck and face, and through strangulation.

At ODVN's Center on Partner-Inflicted Brain Injury, Director Rachel Ramirez said such injuries can be linked to brain trauma.

"So, when we think of the very first picture of a battered woman being a woman with a black eye, we now should be thinking that that woman very well could have had a concussion, and her brain could have been hurt," Ramirez said.

The project's work was featured in a recent federal report, which recommends improved data collection on brain injuries from intimate-partner violence.

According to Ramirez, with better data comes a better understanding, which will help providers better serve survivors.

Ramirez explained that brain injury often is not diagnosed and not well understood by domestic violence prevention programs or survivors. It can manifest in such cognitive challenges as problems with attention or memory; such physical problems as headaches and fatigue; and emotional issues, including depression and anxiety.

"When these issues are untreated and unidentified, things end up getting worse for the survivor," she added. "They aren't getting better; they don't understand what happened to them, and they blame themselves -- instead of understanding what happened to them as a result of an injury that wasn't their fault."

ODVN has developed a new conceptualization of brain injury, known as the CARE framework. CARE stands for "connect, acknowledge, respond, evaluate."

Ramirez described the framework as focusing on building positive relationships with survivors, and acknowledging and responding to the individualized needs of each person accessing services.

A new statewide initiative aims to help connect domestic-violence survivors with medical providers, with a focus on treating traumatic brain injury.

Rachel Ramirez, founder the Ohio Domestic Violence Network's Center on Partner-Inflicted Brain Injury, said survivors often experience severe violence aimed directly at the head, neck and face. But there's been a longstanding gap in accessing the right medical services when individuals come into shelters.

She said $5.12 million dollars in funding will be used to pay for medical services.

"To pay for health care that people are not able to get reimbursed through other means, through Medicaid or insurance. We want to investigate the possibilities of working with occupational therapy to help with brain-injury rehabilitation," Ramirez said.

The three-year project in collaboration with the Ohio Association of Community Health Centers will cover four to six areas of the state. According to data from the Ohio Domestic Violence Network, the state suffered 112 domestic violence-related fatalities between June 2021 and June 2022. More than twenty of those killed were children.

Ramirez said advocates are also working on developing a statewide virtual and call-in center known as the Care Health Connection.

"That will be a place where domestic-violence programs and survivors can also talk to an advocate when they have health-related needs to help them get better connected to either telehealth services, behavioral-health services or other health services in their community," she said.

Emily Kulow, director of mobile advocacy and meaningful access at the Ohio Domestic Violence Network, said the goal is to eliminate barriers that prevent survivors from seeking help, and then providing a holistic approach once a connection has been made.

"So checking in with the survivor about what's going on with their housing, what's going on with their health care. When was the last time they were even seen by a doctor," she said.

According to the National Center for Health Research, women who experience domestic abuse are more likely to suffer from diabetes, asthma, lower back pain, headaches and other chronic conditions.

A bill headed to President Joe Biden's desk addresses a long-standing problem for domestic violence survivors, ending their ties to their abusers' cellphone plans.

A North Dakota coalition predicts the changes will be helpful. The Safe Connections Act recently cleared its final Congressional hurdle. It removes financial penalties for survivors who are trying to separate their phone lines and their dependents' lines from an abuser.

Dana Mees, administrative director of the North Dakota Council on Abused Women's Services, said unresolved phone plans can be a major obstacle for someone from trying to move on from an abusive situation.

"They do give abusers access to call logs, text messages, voice mails, or family tracking features that can be used to monitor, stalk and harass survivors," Mees explained.

She added survivors are forced to pay a lot of money in termination fees, often making it difficult to transition to a safer environment. The bill had bipartisan support, but other advocates say they would have preferred policymakers not include a provision requiring the survivor to provide documentation they were abused, arguing it added to their trauma.

A separate aspect of the bill calls on the Federal Communications Commission to create rules requiring cellphone providers to expunge any calls or texts to hotlines, such as those operated by crisis centers. Mees noted it is another important tool.

"If they're calling a crisis line, and that shows up in their call log, that can tip an abuser off that they're thinking of leaving," Mees pointed out. "It can put them in a more dangerous situation."

As for financial barriers, the bill expands eligibility for the FCC's Lifeline Program, which provides monthly cellphone plan subsidies.

Collectively, Mees believes the actions should help survivors move forward with their lives without having to change a number or get another phone. President Biden is expected to sign the measure.

Rape crisis centers assist sexual abuse survivors and educate about violence prevention, and collaboration is a key aspect of their work.

The Ohio Alliance to End Sexual Violence supports rape crisis centers throughout Ohio, and recent regional meetings offer insight into what is happening on the ground.

Elle Fullenkamp, manager of training and technical assistance for the organization, said many centers are stepping 'outside the box' when it comes to prevention programs.

"Whether that's youth programs, like funding youth centers so that people can have spaces to have healthy relationships," Fullenkamp explained. "There are also community-based prevention programs and collaborations. We saw some tattoo shop and faith-based training projects. That's a really cool thing that we saw happening."

A common theme, she noted, is inadequate funding, which can create staffing shortages and the inability to sustain the programs needed to help survivors.

Caitlin Burke, the group's director of prevention and public health, said some programs are holding listening circles to help them tailor their prevention-based work to meet local needs.

"So, even if the community isn't necessarily worried about sexual violence, maybe they're worried about gun violence, or maybe they're worried about community or gang violence," Burke outlined. "How can we work together? Because we know that if we're working to reduce gun violence, we're likely also going to be working to reduce sexual violence. Violence is often intertwined."

Fullenkamp added many centers shared concerns about how to engage educators and parents about violence prevention in their school-based programs. She emphasized evidence-based programming is needed at an early age, as junior-high students already report they've experienced forms of violence.

"Unhealthy relationships or sexual harassment, bullying, being teased for their bodies, or things like this that are covered in the types of trainings that our programs do in junior highs," Fullenkamp pointed out. "Even at that age it's too late; these things are being experienced by these junior-high students."

Due to the pandemic, it is the first time in two years the regional meetings were held in-person. Burke stressed it allowed for providers to share their successes and concerns, and brainstorm ways to support each other.

"Collaboration just gives chances for innovation; for us to think bigger and learn from each other, and be more creative," Burke remarked." With any sort of project, it's really crucial that folks are able to get together and bounce ideas off each other. And in that way, we are also collectively working towards the same goals."

While sexual violence data is underreported, at least 25,000 survivors are estimated to be served by rape crisis centers and the Ohio Alliance to End Sexual Violence each year.