Part II: Defining a Public Health Approach to Violence Prevention
“There is one universal truth, applicable to all countries, cultures, and communities: violence against women is never acceptable, never excusable, never tolerable.”- Secretary-General Ban Ki-moon
In Part 1 of this series, I discussed the history of violence prevention efforts in the U.S., including major social movements and policy developments, as well as more recent sociopolitical trends related to violence against women and violence prevention efforts. Among other important milestones, I briefly described the CDC’s endorsement of a public health approach to violence prevention, which has provided guiding framework for subsequent research, program design, awareness campaigns, and policy development. In this post, I will first explain what makes violence a public health problem and define what it means to take a ‘public health approach’ to preventing violence against women. Next, I will discuss the implications of such an approach, including the importance of public attitudes and awareness, political action and legislative support, responsible media coverage, social norms and gender role stereotypes, and the underlying cultural context in which violence takes place. Finally, I will conclude with a critical discussion of common myths and misconceptions about violence, with the goal of dispelling these myths through the use of scientific evidence.
As the first part of this series discussed, the CDC officially classified violence as a public health problem for the first time 30 years ago, in 1983. Before this, violence was approached from a criminal justice perspective with a focus on reactive rather than preventive responses (Mercy et al., 1993). However, similar to physical diseases and epidemics, addressing the underlying causes of the problem is a far more effective strategy than waiting to take action until the problem emerges.
The Shift from Criminal Justice to Public Health
So what factors led to the realization that violence is not solely a criminal justice problem? First, an increase in homicide and suicide, youth violence, and gun violence. Since the mid 1960’s, homicide and suicide have consistently been among the top 15 causes of death in the U.S. (CDC & NCIPC, n.d.; CDC, 2009). Around the same time, we saw a dramatic increase in suicide among youth (15-24 years old), with rates almost tripling in just under 40 years between 1950 and the late 1980’s (Alcohol, Drug Abuse, & Mental Health Admin., 1989). Homicide rates increased across age groups, but the increase disproportionately affected youth (particularly males): between 1985 and 1991, homicide rates among 15-19 year-old males increased by over 150%. These alarming trends began to attract public attention and concern, eventually leading to calls for action and effective solutions. A second factor that led to the conceptualization of violence as a public health problem was the general perspective on disease prevention within the public health community at the time. As the leading causes of death in the U.S. shifted from infectious diseases to chronic, preventable diseases, the public health community began to consider behavioral factors as important etiologic agents and potential preventive mechanisms involved in the incidence of disease. A third factor leading to the recognition of violence as a public health problem was the application of epidemiologic research methods to the study of violent incidents, allowing researchers to identify risk factors and characterize the nature of violence and nationwide violence-related trends.
These advancements allowed us to identify different types of violence (e.g. psychological abuse) that may not be recognized as crimes under the criminal justice approach, and therefore have gone unrecognized and understudied; we were also able to gain a new perspective on the incidence and classification of violence by including contextual factors in the study of violence. This led to the development of a new, broader typology of violence focusing not only on the type of crime (e.g. murder, rape, assault) but also the context in which it occurred; e.g., the relationship between the victim and the perpetrator. As a result, researchers began to identify different trends, causes, risk/protective factors, and correlates of specific types of violence, such intimate partner violence, community gun violence, teen dating violence, emotional/psychological abuse, child abuse, and violence against women. All of these developments proved to be significant contributions to the current approach to violence prevention, further validating the adoption of a public health approach.
Before concluding this section, I feel it is important to note that the general consensus within the public health community is that successful violence prevention calls for a collaborative approach involving the criminal justice system, as well as other public and private agencies (Mercy et al., 1993; Moore, 1995). Although the public health approach has contributed significantly to the development of successful violence prevention programs, it also recognized that collaboration with the criminal justice system is necessary and has the potential to create new, effective partnerships and improve the results of violence prevention initiatives.
Why Violence is Classified as a Public Health Problem
As a result of the CDC’s efforts to apply rigorous research methods to describe, measure, and classify violence, the public health community gained the ability to characterize the incidence of violence in our country in a more systematic and standardized way than ever before. The resulting statistics and trends led to some startling discoveries that pushed the public health community to take action. The following findings were major factors in the initial decision to characterize violence as a public health problem:
- Violence is a leading cause of injury, disability, and death. Currently, homicide is the 2nd leading cause of death for youth (ages 10-24), and for each homicide that occurs in the U.S., there are an estimated 1,000 nonfatal violent assaults (BJS, 2003).
- Violence contributes to the pervasiveness of health disparities and inequality among minorities, youth, and low-SES populations. These subgroups of the population are disproportionately affected by violence and subsequent negative consequences. For example, homicide rates among young (10-24 years old) African-American males (58.3 per 100,000) far exceed those of Hispanic (20.9 per 100,000) and White males (3.3 per 100,000) in the same age group (CDC, 2009; CDC, 2013).
- The effects of violence are directly linked with other health problems and risk factors. Exposure to violence is associated with poor self-rated health status and the development of chronic diseases (Coker et al., 2002; Feletti, 1998), mental illness and substance use disorders (Campbell, 2002; Campbell & Lewandowski, 1997; Coker et al., 2002), and disability/restricted functional status (Campbell, 2002; Coker et al., 2002). The physical and mental effects of violence are more severe for women than for men; special women’s health concerns include unintentional pregnancies (e.g. resulting from reproductive coercion), gynecologic problems, obstetric complications, and poor birth outcomes, as well as increased risk of sexually transmitted diseases (Bailey & Daugherty, 2007; Bonomi et al., 2009; Janssen et al., 2003). For children, the effects of violence are long-lasting and severe, leading to increased risk of future victimization and/or perpetration of violence, poor relationships with peers, families, and romantic partners, trauma reactions and PTSD, and problems/delays in cognitive, emotional, and behavioral development (Shakoor & Chalmers, 1991).
- The effects of violence radiate throughout families, neighborhoods, and communities, eventually affecting the nation as a whole. In neighborhoods with high levels of violence, children and adults are less likely to use outdoor space for sports, play, and other physical activity, leading to sedentary lifestyles and increased risk of overweight/obesity and related diseases (Loukaitou-Sideris, 2006; Weir, Etelson, & Brand, 2006). Women who are victims of intimate partner violence are at increased risk of unemployment, homelessness, and loss of productivity, all of which contribute to the economic impact of violence and the disproportionate effects of violence on women’s lives (Benson et al., 2003; Coker et al., 2000; Heise & Garcia-Moreno, 2002).
For all of these reasons – and more – public health organizations and professionals began to approach violence from a new perspective, one emphasizing preventive action over reactive responses. The recognition that the effects of violence are not limited to victims and perpetrators was a defining moment; no longer could the public health community ignore the problem of violence, as we now had epidemiologic data and scientific studies detailing the devastating impact of violence on the health of millions in our country, as well as the economic and social burden of violence. The next challenge would be developing an approach to address violence as a public health problem; although this is still an ongoing challenge, the past 30 years have seen major advancements in the areas of prevention, risk reduction, and policy-related developments.
What Defines a Public Health Approach to Violence Prevention
The World Health Organization (WHO) describes the public health approach to violence prevention as a framework consisting of four main components:
- Surveillance- Defining the problem through systematic data collection in order to establish the magnitude, scope, characteristics, and consequences of violence.
- Identification of risk and protective factors- To establish the causes, correlates, and risk factors of violence, including potentially modifiable risk factors to be considered in violence prevention interventions.
- Intervention Design & Evaluation- To design, implement, and evaluate interventions in an effort to determine the most efficacious strategies for reducing violence.
- Widespread Implementation and Effective Policy Initiatives- Based on the results of evaluative research, to engage in widespread implementation of the most effective and promising intervention strategies, coupled with ongoing monitoring and evaluation of individual interventions and intervention components to identify strategies for long-term, sustainable, and effective prevention.
The nature of violence calls for a flexible, modifiable approach so that as violence-related trends shift, so does the public health response. That is why the public health approach calls for ongoing surveillance and monitoring of violence-related trends in the country, as well as the continuous development and evaluation of new intervention components and health policies.
Implications and Applications for Violence against Women: How, Who, and What is involved in a Public Health Approach to VAW
Now that we have discussed the rationale for establishing violence as a public problem and described the critical components of a public health approach to violence prevention, let us turn our focus to the application of the public health approach to the prevention of violence against women. Instead of getting into a lengthy discussion of the social ecological model (SEM) (which serves as the framework for the CDC’s violence prevention efforts), I will simply provide an outline as it applies to VAW. The SEM provides a framework for understanding the factors that affect violence, as well as the potential effects of violence prevention strategies. The SEM postulates that violence involves a complex interaction of (1) individual, (2) interpersonal/social, (3)community, and (4) societal factors. Some other models based on the social ecological perspective include 5 levels, adding organizational level-factors as the 3rd level, above interpersonal/social-level factors and below community-level factors (Bronfenbrenner, 1979; McLeroy et al., 1988). I think the best way to describe how the SEM framework applies to violence against women is to provide a visual representation of the SEM, followed by a discussion of the function of factors at each level in model in regards to promoting, maintaining, and/or preventing violence:
1. Individual Level Factors Related to VAW
Individual-level factors include those factors directly related to the perpetrator or victim of violence, including demographic characteristics (e.g. race/ethnicity; age; gender; SES), family history, personal history of victimization, childhood experiences including neglectful or permissive parenting, bullying, and abuse, and other past experiences. In addition, individual characteristics and behaviors such as drug and/or alcohol abuse are associated with both victimization and perpetration of VAW. Attitudinal variables such as personal and/or religious beliefs regarding VAW can also contribute to the acceptance of VAW within families or married couples.
Evidence linking various individual-level risk factors to the incidence of VAW is crucial when designing interventions and prevention programs. First, the evidence guides the selection of target populations; for example, we know that young women are at the greatest risk of experiencing VAW in the U.S., so it should be a priority to develop prevention programs targeting this high-risk group. The evidence regarding demographic differences in the causes, prevalence, and risk/protective factors for violence allows program planners to develop specific interventions and prevention programs based on characteristics such as age, gender, culture/ethnicity, Secondly, the evidence informs the development of specific intervention components and prevention initiatives aimed at reducing individual-level risk factors. For example, prevention programs designed for perpetrators of VAW might focus on reducing gender role stereotypes, teaching anger management skills, and changing attitudes about violence.
2. Social/Interpersonal Level Factors Related to VAW
This level focuses mainly on close relationships including significant others, peer groups, family, and other social networks. Having friends and family who engage in violent behavior and/or exhibit victim-blaming attitudes or permissive attitudes about the acceptability of violence, as well as general tolerance of violence within an individual’s social network, are associated with increased risk of perpetration and victimization of VAW.
Prevention efforts at the social/interpersonal level may include basic relationship counseling and communication skills training to encourage the development of healthy relationships and to promote the use of conflict-resolution and problem-solving skills in current relationships. Other social/interpersonal interventions focus on peer influences; for example, mentoring and peer educations programs designed to change attitudes about violence and reduce gender role stereotypes, rape myths, and victim-blaming attitudes within peer groups.
3. Organizational/Structural Level Factors related to VAW
This level of the SEM focuses on characteristics, practices, and rules/policies of organizations and institutions (e.g. schools, hospitals, workplaces) that impact the incidence of VAW. Workplace gender discrimination policies, school-based violence prevention curricula, and violence response procedures in healthcare settings are all important organizational factors that can impact the incidence and effects of VAW. Law enforcement policies and procedures are also organizational level factors, though the general law enforcement response is usually considered a community-level factor (so we will discuss it there).
Most organizational/structural level interventions are found in schools or healthcare settings. The development of early, comprehensive violence prevention programs in schools has been shown to lead to positive changes in the school environment as well as reduced violent/aggressive attitudes and behaviors among students. Interventions in healthcare settings have primarily focused on the development of universal violence screening practices and systematic response procedures including referral to appropriate resources and follow-up services. An important component of successful interventions at this level of the SEM is the cooperation and support of the participating organization(s). Some healthcare providers are reluctant to engage in screening for violence; a variety of barriers have been cited, including lack of time, forgetting (to ask), beliefs that IPV is a personal (not health) issue, stereotypes about the “type” of patient who is at risk, and lack of clarity about their roles and responsibilities (as healthcare providers) in helping victims (see Waalen et al., 2000 for a comprehensive review of barriers to screening in healthcare settings).
4. Community-Level Factors Related to VAW
At the community level, risk factors for VAW include high rates of poverty and crime, neighborhood disorder, lack of community awareness, poor bystander response, poor law enforcement response, limited and/or inadequate services for victims, and local legislation affecting funding and provision of prevention programs and victims’ services.
Many violence prevention programs utilize a community-level response (Pennington-Zoellner, 2009; Shepard & Pence, 1999; Sullivan & Bybee, 1999). Specific strategies targeting community-level factors include efforts to increase community support for funding & violence prevention initiatives, collaborating with law enforcement agencies to develop programs for offenders and victims who come in contact with the criminal justice system, developing bystander interventions, and passing new local legislation to help victims of VAW.
5. Societal/Policy-Level Factors Related to VAW
Since the focus of this blog is on policy and widespread sociocultural trends, the 5th level of the SEM (Societal/Policy Factors) is the most relevant, with its focus on societal attitudes and trends, public policy and legislation, media coverage, cultural/social norms, changes in the political climate, and related factors. Because of the widespread, pervasive impact of societal-level factors, sociocultural factors related to VAW are often the most influential and significant factors in determining the incidence, consequences, and prevention/reduction of VAW. Although factors at other levels of the SEM (e.g. individual; community) are of critical importance, efforts aimed at modifying societal-level factors have the potential to affect the greatest number of people and to have the most significant impact on nationwide VAW trends. Policy-level changes, such as those that first made domestic violence a criminal offense, have a lasting impact that is nearly impossible to match using individual-level strategies alone.
In the third post of this series, we will analyze current sociopolitical trends and recent political/legislative activities as they relate to the incidence and prevention or maintenance of VAW. However, I want to briefly give an example of a societal-level factor that is shown to impact attitudes about, public perceptions of, and even public policy response to VAW (and violence in general. This example comes from my personal research experiences under the direction of my research advisor, who specializes in this area of research. The factor I am talking about is media; in this case, the impact of media representations of VAW. In general, newspapers and television news coverage tend to present VAW, particularly intimate partner/domestic violence, as a series of isolated incidents rather than highlighting the overall trend of VAW. By including coverage of commonalities between incidents, linking current incidents with others in the area, and providing basic statistics about the prevalence of VAW when reporting on specific incidents of VAW, the media has the potential to change the public perception of VAW: rather than presenting VAW as a personal problem to be dealt with by the individuals directly involved in the incident, the media could(should) present more contextual factors related to specific incidents of VAW to raise awareness of the prevalence and nationwide impact of VAW, and ultimately increase the public responsibility for being involved in solving a societal problem. In a rigorous content analysis (click for a link to a brief overview of content analysis as a research method) of newspaper coverage of IPV, the authors found that newspaper coverage is much more likely to present incidents of IPV as isolated episodes of violence while overlooking the larger societal context (i.e. similarities between incidents; linking specific incidents to others; geographic, social, or demographic trends in overall incidence; causal, risk, & protective factors) in which these “isolated incidents” take place (Carlyle, Slater, & Chakroff, 2008). The way the media presents VAW has an impact on public perceptions of VAW; in an experimental study based on the results of the content analysis just cited, researchers found that by manipulating the information presented about perpetrators and victims in newspaper coverage of domestic violence, they could modify attributions of responsibility (for the domestic violence) and ultimately could change the cognitive and emotional appraisals of the domestic violence incident (Palazzolo & Roberto, 2011). By modifying certain aspects of the newspaper story, researchers were able to change the readers’ perceptions of the incident, including their feelings toward the victim and the perpetrator and their attitudes about punishment of perpetrators. Thus, the inclusion of contextual information in news stories about VAW could have a significant impact on the public’s response to VAW as a widespread and pervasive problem, rather than simply isolated events between individuals.
In the third post, I will discuss more about societal factors. For now, I think an appropriate way to conclude this post is to list some common myths, stereotypes, biases, and other misconceptions about VAW, along with a look at the truth behind the myth.
Common Myths and Misconceptions about VAW
1. Myth: VAW mostly occurs in lower class communities
Reality: VAW occurs across races and ethnicities, in rich and poor communities, to educated and uneducated women…it happens anywhere and everywhere, but we just don’t always recognize it as such. Because low-SES women are more likely to depend on community resources, they may be more visible as victims of VAW, but the problem crosses all sociodemographic lines.
2. Myth: Sometimes victims do things to provoke the violence
Reality: No one deserves to be the victim of violence; no action of a women can justify a violent response. VAW is a crime and those who perpetrate violence are criminals. Victims of VAW are just that… victims, who should not be blamed for their victimization.
3. Myth: Men are victims of IPV as often as women
Reality: Although men are victims of IPV, the rates are not comparable with those of women: according to the the Bureau of Justice Statistics, 85% of IPV victimizations occur among women, with the remaining 15% among men. Women also tend to suffer more severe physical, mental, and social consequences of violence when compared with men.
4. Myth: If things were that bad, the woman could/would just leave.
Reality: Leaving a violent relationship is not easy, and may even be dangerous. In fact, the most dangerous time for a woman who is being abused is when she tries to leave. (United States Department of Justice, National Crime Victim Survey, 1995)
5. Myth: VAW is not very common in relationships
Reality: VAW may be present in up to ⅓ of all relationships. 1 out of 3 women will be victimized in her lifetime. VAW is a silent epidemic affecting millions of women.
6. Myth: VAW is a personal problem.
Reality: VAW impacts all of us; it occurs in a societal context that we are all part of. We share responsibility for changing elements of our society that condone or tolerate VAW.
Coming soon: Part 3!
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