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Conclusion: Combatting Gender-Based Violence: Reflections on a Way Forward

• First Online: 25 November 2023

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• Madhumita Pandey 3  

Part of the book series: Advances in Preventing and Treating Violence and Aggression ((APTVA))

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Gender-based violence is a serious violation of human rights and with long-term physical and mental health consequences, even death. Although anyone can be a victim of violence, we know that it disproportionately affects women and girls putting them especially at risk. Whilst not a comprehensive guide, this book attempts to explore and represent a nuanced understanding of gender-based violence. It hopes to highlight the far-reaching impacts of gender-based violence, and its many related practices, along with policy and practice responses. The conclusion chapter presents a summary of the book and urges thinkers and scholars to come together from different perspectives to combat this deeply pervasive and complex crime.

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Reflections and Way Forward

Gendering Violence: Theorising the Links Between Men, Masculinities and Violence

Structures of Violence Throughout the Life Course: Cross-Cultural Perspectives of Gender-Based Violence

Alcoff, L. (1988). Cultural feminism versus post-structuralism: The identity crisis in feminist theory. Signs: Journal of Women in Culture and Society, 13 (3), 405–436.

Google Scholar  

Brownmiller, S. (1975). Against our will: Men. Women and rape . Simon and Schuster.

Griffin, S. (1971). Rape: The all-American crime. Ramparts, 10 , 26–35.

Guy, L. (2006). Re-visioning the sexual violence continuum. Sexual violence prevention. Pennsylvania Coalition to Advance Respect. Available from: https://pcar.org/resource/re-visioning-sexual-violence-continuum

Heise, L. L. (1998). Violence against women: An integrated, ecological framework. Violence Against Women, 4 (3), 262–290.

Article   PubMed   Google Scholar  

Human Rights Watch. (1999). The Enron corporation: Corporate complicity in human rights violations . Human Rights Watch.

Kelly, L. (2013). Surviving sexual violence . Wiley.

McMahon, S., & Baker, K. (2011). Changing perceptions of sexual violence over time . National Online Resource Centre on Violence Against Women.

Sanday, P. R. (2007). Fraternity gang rape: Sex, brotherhood, and privilege on campus . NYU Press. Second Edition.

Schwartz, M. D., & DeKeseredy, W. (1997). Sexual assault on the college campus: The role of male peer support . Sage Publications.

Siegel, R. B. (1996). The rule of love: Wife beating as prerogative and privacy . Faculty Scholarship Series. Paper 1092.

Walker, L. (1979). The battered woman . Harper & Row.

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Pandey, M. (2023). Conclusion: Combatting Gender-Based Violence: Reflections on a Way Forward. In: Pandey, M. (eds) International Perspectives on Gender-Based Violence. Advances in Preventing and Treating Violence and Aggression . Springer, Cham. https://doi.org/10.1007/978-3-031-42867-8_14

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10 Conclusion: Researching Violence against Women—The Point is to End it …

• Published: August 2012
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In the conclusion to the book, Chapter 10 argues that based on our knowledge of the structural determinants of violence against women, we can anticipate the gendered impacts of various political and economic policies and forces. The chapter surveys the future research agendas and questions that arise from the political economy approach to violence against women advanced in the book. Two key areas look to be the most promising approaches and likely to have the most traction in the medium to long term in achieving the goal of ending violence against women: women’s economic empowerment and men’s leadership by example. Through a review of the scholarship on policy change, the chapter explores how anti–violence against women advocates might move beyond saving one woman at a time to bring about the policy changes that recognize and address the political economy roots of violence against women.

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Preventing Violence Against Women and Children: Workshop Summary (2011)

Chapter: 6 papers on research in preventing violence against women and children.

6 Papers on Research in Preventing Violence Against Women and Children

The science behind preventing violence against women and children has evolved greatly over the past several decades. Several speakers offered overviews of the research and described the growing awareness of the complexities of the causes, risk factors, and adverse effects of such violence. They also explored potential intervention points that were illuminated by this discussion.

The first paper is a reprint from the World Health Organization publication Preventing Intimate Partner and Sexual Violence Against Women (WHO and LSHTM, 2010b). The full report provides an overview of the magnitude of the issue; this workshop summary includes Chapter 3 , which is an in-depth analysis of preventive interventions in low- and middle-income countries and was the basis for Claudia García-Moreno’s presentation at the workshop.

The second paper is adapted from the International Men and Gender Equality Survey (IMAGES), a multi-country study that explored men’s perspectives on gender norms and violence. The survey examined the evolving views of men on gender equality as well as whether these views affected men’s sense of well-being and their commitment to reducing violence.

The third paper, by Claire Crooks from the University of Western Ontario and the Centre for Addiction and Mental Health, provides an overview of the intergenerational transmission of violence. It also explores the ways in which violence against children can have long-term impacts as well as what considerations are valuable in designing interventions to prevent child maltreatment.

The final two papers, from Roger Fallot and Julian Ford, explore secondary and tertiary prevention of the long-term effects of violence and associated trauma by including the “trauma lens” in the provision of social services as well as through the empowerment of individuals who are exposed to violence. Trauma-informed care and psychosocial empowerment are two means by which survivors of violence can overcome potential adverse outcomes and prevent the recurrence of violence.

PREVENTING INTIMATE PARTNER AND SEXUAL VIOLENCE AGAINST WOMEN: PRIMARY PREVENTION STRATEGIES 1

Intimate partner and sexual violence are not inevitable—their levels vary over time and between places because of a variety of social, cultural, economic, and other factors. This can result in substantial differences between and within countries in the prevalence of intimate partner and sexual violence (WHO and LSHTM, 2010a). Most importantly, this variation shows that such violence can be reduced through well-designed and effective programs and policies. There are important factors related to both perpetration and victimization—such as exposure to child maltreatment, witnessing parental violence, attitudes that are accepting of violence, and the harmful use of alcohol—that can be addressed (WHO and LSHTM, 2010c).

At present, evidence on the effectiveness of primary prevention strategies for intimate partner and sexual violence is limited, with the overwhelming majority of data derived from high-income countries (HICs)—primarily the United States. Consequently, current high priorities in this field include adapting effective programs from high-income to lower-income settings; further evaluating and refining those for which evidence is emerging; and developing and testing strategies that appear to have potential, especially for use in low-resource settings, with rigorous evaluation of their effectiveness. At the same time, the dearth of evidence in all countries means that the generating of evidence and the incorporation of well-designed outcome evaluation procedures into primary prevention programs are top priorities everywhere. This will help to ensure that the efforts made in this area are founded upon a solid evidence base. Furthermore, program developers should be encouraged to explicitly base programs on existing theoretical frameworks and models of behavior change to allow underlying mechanisms to be identified and to make replication easier. Most of the evaluated strategies aimed at preventing intimate partner and sexual violence have

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1 Reprinted from World Health Organization and London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: World Health Organization.

targeted proximal risk factors—primarily at the individual and relationship levels of the ecological model.

The Need for Upstream Action

In the public health framework, primary prevention means reducing the number of new instances of intimate partner and sexual violence by addressing the factors that make the first-time perpetration of such violence more likely to occur. Primary prevention therefore relies on identifying the “upstream” determinants and then taking action to address these. The impact of widespread, comprehensive programs can then be measured at the population level by comparing the rates at which such violence is either experienced or perpetrated. Given the lifetime prevalence of intimate partner and sexual violence, the hundreds of millions of women worldwide in need of services would outstrip the capacity of even the best-resourced countries (WHO and LSHTM, 2010a). A problem on this scale requires a major focus on primary prevention.

Upstream actions can target risk factors across all four levels of the ecological model. To decrease intimate partner and sexual violence at the population level, it is particularly important to address the societal or outer level of the model.

Such measures include national legislation and supportive policies aimed at social and economic factors—such as income levels, poverty and economic deprivation, patterns of male and female employment, and women’s access to health care, property, education, and political participation and representation. It is sometimes even argued that programs that aim to reduce intimate partner and sexual violence against women without increasing male–female equity will ultimately not succeed in reducing violence against women. However, while many strategies involving legal and educational reform and employment opportunities are being implemented to increase gender equality, few have been assessed for their impact on intimate partner and sexual violence, making the evaluation of such strategies a priority. Any comprehensive intimate partner and sexual violence prevention strategy must address these sociocultural and economic factors through legislative and policy changes and by implementing related programs.

Creating a Climate of Non-Tolerance

Addressing risk factors at the societal level may increase the likelihood of successful and sustainable reductions of intimate partner and sexual violence. For example, when the law allows husbands to physically discipline wives, implementing a program to prevent intimate partner violence may have little impact. National legislation and supportive policies should

therefore be put in place to ensure that women have equal rights to political participation, education, work, social security, and an adequate standard of living. They should also be able to enter freely into a marriage or to leave it, to obtain financial credit, and to own and administer property. Laws and policies that discriminate against women should be changed, and any new legislation and policies should be examined for their impact upon women and men. Legislation and policies that address wider socioeconomic inequalities are likely to reduce other forms of interpersonal violence, which will in turn help to reduce intimate partner and sexual violence.

Legislation and policies that address wider socioeconomic inequalities can make a vital contribution to empowering women and improving their status in society; to creating cultural shifts by changing the norms, attitudes, and beliefs that support intimate partner and sexual violence; and to creating a climate of non-tolerance for such violence.

The human rights of girls and women need to be respected, protected, and fulfilled as part of ensuring the well-being and rights of everyone in society. As a first step toward this, governments should honor their commitments in implementing the following international legislation and human rights instruments:

• Convention on the Elimination of All Forms of Discrimination Against Women (1979);
• The Convention on the Rights of the Child (1991);
• The Declaration on the Elimination of Violence Against Women (1993);
• The Beijing Declaration and Platform for Action (1995);
• The Millennium Declaration (2000); and
• The Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women (Convention of Belem do Para, 1994).

Legislation and criminal justice systems must also be in place to deal with cases of intimate partner and sexual violence after the event. These systems should aim to help prevent further violence, facilitate recovery, and ensure access to justice—for example, through the provision of specialized police units, restraining orders, and multi-agency sexual assault response teams. Potentially, legal protection against intimate partner and sexual violence helps to reinforce non-violent social norms by sending the message that such acts will not be tolerated. Measures to criminalize abuse by intimate partners and to broaden the definition of rape have been instrumental in bringing these issues out into the open and dispelling the notion that such violence is a private family matter. In this regard, they have been very important in shifting social norms (Heise and García-Moreno, 2002; Jewkes et

al., 2002). However, the evidence surrounding the deterrent value of arrest in cases of intimate partner violence shows that it may be no more effective in reducing violence than other police responses, such as issuing warnings or citations, providing counseling, or separating couples (Fagan and Browne, 1994; Garner et al., 1995). Some studies have also shown increased abuse following arrest, particularly for unemployed men and those living in impoverished areas (Fagan and Browne, 1994; Garner et al., 1995). Protective orders can be useful, but enforcement is uneven, and there is evidence that they have little effect on men with serious criminal records (Heise and García-Moreno, 2002). In cases of rape, reforms related to the admissibility of evidence and removing the requirement for victims’ accounts to be corroborated have also been useful but are ignored in many courts throughout the world (Du Mont and Parnis, 2000; Jewkes et al., 2002).

Currently, on the whole, sufficient evidence of the deterrent effect of criminal justice system responses on intimate partner and sexual violence is still lacking (Dahlberg and Butchart, 2005). Dismantling hierarchical constructions of masculinity and femininity predicated on the control of women and eliminating the structural factors that support inequalities are likely to make a significant contribution to preventing intimate partner and sexual violence. However, these are long-term goals. Strategies aimed at achieving these long-term objectives should be complemented by measures with more immediate effects that are informed by the evidence base presented in this paper.

ASSESSING THE EVIDENCE FOR DIFFERENT PREVENTION APPROACHES

From the perspective of public health, a fundamental question is, “Do intimate partner and sexual violence prevention programs work?” That is to say, are there certain programs or strategies that are effective in preventing or reducing intimate partner and sexual violence? Effectiveness can only be demonstrated using rigorous research designs, such as randomized controlled trials or quasi-experimental designs. These typically compare the outcomes of an experimental group (which receives the program) with a control or comparison group (which is as equivalent as possible to the experimental group but which does not receive the program). One major concern is to be able to rule out alternative explanations for any observed changes in outcome in order to be confident that the changes really were due to the program and not some other factor.

Although “testimonials” are not a sound basis for evaluating the effectiveness of a program, they can provide insights into its running and on whether participants find it worthwhile. However, approaches that are based upon testimonials might expend significant resources and capacity on

programs that may be ineffective or may even make things worse (Dahlberg and Butchart, 2005). Various criteria have now been proposed to more systematically evaluate the effectiveness of different programs. The most stringent criteria involve program evaluation using experimental or quasi-experimental designs; evidence of significant preventive effects; evidence of sustained effects; and the independent replication of outcomes.

In spite of the emphasis on and visibility of efforts to promote gender equality and prevent intimate partner and sexual violence, very few of the programs reviewed in this paper meet all of these criteria, while others have not been subjected to any kind of scientific evaluation. Rigorous scientific evaluation of programs for preventing intimate partner and sexual violence are even rarer in low- and middle-income countries (LMICs). The field of intimate partner and sexual violence prevention must therefore be considered to be at its earliest stages in terms of having an established evidence base for primary prevention strategies, programs, and policies. The limited evidence base for intimate partner and sexual violence prevention has three important implications for this paper.

First, the paper extrapolates, when relevant, from the stronger evidence base for child maltreatment and youth violence prevention but clearly signals that these extrapolations remain speculative. Much, however, can be learned from the literature on youth violence and child maltreatment prevention.

Second, the paper describes those primary prevention programs that have the potential to be effective either on the grounds of theory or knowledge of risk factors—even if there is currently little or no evidence to support them or where, in certain cases, they have not yet been widely implemented. In the process, an attempt is made to draw attention to the underlying theories, principles, and mechanisms on which the programs are based. However, it is noted that a firm theoretical base and consistency with identified risk factors do not guarantee the success of a program.

Third, the paper includes programs developed in LMIC settings on condition that they have some supporting evidence (even if it is weak) or are currently in the process of being evaluated, that they appear to have potential on theoretical grounds, or that they address known risk factors. The inclusion criteria are designed on the one hand to avoid setting the bar of methodological standards too high—which would lead to the exclusion of many of the programs developed in low-resource settings on the grounds that they have no or low-quality evidence supporting them. On the other hand, setting the bar too low would run the risk of appearing to endorse programs unsupported by evidence. However, the limitations of the evidence presented are clearly spelt out and the need for rigorous outcome evaluation studies emphasized.

Although still in its early stages, there are sound reasons to believe that this field is poised to expand rapidly in coming years. Some programs have been demonstrated to be effective following rigorous outcome evaluations, evidence is beginning to emerge to support the effectiveness of many more, and suggestions for potential strategies have proliferated. Furthermore, tried and tested methods for developing effective evidence-based primary prevention programs and policies for other forms of interpersonal violence have been reported. The field of evidence-based intimate partner and sexual violence prevention now requires an open mind to promising approaches and to innovative new ideas at all stages of the life cycle.

SUMMARY TABLES OF PRIMARY PREVENTION STRATEGIES AND PROGRAMS

Table 6-1 summarizes the strength of evidence for the effectiveness of those strategies to prevent intimate partner violence and sexual violence for which some evidence is available. Strategies are grouped according to life stage. An important distinction must be drawn between a strategy and a specific program. Although specific programs may have been demonstrated to be effective, this in no way implies that all other programs categorized under the same strategy are also effective. For example, the Nurse Family Partnership, developed in the United States, is a home-visitation program that has been demonstrated to be effective in preventing child maltreatment. Nevertheless, it is the only program within the broader strategy of home visitation (which includes a multitude of different programs) that is supported by solid evidence of its effectiveness (MacMillan et al., 2009). The outcome measures of effectiveness are described in Box 6-1 .

Strategies are ranked for their effectiveness in preventing intimate partner violence and sexual violence as follows:

• Effective: strategies that include one or more programs demonstrated to be effective. Effective refers to being supported by multiple well-designed studies showing prevention of perpetration and/or experience of intimate partner and/or sexual violence.
• Emerging evidence: strategies that include one or more programs for which evidence of effectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing positive changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence.
• Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence.
• Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence.
• Ineffective: strategies that include one or more programs shown to be ineffective. Ineffective refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence.
• Probably harmful: strategies that include at least one well-designed study showing an increase in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/or sexual violence.

As shown in Table 6-1 , there is currently only one strategy for the prevention of intimate partner violence that can be classified “effective” at preventing actual violence. This is the use of school-based programs to prevent violence within dating relationships. However, only three such programs—described below—have been demonstrated to be effective, and these findings cannot be extrapolated to other school-based programs using a different approach, content, or intensity. At present, there are no correspondingly evaluated effective programs against sexual violence.

TABLE 6-1 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence for Which Some Evidence Is Available

1—Effective: strategies that include one or more programs demonstrated to be effective; effective refers to being supported by multiple well-designed studies showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence;

2—Emerging evidence of effectiveness: strategies that include one or more programs for which evidence of effectiveness is emerging; emerging evidence refers to being supported by one well-designed study showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence or studies showing positive changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence;

3—Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence;

4—Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging; emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence;

5—Ineffective: strategies that include one or more programs shown to be ineffective; ineffective refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experiencing of intimate partner and/or sexual violence;

6—Probably harmful: strategies that include at least one well-designed study showing an increase in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/or sexual violence; N/A—Not applicable.

BOX 6-1 Outcome Measures of Effectiveness

The effectiveness of a program can be evaluated in terms of three different types of outcome—each of which can be measured at different intervals after the program:

• Changes in knowledge, attitudes, and beliefs regarding intimate partner and sexual violence. This is the weakest of the three outcomes because changes in knowledge, attitudes, and beliefs do not necessarily lead to changes in violent behavior. In this respect, even successful programs in this area cannot be assumed to be effective at preventing actual intimate partner or sexual violence without further research demonstrating corresponding reductions in violent behavior.
• Reductions in the perpetration of intimate partner or sexual violence.
• Reductions in the experience of intimate partner or sexual violence.

Intimate partner violence is not a unitary construct and can take different forms, including physical, sexual, and psychological violence. Despite this, outcome evaluations generally do not examine effectiveness in relation to these different types of violence—nor are programs generally designed to address specific types of intimate partner violence in particular. It is possible that programs considered to be effective or promising may only be so for certain forms of intimate partner violence (Whitaker et al., 2007a).

Table 6-2 lists those strategies for which there is currently no evidence or very weak evidence but that appear to have potential on the grounds of theory, known risk factors, or outcome evaluations that are methodologically of lower quality; it also includes some promising strategies that are currently undergoing evaluation.

All the strategies reviewed have been organized according to the main life stages. When strategies are relevant to more than one life stage, they have been categorized under the stage at which they are most often delivered. Strategies relevant to all life stages are described last. Because of the way programs are organized, intimate partner violence is considered here to include instances of sexual violence that occur within an intimate partnership, while sexual violence is used here to refer to sexual violence occurring outside intimate partnerships (i.e., perpetrated by friends, acquaintances, or strangers). Dating violence can be considered to incorporate both possibilities because dating partners can range from being little more than acquaintances to more intimate partners. However, in Table 6-1 and Table 6-2 dating violence is classified for the sake of convenience under intimate partner violence.

TABLE 6-2 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence with Potential

During Infancy, Childhood, and Early Adolescence

Home-visitation and parent-education programs to prevent child maltreatment.

As noted in earlier sections of this document, a history of child maltreatment substantially increases the risk of an individual becoming either a perpetrator or victim of intimate partner violence and of sexual violence. It is therefore reasonable to assume that preventing child maltreatment has the potential to reduce subsequent intimate partner and sexual violence (Foshee et al., 2009). However, direct evidence of the effect of such programs on the levels of intimate partner violence is currently still lacking.

In general, however, reducing the risk of the different forms of child maltreatment reviewed in Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence (WHO and International Society for Prevention of Child Abuse and Neglect, 2006) can contribute to reducing the intergenerational transmission of violence and abuse. The most promising strategies for preventing child maltreatment in this area include home-visitation and parent-education programs (Mikton and Butchart, 2009). However, neither type of program has been evaluated for its long-term effects on the prevention of intimate partner and sexual violence among the grown-up children of parents who were involved in such programs.

Improve Maternal Mental Health

Maternal depression (which affects at least 1 in 10 new mothers) can interfere with good bonding and attachment processes. This in turn

increases the risk of persistent conduct disorders in children (a key risk factor for the later perpetration of violence) by as much as five-fold (Meltzer et al., 2003). Effective approaches for addressing maternal depression include early recognition (antenatally and postnatally) followed by peer and social support, psychological therapies, and antidepressant medication (National Collaborating Centre for Mental Health, 2007). The long-term effects on the children of mothers treated for maternal depression in terms of their later involvement in intimate partner and sexual violence have not been assessed, but the approach appears to have potential.

Identify and Treat Conduct and Emotional Disorders in Children

Conduct disorders in childhood and adolescence—a precursor of antisocial personality disorder—are associated with an increased risk of experiencing and/or perpetrating intimate partner and sexual violence. Additionally, emotional disorders are associated with later depression and anxiety in adult years and can increase the risk of postnatal depression and persistent maternal depression. As outlined above, these in turn contribute to as much as a five-fold increased risk of emotional or conduct disorders in the children of mothers with poor mental health (Meltzer et al., 2003). The early identification and effective treatment of conduct and emotional disorders in childhood and adolescence could therefore be expected to reduce the occurrence of subsequent intimate partner and sexual violence.

Good evidence exists of the links between early conduct disorder and later involvement in violence as both victim and perpetrator and of the effectiveness of interventions to reduce conduct disorder and youth offending. However, despite their potential, there is at present no evidence showing that the strategy of identifying and treating conduct and emotional disorders in childhood or early adolescence leads to reductions in intimate partner and sexual violence during later adolescence and adulthood.

Interventions for Children and Adolescents Subjected to Child Maltreatment and/or Exposed to Intimate Partner Violence

Because children or adolescents who have been subjected to child maltreatment or exposed to parental violence are at increased risk of becoming the perpetrators and victims of intimate partner and sexual violence, interventions in this area are particularly important.

One meta-analysis examined 21 programs involving psychological interventions targeted at children and adolescents who had experienced child maltreatment (Skowron and Reinemann, 2005). Results suggested that psychological treatments for child maltreatment yielded improvements among participants: Some 71 percent of treated children appeared to be functioning

better than their non-treated counterparts. All of the interventions were designed to improve cognitive, emotional, and behavioral outcomes, with 11 of the studies considered to be experimental. A randomized trial of one of these programs used adolescent dating violence as an outcome and found a reduction in the experiencing and perpetration of physical and emotional abuse (Wolfe et al., 2003).

Psychological interventions for children and adolescents subjected to child maltreatment and/or exposed to intimate partner violence therefore appear to represent a strategy for the prevention of intimate partner violence supported by emerging evidence. Their effect on sexual violence remains unclear at present.

School-Based Social and Emotional Skills Development

Factors such as impulsiveness, lack of empathy, and poor social competence—which may be indicative of conduct disorder, a precursor of antisocial personality disorder—are important individual risk factors for perpetrating various forms of violence, including intimate partner and sexual violence. Cognitive-behavioral skills training programs and social development programs that address these factors in children and young adolescents are therefore promising strategies for preventing subsequent violence. These programs seek to promote pro-social behavior and to provide social and emotional skills such as problem solving, anger management, increased capacity for empathy, perspective taking, and non-violent conflict resolution. They can either be population-based or targeted at those at high risk and are typically delivered in schools. Although there is strong evidence that such programs can be effective in reducing youth violence and improving social skills, there is currently no evidence that they can reduce sexual and dating violence among adolescents and young adults or intimate partner and sexual violence later in life (Lösel and Beelmann, 2003). Nonetheless, they appear to have potential in preventing subsequent intimate partner violence and sexual violence.

School-Based Training to Help Children to Recognize and Avoid Potentially Sexually Abusive Situations

School-based programs to prevent child sexual abuse by teaching children to recognize and avoid potentially sexually abusive situations are run in many parts of the world, but evaluated examples come mainly from the United States. A recent systematic review of reviews found that although school-based programs to prevent child sexual abuse are effective at strengthening knowledge and protective behaviors against this type of abuse, evidence showing whether such programs reduce its actual

occurrence is lacking (Mikton and Butchart, 2009). Two studies that measured future experience of sexual abuse as an outcome reported mixed results (Finkelhor et al., 1995; Gibson and Leitemberg, 2000). Nonetheless, emerging evidence of their effectiveness in preventing subsequent sexual abuse victimization appears to support the use of such programs. Further research on the long-term impact on actual sexual abuse victimization is, however, required (Finkelhor, 2009).

Bullying Prevention Programs

Bullying has both immediate and long-term consequences on perpetrators and victims, including social isolation and the exacerbation of antisocial behavior that can lead to juvenile and adult crime (for perpetrators) and depression, suicidal ideation, social isolation, and low self-esteem (for victims). Some of these consequences may increase the risk of later involvement in intimate partner and/or sexual violence either as perpetrator or victim. A number of reviews have concluded that bullying prevention programs are effective in reducing bullying (Smith et al., 2004; Baldry and Farrington, 2007). A systematic review and meta-analysis of school-based programs to reduce bullying and victimization showed that, overall, school-based bullying prevention programs are effective in reducing both bullying and being bullied (Farrington and Ttofi, 2009). On average, bullying perpetration decreased by 20 to 23 percent and the experiencing of being bullied decreased by 17 to 20 percent.

Although such programs are likely to have broader potential benefits, evidence of their effect on the experiencing or perpetrating of intimate partner and/or sexual violence later in life is limited. A number of studies, however, have demonstrated an association between bullying and sexual harassment. Some sexual violence prevention programs in the United States include bullying prevention components for elementary- and middle-school-age children (Basile et al., 2009).

During Adolescence and Early Adulthood

School-based programs to prevent dating violence.

Dating violence is an early form of partner violence, occurring primarily in adolescence and early adulthood, and experienced within a “dating relationship.” Dating violence prevention programs have been the most evaluated of all intimate partner violence prevention programs, with 12 evaluations of adolescent dating violence prevention programs, including 5 randomized trials (Foshee et al., 2008). Targeted at early sexual relationships, in contexts where marriage is usually entered into from about 20

years of age, these programs have been shown to prevent dating violence and sexual violence. Furthermore, dating violence appears to be a risk factor for intimate partner violence later in life and is also associated with injuries and health-compromising behaviors, such as unsafe sex, substance abuse, and suicide attempts (Smith et al., 2003; Wolfe et al., 2009). Accordingly, the prevention of dating violence can be assumed to be preventive of intimate partner and sexual violence in later life (Foshee et al., 2009).

One dating violence prevention program that has been well evaluated using a randomized controlled design is Safe Dates. Positive effects were noted in all four published evaluations (Foshee et al., 1998, 2000, 2004, 2005). Foshee et al. (2005) examined the effects of Safe Dates in preventing or reducing perpetration and victimization over time using four waves of follow-up data. The program significantly reduced psychological, moderate physical, and sexual dating violence perpetration at all four follow-up periods. The program also significantly reduced severe physical dating abuse perpetration over time, but only for adolescents who reported no or average prior involvement in severe physical perpetration at baseline. Program effects on the experiencing of sexual dating violence over time were marginal. Safe Dates did not prevent or reduce the experiencing of psychological dating abuse. Program effects were primarily due to changes in dating violence norms, gender role norms, and awareness of community services. The program did not affect conflict-management skills. The program was found to have had a greater impact upon primary prevention as opposed to preventing re-abuse among those with a history of previous abuse (Foshee et al., 1996, 1998, 2000, 2004, 2008).

Two school-based programs for preventing dating violence in Ontario, Canada, have also been evaluated (Wolfe et al., 2003, 2009). An outcome evaluation of The Fourth R: Skills for Youth Relationships used a cluster-randomized design and found that, based on self-reported perpetration at 2.5-year follow-up, rates of physical dating violence were 7.4 percent in the program group and 9.8 percent in the control group—a difference of 2.4 percent. However, for reasons not fully understood, this decrease of self-reported perpetration was found in boys (7.1 percent in controls versus 2.7 percent in intervention students) but not in girls (12.1 percent versus 11.9 percent). The program—evaluated by sampling more than 1,700 hundred students aged 14 to 15 years from 20 public schools—was integrated into the existing health and physical education curriculum and taught in sex-segregated classes. An underlying theme of healthy, nonviolent relationship skills was woven throughout the 21 lessons, which included extensive skills development using graduated practice with peers to develop positive strategies for dealing with pressures and the resolution of conflict without abuse or violence. The cost of training and materials averaged 16 Canadian dollars per student (Wolfe et al., 2009).

The other Canadian school-based program that has been evaluated is the Youth Relationship Project (Wolfe et al., 2003). This community-based program aimed to help 14- to 16-year-olds who had been maltreated as children to develop healthy non-abusive relationships with dating partners. The program educated participants on both healthy and abusive relationships and helped them to acquire conflict resolution and communication skills. A randomized controlled trial showed that the program had been effective in reducing incidents of physical and emotional abuse and the symptoms of emotional distress over a 16-month period after the program (Wolfe et al., 2003). These three school-based programs therefore appear to be effective for the prevention of physical, sexual, and emotional violence in dating relationships in adolescents and may also help to prevent intimate partner and sexual violence among adults. However, there are a number of necessary caveats concerning dating violence prevention programs. Although high-quality evaluations of the three programs described above found reduced violence at moderately long follow-up periods, the evaluations of most other programs have been of poor quality, used short follow-up periods, and only included knowledge and attitude changes as outcomes (for which some positive effects were found). Whether changes in knowledge and attitudes lead to corresponding changes in behavior is uncertain (Whitaker et al., 2006). Moreover, further research is needed to evaluate the effectiveness of dating violence prevention programs in the longer term, when integrated with programs for the prevention of other forms of violence, and when delivered outside North America and in resource-poor settings. A particular concern that has been raised about programs such as Safe Dates is the extent to which they are culture-bound to North America and hence may be of limited value in LMICs.

School-Based Multi-Component Violence Prevention Programs

Universal multi-component programs are the most effective school-based violence prevention programs (Dusenbury et al., 1997; Adi et al., 2007; Hahn et al., 2007). Such programs are delivered to all pupils and go beyond the normal components of curriculum-based teaching to include teacher training in the management of behavior, parenting education, and peer mediation. There can also be after-school activities and/or community involvement. One systematic review estimated that, on average, universal multi-component programs reduced violence by 15 percent in schools that delivered the programs compared to those that did not (Hahn et al., 2007).

School-based multi-component violence prevention programs have mostly focused upon bullying and youth violence as outcomes. Given that the risk factors for youth violence and intimate partner and sexual violence are to some extent shared, such programs would appear to have some

potential for preventing these latter forms of violence. However, there is currently no evidence of their effectiveness in these areas.

Sexual Violence Prevention Programs for School and College Populations

In the United States, the majority of programs for the primary prevention of sexual violence by strangers, acquaintances, and non-intimate dating partners have focused on college students—though they have also increasingly been delivered to high school and middle school pupils. In settings where few go into higher education this approach has obvious limitations. Developmentally, it makes sense to educate young people in appropriate and inappropriate sexual behavior at a time when their sexual identities are forming and their attitudes to romantic partners are beginning to take shape. However, once again there is a severe paucity of evidence to confirm the effectiveness or otherwise of such programs (Schewe, 2007).

Two recent systematic reviews in the United States have evaluated the effectiveness of specific primary prevention programs in this area. The first of these included college, high-school, and middle-school populations and found that programs usually included several components (most often the challenging of rape myths, information on acquaintance and date rape, statistics on rape, and risk reduction and protective prevention skills) (Morrison et al., 2004). Of the 50 studies reviewed, 7 (14 percent) showed exclusively positive effects on knowledge and attitudes, but none used the actual experiencing or perpetration of violence as outcomes; 40 (80 percent) reported mixed effects; and 3 (6 percent) indicated no effect. The studies also had a number of serious methodological limitations that led the reviewers to conclude that the effectiveness of such programs remains unclear. These limitations included the use of knowledge and attitude as the only outcome measures, studies of higher-quality design showing poorer results, and the positive effects of the programs being found to diminish over time.

The second systematic review examined 69 education programs for college students on sexual assault and found little evidence of the effectiveness of such programs in preventing such assaults or in increasing levels of rape empathy (the cognitive–emotional recognition of a rape victim’s trauma) or awareness (Anderson and Whiston, 2005). However, the programs evaluated were found to increase factual knowledge about rape and to beneficially change attitudes toward it. The acute shortage of studies that use behavior as outcomes led the authors to conclude that more research using such outcomes was needed before definitive conclusions could be reached. The effectiveness of such programs, on the basis of these two reviews, is currently unclear. It has been found that the provision of “factual” information as part of addressing rape myths appears to have no effect on attitudes to rape or on the levels of empathy for its victims (Schewe, 2007).

Evaluation studies indicate that rape awareness and knowledge programs based on imparting such information rarely work. Similarly, educating women on effective self-defense strategies without teaching them actual self-defense skills has been found to be of questionable value and may even be potentially harmful in some contexts (Schewe, 2007). Two evaluations of programs that focused on a discussion of self-defense strategies without teaching the corresponding skills found no reduction in sexual assault risk at follow-up (Breitenbecher and Gidycz, 1998; Breitenbecher and Scarce, 2001). Rape prevention programs that use a style of personal confrontation with participants actually appear to be harmful. One study evaluating such a program found that it resulted in greater tolerance among men of the justifiability of rape (Fisher, 1986).

A number of other approaches have been tried for which there is presently very limited evidence of effectiveness. Encouraging victim empathy has been associated with both improvements and worsening of attitudes toward sexual violence and the acceptance of rape myths (Schewe, 2007). Educating women on how to avoid high-risk situations (such as hitchhiking, abusing alcohol, or becoming involved with older men) has also led to mixed results, and it too has been associated with greater acceptance of rape myths. To avoid the encouragement of victim-blaming, it is crucial that such education is delivered to female-only audiences. There have also been mixed indications of the effectiveness of programs that emphasize the negative consequences of sexual violence to men and that try to persuade them to see such sex as less rewarding than consensual sex.

Finally, several programs for preventing sexual violence have been proposed that have as yet been neither widely implemented nor evaluated. These include providing universal rape prevention education and parent education in sexual violence prevention throughout schools and workplaces, educating teachers and coaches about sexual violence and its prevention, and changing organizational practices to include activities such as mandatory training in the prevention of violence against women.

During Adulthood

Empowerment and participatory approaches to reduce gender inequality.

Empowerment is an approach that helps individuals and communities to identify their own problems and to develop, through participatory methods, the resources, skills, and confidence needed to address them. This approach emphasizes the role of individuals and communities as agents of change and prioritizes community ownership and leadership of the entire process. Comprehensive programs deal with the community as a whole or

with multiple subgroups of the population, have several components, and are designed to effect social change by creating a supportive environment for changing individual and community attitudes and behavior. Such approaches often utilize a combination of participatory rapid needs assessment, education or training, public awareness campaigns, and community action (Lankester, 1992).

Two examples of empowerment approaches for preventing intimate partner violence are the use of microfinance with gender-equality training and the Stepping Stones training package.

A number of initiatives involving microfinance have now been established to increase the economic and social power of women. These initiatives provide small loans to mobilize income-generating projects that can alleviate poverty. Stand-alone credit and rural development programs such as Grameen Bank and the Bangladesh Rural Advancement Committee target women and appear to show some promise in reducing intimate partner violence. However, the evaluation of such programs needs to take into account reports of lenders exploiting disadvantaged borrowers with very high rates of interest, which can trap people in debt and contribute to further poverty, as well as reports of increases in intimate partner violence (Kabeer, 2001; Rhyne, 2001). Disagreements over the control of newly acquired assets and earnings combined with women’s changing attitudes toward traditional gender roles, improved social support, and greater confidence in defending themselves against male authority has sometimes led to marital conflicts and violence against women perpetrated by their partners (Schuler et al., 1996). Increases in violence following participation in credit programs have also been reported elsewhere, at least in the initial stages of membership (Rahman, 1999; Ahmed, 2005). Pre-existing gender roles appear to affect the violence-related outcomes of credit programs—in communities with rigid gender roles, women’s involvement can result in increased levels of intimate partner violence not seen in communities with more flexible gender roles (Koenig et al., 2003). The outcome evaluations conducted to date of such stand-alone microfinance programs have not been as rigorous as that of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) program described in Box 6-2 .

Although microfinance programs can operate as discrete entities, IMAGE is an example of such a program that also incorporates education sessions and skills-building workshops to help change gender norms, improve communication in relationships, and empower women in other ways and has been shown to be effective at reducing intimate partner violence (Kim et al., 2009). Through education and skills building for women and engagement with boys and men and the broader community, IMAGE was effective in reducing intimate partner violence and supporting women. This was achieved without producing the type of negative effects seen in other

BOX 6-2 Intervention with Microfinance for AIDS and Gender Equity (IMAGE)

One of the most rigorously evaluated and successful microfinance and women’s empowerment programs to date has been the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in South Africa. This program targets women living in the poorest households in rural areas, and combines a microfinance program with training and skills-building sessions on preventing HIV infection, and on gender norms, cultural beliefs, communication, and intimate partner violence.

The program also encourages wider community participation to engage men and boys. It aims to improve women’s employment opportunities, increase their influence in household decisions and their ability to resolve marital conflicts, strengthen their social networks, and reduce HIV transmission.

A randomized controlled trial found that two years after completing the program, participants reported experiencing 55 percent fewer acts of violence by their intimate partners in the previous 12 months than did members of a control group. In addition, participants were more likely to disagree with statements that condone physical and sexual violence toward an intimate partner (52 percent of participants versus 36 percent of the control group).

settings where cultural shifts and other changes have taken place in the absence of efforts to engage men.

The Stepping Stones training package is another participatory approach that promotes communication and relationship skills within communities. Training sessions are run in parallel for single-sex groups of women and men. Originally designed for the prevention of HIV infection, several communities have now incorporated elements of violence prevention. The approach has been used in 40 LMICs in Africa, Asia, Europe, and Latin America. Versions of the program have now been evaluated in a number of countries (Welbourn, 2009). The most thorough evaluation to date has been a randomized controlled trial in the Eastern Cape province of South Africa, with participants aged 15 to 26 years. This study indicated that a lower proportion of men who had participated in the program committed physical or sexual intimate partner violence in the two years following the program compared with men in a control group (Jewkes et al., 2008).

Furthermore, an evaluation in Gambia compared two villages where the program was carried out with two control villages and followed participating couples over one year. It found that, compared to couples not receiving the program, communication was improved and quarrelling reduced in participating couples. In addition, participating men were found

to be more accepting of a wife’s refusal to have sex and less likely to beat her (Paine et al., 2002).

SASA! is an “activist kit” for mobilizing communities to prevent violence against women, focusing in particular on the connection between HIV/AIDS and violence against women. “Sasa” is a Kiswahili word meaning “now,” and the kit includes practical resources; activities-monitoring and assessment tools to support local activism, media, and advocacy activities; and communication and training materials. It targets community norms and traditional gender roles and aims to change knowledge, attitudes, skills, and behavior to redress the power imbalance between men and women. It was created by Raising Voices, a Uganda-based nongovernmental organization that works in the Horn of Africa and Southern Africa. The London School of Hygiene and Tropical Medicine, Raising Voices, the Kampala-based Center for Domestic Violence Prevention, and Makerere University are currently conducting a joint randomized controlled trial to evaluate the effectiveness of the approach.

Thus evidence is emerging of the effectiveness in LMICs of empowerment and participatory approaches in preventing intimate partner violence through microfinance combined with gender-equality training and through the Stepping Stones training package.

The results of the SASA! evaluation are expected to provide further evidence on the effectiveness of this type of program, which seems to have potential for reducing intimate partner violence. There is a need to replicate and scale up this type of approach. Several other participatory and community-empowerment strategies to prevent intimate partner violence may be of value, although these have seldom been implemented as primary prevention strategies or rigorously evaluated. Couples counseling focuses on violence and/or substance abuse and may be effective for couples who have not resorted to intimate partner violence but who may be at risk. Family programs to promote positive communication and healthy relationships and prevent family violence might also be effective in preventing both intimate partner and sexual violence, given the importance of family factors in their development. In Ecuador one intimate partner violence prevention program that was implemented (but not evaluated) consisted of close friends or relatives being assigned to “monitor” newlyweds and to intervene should serious conflict arise. There is also some initial evidence that social cohesion among residents increases a community’s capacity to manage crime and violence (by increasing “collective efficacy”), leading to decreases in both lethal and non-lethal intimate partner violence. Such community-level interventions can beneficially change community-level characteristics and warrant further evaluation.

Home Visitation Programs to Prevent Intimate Partner Violence

A systematic review of home visitation programs (Bilukha et al., 2005) identified only one evaluation study (Eckenrode et al., 2000) that examined the effect of home visitation on levels of intimate partner violence. No significant difference in the incidence of such violence among the program and control groups was found.

A five-year project (2007-2012) funded by U.S. Centers for Disease Control and Prevention is currently under way, which will develop, test, and evaluate a program to reduce intimate partner violence among low-income women enrolled in the Nurse Family Partnership during pregnancy and in the first two years postpartum. The Nurse Family Partnership is a nurse home visitation program of demonstrated effectiveness in reducing child maltreatment. The primary aims are to develop a model for an in-home intimate partner violence prevention program for enrolled mothers at risk of such violence, to test the feasibility and acceptability of the program, and in a randomized controlled study to compare the effectiveness of the approach to that of the Nurse Family Partnership alone.

An evaluation of the Hawaii Healthy Start Program—an early childhood home visitation program—found that when compared with a control group, the participation of mothers was associated with reduced perpetration and experiencing of intimate partner violence. The effect persisted for the first three years of a child’s life, with small decreases in both the perpetration and experiencing of maternal intimate partner violence at follow-up when the child was seven and nine years old (Bair-Merritt et al., 2010). Evidence for the effectiveness of such programs can currently thus be considered to be unclear.

U.S. Air Force Multi-Component Program to Prevent Suicide

This program was primarily aimed at reducing the rate of suicide among U.S. Air Force (USAF) personnel but was also shown to reduce “family violence,” which included both intimate partner violence and child maltreatment. The program was based upon:

• the full involvement of the USAF leadership to ensure the program had the support of the entire service;
• incorporation of suicide prevention into professional military education;
• community education and training of military personnel to identify risk factors, provide appropriate intervention, and refer individuals who were potentially at risk of suicide; and
• the creation of a multidisciplinary team consisting of mental health providers, medical providers, and chaplains who could respond to traumatic events at the community level, including suicides.

The program reduced the rate of suicide by 33 percent and the rates of severe and moderate family violence by 54 percent and 30 percent, respectively. Because of the combination of intimate partner violence and child maltreatment in the same outcome measure, it is not possible to determine the effect of the program on intimate partner violence specifically (Knox et al., 2003); hence this program is considered to have potential, rather than being supported by emerging evidence.

All Life Stages

Reduce access to and harmful use of alcohol.

Harmful use of alcohol is associated with the perpetration of intimate partner and sexual violence (WHO and LSHTM, 2010c). It can therefore be hypothesized that reducing both access to alcohol and its harmful use will lead to reductions in intimate partner and sexual violence. However, the relationship between harmful use of alcohol and violence is complex—not everyone who drinks is at equally increased risk of committing violence, and intimate partner and sexual violence can occur at high rates in cultures where alcohol use is taboo. Furthermore, there is disagreement among experts on whether or not alcohol can be considered to be a “cause” of intimate partner and sexual violence or whether it is better viewed as a moderating or contributory factor. It seems clear, however, that individual and societal beliefs that alcohol causes aggression can lead to violent behavior being expected when individuals are under the influence of alcohol and to alcohol being used to prepare for and excuse such violence. To date, research focusing on the prevention of alcohol-related intimate partner and sexual violence is scarce. There is, however, some emerging evidence suggesting that the following strategies aimed at reducing alcohol consumption may be effective in preventing intimate partner violence:

• Reducing alcohol availability: In Australia, a community intervention that included restricting the hours of sale of alcohol in one town reduced the number of domestic violence victims presenting to hospital (Douglas, 1998). In Greenland, a coupon-based alcohol rationing system implemented in the 1980s that entitled adults to alcohol equivalent to 72 beers per month saw a subsequent 58 percent reduction in the number of police call outs for domestic

quarrels (Finnish Foundation for Alcohol Studies and World Health Organization, 2003).

• Regulating alcohol prices: Increasing the price of alcohol is an effective means of reducing alcohol-related violence in general (Chaloupka et al., 2002). Although research evaluating the effectiveness of this approach in reducing intimate partner violence specifically is scarce, one study using economic modeling estimated that in the United States a 1 percent increase in the price of alcohol may decrease the probability of intimate partner violence toward women by about 5 percent (Markowitz, 2000).
• Treatment for alcohol-use disorders: In the United States, treatment for alcohol dependence among males significantly decreased husband-to-wife and wife-to-husband intimate partner violence 6 and 12 months later, suggesting that such treatment may also be an effective primary prevention measure (Stuart et al., 2003).

Intimate partner and sexual violence may also be reduced through primary prevention programs to reduce the more general harms caused by alcohol (Anderson et al., 2009). Approaches for which effectiveness is well supported by evidence include:

• Making alcohol less available: This can be achieved by introducing minimum purchase-age policies and reducing the density of alcohol retail outlets and the hours or days alcohol can be sold. Such an approach has been shown to lead to fewer alcohol-related problems, including homicide and assaults (Duailibi et al., 2007).
• Banning of alcohol advertising: Alcohol is marketed through increasingly sophisticated advertising in mainstream media; through the linking of alcohol brands to sports and cultural activities; through sponsorships and product placements; and through direct marketing via the Internet, podcasting, and mobile telephones. The strongest evidence for the link between alcohol advertising and consumption comes from longitudinal studies on the effects of various forms of alcohol marketing—including exposure to alcohol advertising in traditional media and promotion in the form of movie content and alcohol-branded merchandise—on the initiation of youth drinking and on riskier patterns of youth drinking (Anderson et al., 2009). However, evidence showing that such measures reduce intimate partner and sexual violence is currently lacking.
• Individually directed interventions to drinkers already at risk: These include screening and brief interventions. Alcohol screening and brief interventions in primary health care settings have

proven effective in reducing levels and intensity of consumption in LMICs and HICs (Finnish Foundation for Alcohol Studies and World Health Organization, 2003). However, their direct effect on alcohol-related intimate partner violence has not been measured. Evidence indicates that drinkers may reduce their consumption by as much as 20 percent following a brief intervention and that heavy drinkers who receive such an intervention are twice as likely to reduce their alcohol consumption as heavy drinkers who receive no intervention. Brief interventions include the opportune provision of advice and information in health or criminal justice settings (typically during a 5- to 10-minute period) but can also extend to several sessions of motivational interviewing or counseling (FPH, 2008; Sheehan, 2008).

School-based education on alcohol does not appear to reduce harm, but public-information and education programs (while again apparently ineffective at reducing alcohol-related harm) can increase the attention given to alcohol on public and political agendas (Anderson et al., 2009).

As with most primary prevention programs to prevent intimate partner and sexual violence, programs to reduce access to and harmful use of alcohol have mainly been conducted and evaluated in HICs, and little is known of their suitability or effectiveness outside such countries. For many LMICs, programs such as efforts to strengthen and expand the licensing of outlets could be of great value in reducing alcohol-related intimate partner and sexual violence. In many developing societies, a large proportion of alcohol production and sales currently takes place in unregulated informal markets. One study in São Paolo, Brazil, found that just 35 percent of alcohol outlets surveyed had a license of some form, and that alcohol vendors (whether licensed or not) faced few apparent restrictions on trading (Laranjeira and Hinkly, 2002). Furthermore, in many LMICs there are far fewer specialist health facilities, reducing the opportunities for alcohol treatment or screening. In such settings it may instead be beneficial to develop the role of primary health care workers or general practitioners in identifying and alleviating the harmful use of alcohol.

Although evidence for the effectiveness of measures to reduce access to and harmful use of alcohol is only beginning to emerge and high-quality studies showing their impact on intimate partner and sexual violence are still largely lacking, alcohol-related programs for the prevention of intimate partner violence and sexual violence appear promising. The strong association between alcohol and intimate partner and sexual violence suggests that primary prevention interventions to reduce the harm caused by alcohol could potentially be effective. Approaches to preventing alcohol-related intimate partner and sexual violence should also address the social acceptability of

excessive drinking as a mitigating factor in violence, while altering normative beliefs about masculinity and heavy drinking. There remains a pressing need for additional research to evaluate the effectiveness of such approaches in reducing intimate partner and sexual violence, especially in LMICs.

Change Social and Cultural Norms Related to Gender That Support Intimate Partner and Sexual Violence

Cultural and social gender norms are the rules or “expectations of behavior” that regulate the roles and relationships of men and women within a specific cultural or social group. Often unspoken, these norms define what is considered appropriate behavior, govern what is and is not acceptable, and shape the interactions between men and women. Individuals are discouraged from violating these norms through the threat of social disapproval or punishment or because of feelings of guilt and shame in contravening internalized norms of conduct. Often traditional social and cultural gender norms make women vulnerable to violence from intimate partners, place women and girls at increased risk of sexual violence, and condone or support the acceptability of violence ( Box 6-3 ).

Efforts to change social norms that support intimate partner and sexual violence are therefore a key element in the primary prevention of these

BOX 6-3 Examples of Social and Cultural Norms That Support Violence Against Women

• A man has a right to assert power over a woman and is considered socially superior. Examples: India (Mitra and Singh, 2007), Nigeria (Ilika, 2005), and Ghana (Amoakohene, 2004).
• A man has a right to physically discipline a woman for “incorrect” behavior. Examples: India (Go et al., 2003), Nigeria (Adegoke and Oladeji, 2008), and China (Liu and Chan, 1999).
• Physical violence is an acceptable way to resolve conflict in a relationship. Example: United States (Champion and Durant, 2001).
• Intimate partner violence is a “taboo” subject. Example: South Africa (Fox et al., 2007).
• Divorce is shameful. Example: Pakistan (Hussain and Khan, 2008).
• Sex is a man’s right in marriage. Example: Pakistan (Hussain and Khan, 2008).
• Sexual activity (including rape) is a marker of masculinity. Example: South Africa (Petersen et al., 2005).
• Girls are responsible for controlling a man’s sexual urges. Example: South Africa (Ilika, 2005; Petersen et al., 2005).

forms of violence. Approaches have been adopted, although rarely evaluated, throughout the world to break the silence that often surrounds intimate partner and sexual violence, to try to inform and influence social attitudes and social norms on the acceptability of violence, and to build political will to address the problem. The use of research findings for advocacy has been shown to be promising in bringing attention to, and raising awareness of, the problem and in contributing to the shaping of reforms and policies (Ellsberg et al., 1997). Currently the three main approaches for changing social and cultural norms that support intimate partner and sexual violence are social norms theory (i.e., correcting misperceptions that the use of such violence is a highly prevalent normative behavior among peers), media awareness campaigns, and working with men and boys. Often several approaches are used in one program.

Social norms theory assumes that people have mistaken perceptions of other people’s attitudes and behaviors. The prevalence of risk behaviors (such as heavy alcohol use or tolerance of violent behavior) is usually overestimated, while protective behaviors are normally underestimated. This affects individual behavior in two ways: (1) by increasing and justifying risk behaviors, and (2) by increasing the likelihood of an individual remaining silent about any discomfort caused by risky behaviors (thereby reinforcing social tolerance). The social norms approach seeks to rectify these misperceptions by generating a more realistic understanding of actual behavioral norms, thereby reducing risky behavior.

In the United States, the social norms approach has been applied to the problem of sexual violence among college students. Among such students, men appeared to underestimate both the importance most men and women place on sexual consent and the willingness of most men to intervene against sexual assault (Fabiano et al., 2003). Although the evidence is limited, some positive results have been reported. In one university in the United States, the A Man Respects a Woman project aimed to reduce the sexual assault of women, increase accurate perceptions of non-coercive sexual behavior norms, and reduce self-reported coercive behaviors by men. The project used a social norms marketing campaign targeting men, a theater presentation addressing socialization issues, and male peer-to-peer education. Evaluation of the campaign two years after its implementation found that men had more accurate perceptions of other men’s behavior and improved attitudes and beliefs regarding sexual abuse. For example, a decreased percentage of men believed that the average male student has sex when his partner is intoxicated; will not stop sexual activity when asked to if he is already sexually aroused; and, when wanting to touch someone sexually, tries and sees how they react. However, the percentage of men indicating that they have sex when their partner is intoxicated increased (Bruce, 2002).

Media awareness campaigns are a common approach to the primary prevention of intimate partner and sexual violence. Campaign goals might include raising public awareness (for example, about the extent of the problem, about intimate partner violence, and sexual violence as violations of women’s human rights and about men’s role in ending violence against women); providing accurate information; dispelling myths and stereotypes about intimate partner violence and sexual violence; and changing public opinion. Such campaigns have the potential to reach large numbers of people. An example of a media-awareness campaign is Soul City in South Africa. This multimedia health promotion and change project examines a variety of health and development issues, imparts information and aims to change social norms, attitudes, and practice. It is directed at individuals, communities, and the socio-political environment. One of its components aims to change the attitudes and norms that support intimate partner and sexual violence. This multi-level intervention was launched over six months and consisted of a series of television and radio broadcasts, print materials, and a helpline. In partnership with a national coalition on preventing intimate partner violence, an advocacy campaign was also directed at the national government with the aim of achieving implementation of the Domestic Violence Act of 1998. The strategy aimed for impact at multiple levels from individual knowledge, attitudes, self-efficacy, and behavior to community dialogue, shifting social norms, and the creating of an enabling legal and social environment for change. An independent evaluation of the program included national surveys before and after the intervention, focus groups, and in-depth interviews with target audience members and stakeholders at various levels. It found that the program had facilitated implementation of the Domestic Violence Act of 1998, had positively impacted on problematic social norms and beliefs (such as that intimate partner violence is a private matter), and had improved levels of knowledge of where to seek help. Attempts were also made to measure its impact on violent behavior, but there were insufficient data to determine this accurately (Usdin et al., 2005).

As the Soul City project indicates, evidence is emerging that media campaigns combined with other educational opportunities can change knowledge, attitudes, and beliefs related to intimate partner and sexual violence. Although good campaigns can increase knowledge and awareness, influence perceptions and attitudes, and foster political will for action, evidence of their effectiveness in changing behavior remains insufficient (Whitaker et al., 2007a).

Working with men and boys —There has been an increasing tendency to focus efforts to change social and cultural norms on adolescent males or younger boys using universal or targeted programs that are delivered

through a variety of mechanisms, including school-based initiatives, community mobilization, and public awareness campaigns.

Objectives typically include increasing an individual’s knowledge, changing attitudes toward gender norms and violence, and changing social norms around masculinity, power, gender, and violence. Some programs also aim to develop the capacity and confidence of boys and young men to speak up and intervene against violence, with the goal of changing the social climate in which it occurs (Katz, 2006). Failure to engage men and boys in prevention may result in the type of negative effects seen in some settings where cultural shifts and other changes have taken place in the absence of efforts to engage them ( Box 6-4 ).

BOX 6-4 Nicaraguan Backlash Shows the Need to Engage Men as Well

Since 2000, Nicaragua has pioneered a number of initiatives to protect women against domestic violence. These have included:

• a network of police stations for women (Comisaria de la Mujer) where women who have been abused can receive psychological, social, and legal support;
• a ministry for family affairs (Mi Familia), which among other responsibilities ensures that shelter is available to women and children who suffer domestic violence; and
• reform of the national reproductive health program to address gender and sexual abuse.

During the same period, civil society groups have campaigned to promote the rights of women and to empower them to oppose domestic abuse. Because of these efforts, the reported frequency of intimate partner violence and sexual violence against women has increased dramatically. The more advocacy and awareness, the more likely women will report violence against them. For example, the number of reported cases of sexual violence received by the Comisaria de la Mujer rose from 4,174 (January to June 2003) to 8,376 (January to June 2004).

Researchers at the Universidad Centro Americana and the Institute for Gender Studies say a number of factors explain this increase—growing awareness among women that the cultural traditions that foster violence are no longer acceptable under international law and the Nicaraguan Domestic Violence Law, and better reporting of cases as women are encouraged to speak out. However, as Nicaraguan women have more actively opposed male hegemony, domestic conflicts have also increased and more men have resorted to intimate partner violence. These findings suggest that responses to intimate partner violence must not focus exclusively on women, but must also target men to prevent this type of backlash (Schopper et al., 2006).

A review of programs that work with men and boys to prevent violence against women (Barker et al., 2007) included 13 primary prevention programs, 5 of which were implemented in LMICs. Four of these programs were judged by the reviewers to be “effective,” six “promising,” and three “unclear.” For example, one community outreach and mobilization campaign in Nicaragua judged to be effective was called Violence Against Women: A Disaster We Can Prevent as Men (Solórzano et al., 2000). This was aimed at men aged 20-39 years who were affected by Hurricane Mitch. The campaign’s main messages addressed men’s ability and responsibility to help prevent or reduce violence against their partners. Constructing masculinity without intimate partner violence was a group-education program aimed at men in periurban districts of Managua, Nicaragua (Welsh, 1997). The effect of the program was, however, unclear because of the weakness of the outcome evaluation.

Indeed, the methodological quality of most of the outcome evaluations was very low, and outcome measures consisted mainly of attitude changes and self-reported rates of gender-based violence, often using only small sample sizes. One campaign in New South Wales in Australia—Violence Against Women: It’s Against All the Rules—targeted 21- to 29-year-old men and aimed to influence their attitudes. Sports celebrities delivered the message that violence toward women is unacceptable and that a masculine man is not a violent man. It also sought to enhance the community’s capacity to challenge and address violence against women. A post-campaign survey indicated that the campaign achieved some positive results: 83 percent of the respondents reported that the message of the campaign was that violence against women is “not on,” and 59 percent of respondents could recall the campaign slogan. However, 91 percent of the target group reported that the issue was not one they would talk about with their peers, irrespective of the campaign.

Similarly, in the United States Men Can Stop Rape runs a public education campaign for men and boys with the message: “My strength is not for hurting.” This campaign runs in conjunction with Men of Strength (MOST) clubs—a primary prevention program that provides high-school-age young men with a structured and supportive space to learn about healthy masculinity and the redefining of male strength.

Although programs to alter cultural and social norms are among the most visible and ubiquitous of all strategies for preventing intimate partner and sexual violence, they remain one of the least evaluated. Even where evaluations have been undertaken, these have typically measured changes in attitudes and beliefs rather than in the occurrence of the violent behaviors themselves, making it difficult to draw firm conclusions on their effectiveness in actually preventing intimate partner and sexual violence. Nonetheless, some evidence is emerging to support the use of the three types of programs reviewed above in changing the social and cultural gender norms

that support intimate partner and sexual violence. However, these must now be taken to scale and more rigorously evaluated.

KEY MESSAGES

• To achieve change at the population level it is important to target societal-level factors in the primary prevention of intimate partner and sexual violence. Approaches include the enactment of legislation and the development of supporting policies that protect women, addressing discrimination against women, and helping to move the culture away from violence—thereby acting as a foundation for further prevention work.
• Currently, there are no strategies of demonstrated effectiveness for preventing sexual violence outside intimate partner or dating relationships. Only one strategy has been demonstrated to be effective in preventing intimate partner violence, namely school-based programs for adolescents to prevent violence within dating relationships—and this still needs to be assessed for use in resource-poor settings.
• Although it is too early to consider them proven, evidence is emerging of the effectiveness of several other strategies for the prevention of intimate partner and sexual violence, particularly the use of microfinance with gender equality training and of programs that promote communication and relationship skills within communities.
• Developing the evidence base for programs for the primary prevention of intimate partner and sexual violence is still very much in the early stages. But there is every reason to believe that rigorous outcome evaluations of existing programs and the development of new programs based on sound theory and known risk factors will lead to a rapid expansion in coming years.

INTERNATIONAL MEN AND GENDER EQUALITY SURVEY 2

Gary barker, juan manuel contreras, brian heilman, ajay singh, ravi verma, and marcos nascimento.

The International Men and Gender Equality Survey (IMAGES) is a comprehensive household questionnaire on men’s attitudes and practices—as well as women’s opinions and reports of men’s practices—on a wide

2 Adapted from: Barker, G., J. M. Contreras, B. Heilman, A. K. Singh, R. K. Verma, and M. Nascimento. 2011. Evolving men: Initial results from the International Men and Gender Equality Survey (IMAGES). Washington, DC: International Center for Research on Women.

variety of topics related to gender equality. From 2009 to 2010, household surveys were administered to more than 8,000 men and 3,500 women ages 18 to 59 in Brazil, Chile, Croatia, India, Mexico, and Rwanda. Topics in the questionnaire included gender-based violence, health and health-related practices, household division of labor, men’s participation in care-giving and as fathers, men’s and women’s attitudes about gender and gender-related policies, transactional sex, men’s reports of criminal behavior, and quality of life. This report focuses on the initial, comparative analysis of results from the men’s questionnaires across the six countries, with women’s reports on key variables.

Methodology

IMAGES followed standard procedures for carrying out representative household surveys in each participating city, with the exception of Rwanda, where the survey is a nationally representative household sample. The survey was carried out in one or more urban settings in each country (and rural and urban areas in Rwanda) with men and women ages 18 to 59, guided by the following parameters:

• The men’s questionnaire has approximately 250 items and took from 45 minutes to an hour to administer; the questionnaire for women is slightly shorter and took from 35 minutes to an hour to administer. The survey instruments were pretested in the participating countries, and the study protocol was approved by the institutional review board (IRB) of the International Center for Research on Women and by in-country IRBs, when such existed.
• The survey instrument was designed to be relevant for adult men and women in stable, co-habitating relationships as well as those not in a stable relationship; women and men who define themselves as heterosexual as well as men and women of different sexual orientations and practices; and women and men who have children in the household (biological or otherwise) and those who do not.
• Double-back translation of the questionnaire was carried out to ensure comparability and consistency of questions across settings. Some country-specific questions were included; some countries excluded items because of local political or cultural considerations.
• In Brazil, Chile, Mexico, and Rwanda the questionnaire was an interviewer-administered paper questionnaire. In India the questionnaire was carried out using hand-held computers, with a mixture of self-administered questions and interviewer-asked questions. In Croatia the questionnaire was self-administered (using a paper

questionnaire). Standard procedures were followed for ensuring anonymity and confidentiality.

• All research sites followed standard World Health Organization (WHO) practices for carrying out research on intimate partner violence in terms of offering referrals and information for services and special training of interviewers. Following these guidelines, men and women were not interviewed from the same household in any of the research sites.
• More sensitive questions were asked later in the questionnaire, and some key variables were included in multiple questions (to compare and thus be more informed in affirming validity). The questionnaire was pretested in all the settings prior to application.
• In all settings, male interviewers interviewed male respondents, and female interviewers interviewed female respondents, with the exception of Mexico, where some interviews with men were carried out by female interviewers (but only women interviewed women).
• Survey locations were chosen to represent different contexts in each country to achieve a mixture of major urban areas and a secondary city or cities. Within a survey location, neighborhoods or blocks were chosen based on population distributions from the most recent census data. Rural areas were included only in Rwanda and Croatia. Stratified random sampling and probability proportion to size sampling methods were used within each neighborhood or community to ensure the inclusion of adequate sample sizes by age and residence (and also socioeconomic status in the case of Chile).
• Although every participating country’s questionnaire included questions on all the themes that make up IMAGES, the questionnaire is not identical in all countries; thus data are not available from every country for every question. The questionnaire in Rwanda was the most abbreviated of the six study countries because of the much larger sample size—and thus the sheer number of interviews—required to make the study nationally representative. In those cases where Rwandan data does not appear in a table or figure in this document, that particular question was not included in the Rwandan questionnaire.

The questionnaire covers key topics in gender equality, including intimate relationships, family dynamics, and key health and social vulnerabilities for men. Based on previous research that found associations between early childhood exposure to violence and different gendered practices related to childrearing, items on childhood antecedents to particular men’s practices were included. Specific topics in the questionnaire include:

• Employment. Employment experience; unemployment and underemployment; stress and reactions associated with unemployment; reaction by spouse/partner when unemployed; income differentials between men and women; perceived gender dynamics in the workplace; work–life balance; and job satisfaction.
• Education. Educational attainment; perceived gender norms and patterns in school.
• Childhood experiences. Victimization by violence as children; witnessing of gender-based violence; gender-related attitudes perceived in family of origin; changes perceived from previous generation to the present; gender balance in work/child care in family of origin; gender patterns of childhood friendships.
• Relations at home (in current household). Marital/cohabitation status; division/participation in household chores; perceived satisfaction in family life; household decision making; time use in specific domestic chores and family care, including child care.
• Parenting and men’s relationships with their children (and with non-related children who may live in the household). Number of children; living situation of each child; time/money spent in care of each child; use of paternity/maternity leave; perceptions/attitudes toward existing parental leave in country; and child-care arrangements.
• Attitudes toward women and masculinity. Attitudes toward gender equality (using the Gender-Equitable Men [GEM] Scale and other measures); attitudes toward various gender-equality policies that may have been implemented in each country.
• Health and quality of life. Lifestyle questions (substance use, exercise, etc.); use of health services; sexual and reproductive behavior (contraceptive use, condom use); sexually transmitted infections, including HIV (past history, HIV testing); satisfaction with sexual relations; mental health issues (depression, suicide ideation); social support; use of/victimization by violence in other contexts; morbidity.
• Partner relations and spousal relations. Current relationship status/satisfaction; use of services/help-seeking in times of violence or relationship stress; relationship history.
• Relationship, gender-based violence, and transactional sex. Use of violence (physical, sexual, psychological) against partner (using WHO protocol); victimization of violence by partner (using WHO protocol); men’s use of sexual violence against non-partners; men’s self-reported purchasing of sex or paying for sex, including with underage individuals.
• Sexual behavior. Sexual experience; sexual orientation; behaviors related to sexual and reproductive health, HIV/AIDS; use of health services related to sexual and reproductive health.

Analytical Strategy

The report focuses on men’s attitudes and practices related to relationship dynamics, parenting and caregiving, health-related practices and vulnerabilities, violence (intimate partner violence and other forms), transactional sex, and attitudes toward existing gender equality policies. Women’s reports of men’s practices are included for some key variables.

The selection of questions in this initial data analysis was informed by previous research confirming the associations or impact of early childhood experiences, individually held gender-related attitudes, educational attainment, age (as a proxy of generational differences as well as developmental stage), social class (or income), and employment status and economic stress on women’s and men’s attitudes and practices in terms of their intimate relationships, their sexual practices, their use of violence, their domestic practices, and their health-seeking behaviors. Men’s knowledge of and attitudes toward key policy issues related to gender equality are also included. The report focuses on descriptive statistics and bi-variate analyses of the associations between these practices and educational levels, economic or work-related stress, gender-related attitudes, and age. In all cases where statistically significant differences are reported, these are at the p < .05 level as assessed using the Pearson’s chi-square test. As noted earlier, we also have an interest in understanding generational changes, or changes over time, in terms of men’s practices. IMAGES is not a longitudinal study; nonetheless, by comparing responses stratified by age groups we can make some inferences about generational change.

Key Findings

Work-related stress.

Work-related stress is commonplace in all survey sites. Between 34 percent and 88 percent of men in the survey sites reported feeling stress or depression because of not having enough income or enough work. Men who experienced work-related stress were more likely to report depression, suicide ideation, previous arrests, and use of violence against intimate partners.

Gender Attitudes

Men showed tremendous variation in their gender-related attitudes, with India and Rwanda showing the most inequitable attitudes. As a measure of men’s and women’s gender-related attitudes, IMAGES applied the GEM Scale. Rwandan and Indian men consistently supported the least

equitable norms among the settings studied. For example, for the statement “Changing diapers, giving kids a bath and feeding kids are the mother’s responsibility,” only 10 percent of men in Brazil agreed, whereas 61 percent in Rwanda and more than 80 percent in India agreed with the statement. Men with higher educational attainment and married men had more equitable attitudes; unmarried men had the least equitable attitudes. Homophobic attitudes were common, although they varied tremendously by context. Men who said they would be ashamed to have a gay son ranged from 43 percent of men in Brazil to a high of 92 percent in India. A slightly lower, but still high proportion of men said that being around homosexual men makes them uncomfortable, ranging from a low of 21 percent of men in Brazil to a high of 89 percent in India. Younger men and men with higher levels of education were generally less homophobic.

Relationship Dynamics and Domestic Duties

Younger men, men with more education, and men who saw their fathers do domestic work are more likely to carry out domestic duties. Nearly half of men in all the sites said they play an equal or greater role in one or more household duties—with the exception of India, where only 16 percent of men reported that they played an equal or greater role in household duties. These household or domestic duties included washing clothes, repairing the house, buying food, cleaning the house, cleaning the bathroom or toilet, preparing food, and paying the bills. The tasks that men said they play an equal or greater role in are those traditionally associated with men—namely repairing the house, paying bills, and buying groceries. Men reported higher levels of sexual and relationship satisfaction than women. Women who said their partners do more domestic work are more sexually satisfied. Men reported relatively high rates of sexual satisfaction with their current stable partners, ranging from 77 percent in Croatia to 98 percent in India. In all the countries except India, men who reported more gender-equitable attitudes were more likely to report being sexually satisfied with their current female partner. In India, Brazil, and Croatia, women who reported that their male partner plays an equal or greater role in one or more domestic duties also reported higher levels of overall relationship and sexual satisfaction.

Parenting and Involvement in Childbirth

The majority of men were neither in the delivery room nor in the hospital for the birth of their last child. In Chile, however, a dramatic generational shift is under way in men’s presence at childbirth. Younger Chilean men reported much greater rates of presence in the delivery room

for the birth of their last child than older men. This shift is largely due to a national policy, aimed at “humanizing” the birth process, which encourages women to have a male partner or other person of their choice present during birth at public maternity wards. Men are taking few days of paid or unpaid paternity leave. Among men who took leave, the average duration ranged from 3.36 to 11.49 days of paid leave and from 3.8 to 10 days of unpaid leave. Younger men and men with more education were more likely to take leave. Close to half of men with children said they are involved in some daily care-giving. Unemployed men are dramatically more likely to participate in the care of children than employed men. For men with children under age four, play is the most common daily activity in which they participate (as affirmed by women and men).

Health Practices and Vulnerabilities

Men’s rates of regular abuse of alcohol—defined as having five or more drinks in one night on a once monthly or greater basis—vary from 23 percent in India to 69 percent in Brazil and are significantly higher than women’s reported alcohol abuse in all survey sites. In most sites, younger men and men with more inequitable gender attitudes are more likely to regularly abuse alcohol. High proportions of women who reported having sought an abortion affirmed that a male partner was involved in the decision to seek an abortion (ranging from 39 percent to 92 percent). Men reported high self-esteem, with the exceptions of Croatia and India; at the same time, men showed relatively high levels of depression and suicide ideation. The rates of experiencing depression at least once in the past month ranged from 9 percent in Brazil to a high of 33 percent in Croatia. The percentages of male respondents who reported having suicidal thoughts “sometimes or often” in the past month ranged from 1 percent in Brazil and Mexico to 5 percent in Croatia.

Violence and Criminal Practices

Men reported lifetime rates of physical intimate partner violence ranging from 25 percent to 40 percent, with women reporting slightly higher rates. Factors associated with men’s use of violence were rigid gender attitudes, work stress, experiences of violence in childhood, and alcohol use. Men’s reports of perpetration of sexual violence against women and girls ranged from 6 percent to 29 percent; in India and Mexico the majority of sexual violence took place against a current or former partner. Relatively high percentages of men reported ever having participated in criminal or delinquent acts; between 6 percent and 29 percent of men reported ever having been arrested. In terms of factors associated with

men’s participation in criminal activity, men’s socioeconomic situation was the most significant. Men who owned firearms or carried out violence or criminal behavior were also more likely to report having used intimate partner violence.

Transactional Sex

Between 16 and 56 percent of men surveyed said they have paid for sex at least once. Men with lower educational attainment and less gender-equitable attitudes and men who reported less sexual satisfaction with their current partner were more likely to have paid for sex.

Knowledge and Attitudes About Policies and Laws Related to Gender Equality

Men in all the countries, with the exception of India, were generally supportive of gender equality, with 87 percent to 90 percent agreeing that “Men do not lose out when women’s rights are promoted.” Even when asked about specific policies—quotas for women in executive positions, in university enrollment, or in government—men’s support for such policies was reasonably high, with 40 percent to 74 percent of men supporting such quotas. Among themes related to gender equality, men reported the highest exposure to campaigns about gender-based violence. At the same time, across the sites, men showed negative attitudes toward laws related to gender-based violence.

Overall, IMAGES results affirm that gender equality should be promoted as a gain for women and men. Change seems to be happening as younger men and men with higher levels of education show more gender-equitable attitudes and practices. Men who reported more gender-equitable attitudes are more likely to be happy, to talk to their partners, and to have better sex lives. Women who reported that their partners participate in daily care work report higher levels of relationship and sexual satisfaction. Findings suggest that most men in most of the survey sites accept gender equality in the abstract even if they are not yet living it in their daily practices.

THE SCIENCE OF PREVENTION/ INTERRUPTING THE CYCLE OF VIOLENCE

Claire crooks, ph.d. centre for addiction and mental health, centre for prevention science and university of western ontario.

This summary describes what we know and, perhaps more importantly, what we don’t know about intervening in the cycle of violence. It encompasses both direct child abuse and exposure to domestic violence. First, the term cycle of violence is clarified, as it is a term that has been adopted into the everyday lexicon without much clarity of concept. Next is a review of some of the key findings from comprehensive review papers summarizing child abuse prevention. Finally, five gaps are identified that indicate possible future directions for research into primary prevention in this domain.

What Is the Cycle of Violence?

The cycle of violence is a phrase used to describe the observed intergenerational pattern by which many children and youth who experience direct or indirect exposure to violence later come to perpetrate violence in their own relationships. For example, children who experience child abuse and are exposed to domestic violence are at an elevated risk for perpetrating dating violence and domestic violence. Essentially, there is a continuity in their relationships such that problems with violence are evident in different ways at different times. Researchers tend to look at this cycle from different vantage points depending on their main areas of interest. Bullying researchers, for example, might note that children who bully others are more likely to perpetrate dating violence as adolescents. 3 Dating violence researchers might look at the continuity of violence between dating and adult intimate partner relationships. The investigation of direct and indirect exposure to violence has even been segmented, with child abuse researchers tending to focus on the former and domestic violence researchers tending to take on the latter. The result is a greatly segmented landscape, but one that can be pieced together to depict the cycle shown in Figure 6-1 .

3 Bullying prevention programs have been researched quite extensively and are outside the purview of this summary. Bullying/peer aggression was included in the cycle of violence figure as a reminder that children exposed to family violence have difficulties in multiple settings and often perpetrate or experience violence in relationships outside their families. A holistic approach to the impact of violence on children’s lives requires a commitment to beginning to piece together these formerly disparate areas of research.

FIGURE 6-1 Cycles of violence. SOURCE: Crooks, 2011.

It is crucial to understand that the cycle of violence is probabilistic, not determinative. That is, experiencing child abuse increases the risk for subsequently perpetrating violence in relationships, but there is significant variability in trajectories. There are a few important qualifiers for the cycle of violence idea, and they are discussed below.

Abusive Behavior Is Multiply Determined

There is no one pathway to abusive behavior. Rather, it is a final com mon pathway for a host of social, behavioral, biological, and personality risk factors. Results of a 20-year prospective study show that children’s direct and indirect exposure to violence are important risk factors for perpetration of abusive behavior (Ehrensaft et al., 2001). Furthermore, the risk for experiencing intimate partner violence as an adult (as a victim or perpetrator) increases with the number of types of abuse and additional stressors experienced as a child (Whitfield et al., 2003). At the same time, many children and youth who are abused do not become perpetrators of abuse with their own children. A review of studies suggested that approximately one-third became seriously inept, abusive, or neglectful as parents of their own children; an additional one-third remained at risk for perpetrating child abuse because of their vulnerability to social stress; while the remaining one-third were not abusive (Oliver, 1993).

Experiences of Abuse Show a Dosage Response

The Adverse Childhood Experiences (ACE) Study 4 carried out jointly by the Centers for Disease Control and Prevention and Kaiser Permanente has conclusively demonstrated a dosage effect for child maltreatment. This ongoing longitudinal study has been analyzing the relationships between multiple categories of childhood trauma and negative health and behavioral outcomes later in life. David Finkelhor’s work on poly-victimization is also instructive in identifying both the high frequency of poly-victimization and the relationship between multiple forms of abuse and poor outcomes for children (Finkelhor et al., 2009). Research with adolescents has docu mented this same relationship between multiple forms of abuse and the perpetration of violent delinquency as an adolescent, with each additional form of abuse translating to a 124 percent increase in the relative odds of engaging in violent delinquency (Crooks et al., 2007).

Co-Existing Adversities Increase the Likelihood of Negative Outcomes

Abuse affects different children differently. The ACE Study has documented the additive detrimental effects of experiences such as exposure to woman abuse, a parent with substance abuse or mental health problems, and incarceration of a parent. Low socioeconomic status can further compound difficulties for children who are experiencing child abuse. Conversely, access to protective factors (including at least one stable, nonviolent caregiver) can mitigate these impacts (Herrenkohl et al., 2008).

To summarize what we know about childhood experiences of abuse and exposure to domestic violence as a risk factor for perpetrating violence as an adolescent or adult, it is clear that childhood exposure to violence is a strong risk factor. However, there is still considerable variability among individual outcomes, and additional risk or protective factors can either exacerbate or mitigate the risk conferred by child abuse. Cumulative experiences of child abuse tend to lead to more negative outcomes, both in terms of perpetrating violence and a whole host of other negative social and physical health outcomes. The cycle of violence depicts the what of intergenerational transmission, but it does not explain the how or why. It is important to understand the cycle of violence in terms of how it works, because understanding the mechanisms underlying the intergenerational transmission of violence provides an important basis for understanding intervention opportunities.

4 Results of the study are available at http://www.cdc.gov/ace/index.htm .

How Does the Cycle of Violence Work?

At a superficial level, the intergenerational transmission of violence seems counterintuitive—if someone knows how devastating it is to be abused as a child, how can he or she turn around and do the same thing as a parent? The answer lies in understanding the impact of child abuse on a developing child and understanding how experiences of child direct and indirect exposure to violence change how an individual sees the world and others around him or her. This understanding also explains why child exposure to violence is not something that a person can just “get over.” Three particularly useful frameworks and theories for explaining the intergenerational cycle of violence are attachment, social learning theory, and trauma.

The Role of Attachment

Attachment refers to the quality of the relationship that develops between an infant and his or her primary caregiver(s) (Bowlby, 1980, 1990). Secure attachment emerges within the context of responsive caregiving. The extent to which an infant is fed when she is hungry, changed when she is wet and uncomfortable, and soothed when she is upset or afraid provides a basis for secure attachment. This first relationship becomes a template for future relationships and organizes the way an infant comes to see the world: Is it a safe and predictable place or a scary and bizarrely unpredictable one? Decades of research demonstrate that when attachment develops in a disorganized manner, an individual is at risk for ongoing difficulties in relationships with others. Child abuse and attachment are connected in a number of ways, including the development of attachment, the impacts of abuse, and the later perpetration of abuse (Bacon and Richardson, 2001). Experiences of direct and indirect child exposure to violence undermine the potential for secure attachment and provide an early experience of relationships as dangerous and unpredictable.

Although attachment is most often discussed in the context of parent–infant relationships, it continues to play an important role throughout a youth’s development. Recent longitudinal research demonstrated that youth dually exposed to direct and indirect violence (i.e., child abuse and exposure to domestic violence) were less attached to their parents in adolescence than those who experienced only direct or only indirect exposure (Sousa et al., 2011). Furthermore, attachment to parents during adolescence played an important protective role against antisocial behavior, independent of abuse status.

Social Learning Theory

Social learning theory is a well-established paradigm that highlights the importance of reinforcement for promoting certain behavioral responses and inhibiting others (Bandura, 1977, 1986). Furthermore, our experi ences with behavior and reinforcement come to shape our attitudes and attributions. One of the key tenets of social learning theory is that humans learn very well from modeling, that is, from what they see others do. This modeling is not indiscriminate. Children do not copy everything around them, but they copy what they see that works. When they are exposed directly and indirectly to violence, they learn harsh but effective lessons about power and may come to see the world as made up of victims and victimizers (Dodge et al., 1994). Given such a dichotomy, they may begin to model after the victimizer to avoid further abuse. These children develop a hostile attribution bias , which is a cognitive framework for expecting the worse, even in threat-neutral situations (Fontaine, 2010). As a result, these children seem hostile and aggressive to their peers, and may be rejected by their more pro-social peers (Dodge et al., 1990). There is some evidence that exposure to family violence is a bigger contributor to later pro-violence attitudes (such as comfort with aggression, aggressive responses to shame, excitement about guns, and violence as means of preserving power) than violence experienced in the school or community (Slovak et al., 2007). In addition to underscoring the importance of what children learn, social learning theory would also draw attention to what these children do not learn, namely, egalitarian relationships, non-violent approaches to conflict resolution, and emotional regulation skills.

A third perspective that has been explored for understanding the cycle of violence is the trauma perspective. Based on his work with adolescent boys who have perpetrated lethal violence, James Garbarino has identified a process which he refers to as “hibernation of the soul” (Garbarino, 1999). Essentially, under conditions of severe, early, and chronic violence, these children may come to suppress their more humane aspects as a survival mechanism. The detachment from emotion and compassion that allows a person to survive chronic abuse is the same detachment that facilitates perpetration of severe violence without apparent remorse. Even in less extreme cases of trauma, the dysregulation of anger and arousal that develop create potent risk factors for the intergenerational transmission of violence. A significant literature has emerged to support these processes from a neurobiological perspective, which demonstrates that over-activation of the fight or flight response can result in a weak foundation for the development

of emotional regulation and self-soothing (van der Kolk and Greenberg, 1987).

In considering these three frameworks for understanding the cycle of violence—attachment, social learning, and trauma—it is evident that there are no quick fixes for breaking this cycle. Child abuse does not arise because of a lack of discipline; consequently, get-tough approaches with parents will not redress the risks. Similarly, it does not arise merely from a lack of parental support; as such, increasing support without targeting the underlying causes will not be very successful in preventing and reducing a child’s direct and indirect exposure.

What Programs Are Effective or Promising?

In efforts to prevent child abuse and exposure to domestic violence, there are a number of points for possible intervention. Prevention in other areas is often divided into universal (or primary), selective (or secondary), and indicated (or tertiary). However, an argument can be made that using this type of classification locates the abuse with the victim and pathologizes the experience of abuse. Macmillan and colleagues have proposed an alternative schema for identifying intervention points, presented in Figure 6-2 (Macmillan et al., 2009). With this approach it is clear that one can work to prevent abuse before it occurs, to prevent abuse from recurring, and to prevent impairment following abuse. Each of these targets is necessary in a comprehensive approach, and different strategies will be effective at different points.

FIGURE 6-2 Intervention to prevent child maltreatment and associated impairment. SOURCE: Macmillan et al., 2009.

Comprehensive reviews to identify what works to prevent child abuse or recurrence of child abuse follow one of two basic approaches. The first approach is to look across all previous summaries and reviews and amalgamate all of the existing evidence (Mikton and Butchart, 2009). This approach provides a somewhat bleak picture, because when studies are combined, results are generally mixed or disappointing. However, such an approach can be misleading because it includes studies that vary greatly in quality both in terms of the intervention and the research design. By contrast, the review by MacMillan and colleagues looks at high-quality programs that have shown good effects under reasonable research conditions but perhaps have yet to be replicated (Macmillan et al., 2009). Reviewing the existing studies in these two ways finds three approaches that can be considered effective or promising. Additional approaches may improve protective factors or reduce risk factors, but these three are the only ones that have been shown to prevent the occurrence or recurrence of abuse.

Home Visitation

Home visitation is the most effective child maltreatment prevention program to date (Macmillan et al., 2009). There is considerable variability in home-visiting interventions in terms of their models, service delivery, and home staffing. Two models, the Nurse-Family Partnership and the Early Start program, have been shown to be effective in reducing some indicators of child abuse. However, effects have not been uniform across other approaches to home visiting, and there are a few caveats for the success of home visiting. First, most of what we know is based on David Olds’ pioneering work, and efforts to replicate his work have had mixed success. Second, home visitation has proved to be more effective when carried out by nurses than by paraprofessionals. Third, it may be more effective with certain types of families (such as first-time mothers) than others (Macmillan et al., 2009). Finally, the presence of domestic violence may undermine the effectiveness of home visiting. In the Elmira Home Visiting study the intervention reduced reports of child maltreatment, but not for families with mothers reporting more than 28 incidents of domestic violence (Eckenrode et al., 2000).

Parent Training and Education

The results for parent training and education in general are mixed, but there are two programs that have evidence supporting their use. First, the Positive Parenting Program (Triple P) has shown promise in one study for preventing abuse, and replication is currently under way. The Triple P uses multiple levels of social learning–based programs to meet the needs of different families and offers five levels of intervention with increasing intensity

to match higher-needs families (Prinz et al., 2009). Mark Chaffin and colleagues’ work on Parent–Child Interaction Training has also been very promising in that it has been shown effective in lowering recurrence of physical child abuse (Chaffin et al., 2004). Parent–Child Interaction Training uses behavioral conditioning principles and provides immediate and detailed feedback for parents in their interactions with their children. It has been shown to both increase positive interactions and decrease recurrence of child abuse. Both of these programs warrant further investigation, particularly with larger samples of fathers, as most research has focused on mothers.

Educational Prevention of Abusive Head Trauma

The final effective strategy to date is education aimed at preventing abusive head injury (also known as shaken baby syndrome). Offered mainly through hospitals, this education offers normative information about babies’ crying, coping strategies for parents, and the impacts of shaking an infant. There is a one study to date that found that the introduction of this program lowered the rates of abusive head trauma (Dias et al., 2005). Additional trials are under way. This program appears to be a cost-effective way to reduce one specific type of child abuse.

Interventions Lacking Empirical Evidence

Consistent with the general move to positive psychology, there has been much interest in interventions that build on parents’ strengths. Many of these approaches use a mentoring or mutual support model of parents helping other parents in a way to normalize intervention and build informal support networks. The general benefits of mentoring and of encouraging strong social networks are widely accepted, but these approaches have not been found effective in the prevention of child exposure to direct or indirect violence (Macmillan et al., 2009). It is critical to recognize the distinction. A parenting program may increase parents’ satisfaction with parenting, improve their social connections, and even lead to more positive attitudes and skills, and yet it may not reduce direct child abuse or exposure to domestic violence. If a program is being espoused as a child abuse prevention program, then the research must look at child abuse outcomes and not rely on proxies or interpret the promotion of positive parenting attitudes and skills as synonymous with the prevention of abuse.

Preventing Child Exposure to Direct and Indirect Violence: The Big Picture

A review of the state of the science of child abuse prevention reveals a number of basic facts. First, there are some effective and promising

interventions, but even these have limited evidence compared to many other areas of social and medical science. Second, it obscures the picture to collapse evidence across types of intervention (e.g., with meta-analytic techniques) with no consideration for the quality or features of the program. Quality of implementation matters, training of implementers matters, and matching the intervention to the risk level of the families matters. Third, at this point there is little available evidence concerning programs that are effective for preventing emotional abuse. Finally, there have not been any trials on programs to reduce exposure to domestic violence. Community-based approaches to preventing domestic violence have not been well researched, and there are no studies evaluating strategies for preventing exposure when domestic violence is occurring. On a more hopeful note, there are many innovative interventions in varying degrees of development and evaluation. It takes a long time to reach the point where a randomized controlled trial or multi-site replication is feasible.

Gaps and Challenges

A review of the state of the research shows clearly that while we have an emerging idea of effective practice in some specific areas, there are still many gaps. Below are five gaps in research and practice.

Where Are the Dads?

Much research has focused exclusively on mothers or not included enough fathers for useful subgroup analysis. This lack of representation in research mirrors the child protection policies and practices, which tend to focus on mothers and view fathers as either dangerous or irrelevant. The reality is that men who have perpetrated violence often remain part of their children’s lives and require specific and intentional strategies to change attitudes and beliefs that support their abusive behavior, particularly when these men have also abused the children’s mothers (Scott and Crooks, 2004). Furthermore, there is a dearth of programs that both address the gendered nature of violence and address men’s abuse of their intimate partners and children concurrently. The Fathering After Violence initiative 5 for men who have been abusive to intimate partners and the Caring Dads program 6 for men who have been abusive to their partners and their children are exceptions to the rule.

5 See http://endabuse.org/section/programs/children_families/_breaking_cycle .

6 See http://www.caringdadsprogram.com .

Is Stopping the Violence Enough for Positive Child Outcomes?

When we look for successful outcomes in research, we often use the idea of recidivism or repeat violence as a sign of failure, but the corollary to that is that success is equated with no further violence. The reality is that, in the life of a child who has been victimized, just stopping the violence might not be good enough. There has been some discussion about restorative parenting and applying restorative justice models to the parent–child relationship, but we do not actually have a good sense yet about what that looks like or the implications for the child. Some work has been done in this area of child sexual abuse, but very little has been carried out that looks at father–child relationship restoration after domestic violence. There is a significant need to develop and evaluate protocols for deciding when it is safe to restore parent–child relationships post-violence and how this can be achieved with minimal risk to children.

Compartmentalization of Efforts

There have been some big strides in breaking down silos between types of abuse since the “Greenbook” was published as a model for collaboration between child protection and domestic violence sectors (Schecter and Edleson, 1999), but there is still too much compartmentalization within fields. Often researchers emphasize one type of abuse without looking at the complexities of poly-victimization or, what is even trickier, the co-occurrence of perpetration and victimization. For example, most research and programming for children exposed to domestic violence still does not inquire about the direct victimization experience of the children, particularly for abuse perpetrated by the victim parent. There are philosophical and practical reasons for these practices, but they hinder a fuller understanding and more effective response to children.

What Do Culturally Relevant Programs Look Like?

Virtually every paper or chapter ends with a plea for more culturally diverse and appropriate services, yet we have only scratched the surface in exploring what this really means. Is it merely resources translated into different languages? Is it trained therapists from the same ethnic or cultural background as the families? Is it program manuals that have different faces on them? It can be argued that we need to go much further than these superficial changes and that we have not done a good job of documenting or evaluating these processes of cultural adaptation. The challenge for cultural adaptation is further complicated when we look at implementing promising practices on a global scale, particularly in countries with less developed child protection or mental health systems.

What Is an Effective Specialized Response in the Highest Risk Cases?

Finally, for the most high-risk families, there is a complexity in terms of system involvement and information sharing that can only be addressed by collaboration across systems. Any comprehensive approach to preventing violence against children requires specialized responses that can be activated in the most high-risk cases. With the advent of domestic violence homicide review committees, a clearer picture of the risk factors for lethality to women and their children is emerging (Jaffe et al., 2003; Campbell, 2005; Jaffe and Juodis, 2006). In these cases, home visiting and parent education are not sufficient or appropriate for the degree of risk. In addition to developing clinical interventions for a wide range of families, we need to develop specialized collaborative protocols for the highest-risk cases.

In closing, although reviews that combine all interventions of a certain type tell a disheartening story, there are some bright spots in our search for effective interventions. Home visiting, parent education and training, and education approaches to abusive head trauma have all shown promise and a solid degree of evidence. The science is at the point where we know enough to know that there are no easy answers and no quick fixes. Different families need different types of support and intervention at different points in time, and we need to develop a comprehensive and coordinated system of care to ensure that no children fall between the cracks. It is a colossal task, but a vital one, because at the end of the day our children need to be safe from abuse and violence to develop to their full potential and grow into the type of adults who will contribute to a compassionate and productive society.

TRAUMA-INFORMED CARE: A VALUES-BASED CONTEXT FOR PSYCHOSOCIAL EMPOWERMENT

Roger d. fallot, ph.d. community connections.

We make a fundamental distinction between trauma-informed care and trauma-specific services (Harris and Fallot, 2001). Psychosocially empowering, trauma-specific interventions take as their primary goals ameliorating trauma-related difficulties and facilitating trauma recovery and healing. The Trauma Recovery and Empowerment Model, Seeking Safety, Trauma Affect Regulation: Guide for Education and Therapy (TARGET), the Boston Consortium Model, and Beyond Trauma, among others, are manualized approaches to helping women (and sometimes men as well) develop the skills necessary to cope more effectively with the impact of violence and abuse and to avoid revictimization (Harris, 1998; Najavits, 2002;

Covington, 2003; Ford and Russo, 2006; van Lier et al., 2009; Amaro, 2011). These interventions and many individual ones that focus primarily on post-traumatic stress disorder, such as exposure therapy, cognitive processing therapy, and other cognitive-behavioral approaches (e.g., Mueser et al., 2008), are an important component of trauma-informed care (Resick et al., 2008; Powers et al., 2010).

However, “cultures of trauma-informed care” refer to the programmatic, organizational, and community contexts that are necessary and valuable in supporting survivors and the staff who serve them. Any setting can be trauma-informed when it takes fully into account what we know about trauma, its impact, and the diverse, individualized paths to trauma recovery. In this way, not only behavioral health care settings but also primary care institutions, schools, and even correctional facilities can be trauma-informed. When an organizational culture becomes trauma-informed, it becomes more welcoming and hospitable for trauma survivors (as well as the rare individual who does not have a history of exposure to violence); it minimizes the possibility of revictimization; it indirectly facilitates healing, recovery, and empowerment; and it builds collaborations throughout the service system.

Trauma-informed care is important for a number of reasons:

• Trauma and, in particular, violent victimization are pervasive.
• The impact of trauma is broad, extending well beyond the post-traumatic stress disorders frequently perceived to be the most common outcome.
• The impact of trauma is often deep and life-shaping.
• Trauma, especially caused by interpersonal violence, is often self-perpetuating.
• Violence is even more common in the lives of those who are socially and politically vulnerable, including the poor, many racial and ethnic minorities, women and children, those diagnosed with mental health or substance abuse problems, and people who are developmentally disabled.
• Trauma affects the way people approach the human service setting, heightening fear and suspiciousness.
• The service system itself has too often been retraumatizing.

Retraumatization in the behavioral health care setting is one of the experiences that originally fueled awareness of the need for trauma-informed care (Jennings, 1998). Two types of retraumatization are noteworthy. First are the many ways in which traumagenic dynamics may be replicated in service provision. Examples include providers’ lack of interest in traumatic violence or their disbelief of individuals’ reports of violent victimization; both of these patterns may replicate earlier experiences, in which signs and

reports of violence were minimized or denied. Coercive approaches involving involuntary medication and hospitalization are still too common in many settings. And the presumption of incompetence (e.g., the inability to handle one’s own finances) may be a part of standard operating procedure in many programs, a visible reminder of the ways in which survivors’ skills are overlooked.

Second are instances of “sanctuary harm” (Robins et al., 2005). Consumers surveyed about their experiences in behavioral health care settings report violence and the fear of violence (including physical restraint and seclusion) as well as negative interactions with staff involving disrespect and humiliation. Taken as a whole, then, it is not surprising that one prominent psychiatrist has written that the past 30 years has evinced a continuing story of “destroying sanctuary” in the human services system (Bloom and Farragher, 2010).

As a counter to this destructive organizational culture, we have developed a model of trauma-informed care that builds on core values of safety, trustworthiness, choice, collaboration, and empowerment (Fallot and Harris, 2008, 2009). These values are key antidotes to the toxic effects of violence in the lives of consumers and staff members in human service delivery settings. For those who have been exposed to violence repeatedly and unpredictably, physical and emotional safety is a high priority. For those individuals affected by violence perpetrated by those who were supposed to be family or institutional caretakers, trustworthiness is a high priority. For those whose sense of voice and control has been attenuated by violent victimization, choice is a high priority. For those who have experienced the world as consistently arrayed in one-up, one-down relationships in which they have been the one down, the realistic offer to share power in a collaborative way is a high priority. And for those who have felt powerless to do anything about these other realities, empowerment is a high priority.

As a change in organizational culture, then, trauma-informed care extends far beyond any new service; it involves the physical setting, each contact, each activity, and each relationship in the organization. It extends beyond the training of clinical staff by engaging with all staff (including administrators, service staff, and support staff) and, importantly, all consumers to direct and monitor this change. Finally, trauma-informed care represents an opportunity to make these values into a routine part of the setting; it is broader than simply being “trained” in this approach.

Cultures of trauma-informed care balance trauma-specific emphases on individual empowerment and skills development with organizational emphases on safety, trustworthiness, choice, collaboration, and empowerment. This approach is consistent with other values-based approaches that have become prominent in the past two decades in behavioral health: recovery orientation, gender responsiveness, and cultural competence (Farkas et al.,

2005; Covington, 2007; Whitaker et al., 2007a). Furthermore, the core values of trauma-informed care are consistent with, and strongly supportive of, many evidence-based interventions, such as motivational interviewing, shared decision making, and psychosocial empowerment groups.

Basic shifts in both understanding and practice are fundamental in changing a traditional human service or community culture to one that is trauma-informed. Our protocol for developing a culture of trauma-informed care thus emphasizes both a paradigm shift in understanding and a thoroughly collaborative way to change practice (Harris and Fallot, 2001; Fallot and Harris, 2009). For instance, one of the key changes in understanding is establishing a “trauma first” mode of thinking about a consumer or staff member. Thus, we adopt a “trauma lens” through which other aspects of a person’s life may be viewed. Rather than asking, implicitly or explicitly, “What is wrong with you?” or “What is your problem?” we ask “What have you been through?” and “How have you tried to cope with it?” This basic change in orientation affects the organization’s view of not only consumers and staff members but also the nature of trauma itself, the services provided, and the relationship between consumer and provider. As the basic questions change, so do the approaches, from “Here is what I can do to fix you,” to “How can you and I work together to further your goals for recovery and healing?” Collaborative decision making and planning pervade trauma-informed cultures; not only are consumers’ opinions frequently sought and incorporated into individual service planning and organizational strategies, but also staff perspectives become central to administrators’ thinking as well.

In putting these ideas into practice, we address six domains of organizational culture in human service settings; three are service-level domains, and three are at the systems-level (Fallot and Harris, 2009):

Services-level changes in a culture of trauma-informed care:

• Informal service procedures and settings
• Formal service policies
• Trauma screening, assessment, service planning, and trauma-specific services

Systems-level changes in a culture of trauma-informed care:

• Administrative support for developing and sustaining this culture
• Staff training and education
• Human resources practices

As an example, let us examine our approach to informal service procedures and settings. Here we ask agency workgroups representing all constituencies (upper-level administrators, supervisors and middle management, service staff, support staff, and consumers) to review the sequence of

settings, activities, and people to whom consumers are likely to be exposed from the time of their first call to their final visit. We sometimes recommend a walk-through, in which staff literally put themselves in the place of consumers by going through the same procedures as a new consumer would in entering the agency. Once each physical setting, activity, contact, and relationship has been outlined, we ask key questions related to the core values:

• How can we ensure physical and emotional safety for consumers throughout our organization and larger system of care?
• How can we maximize trustworthiness? Make tasks clear? Maintain appropriate boundaries?
• How can we enhance consumer choice and control?
• How can we maximize collaboration and the sharing of power with consumers?
• How can we prioritize consumer empowerment and skill-building at every opportunity?

Agencies have taken this task on with enthusiasm, developing creative solutions to identified problems in these domains. For example, one residential substance abuse setting had a large sign that read “Denial stops here” over the entrance to the residential areas of its building. Deciding that this sign did not create a hospitable or emotionally safe first impression of their setting, they replaced it with a “Welcome” sign that was much more inviting. Clearer and more positive signs, more comfortable waiting rooms (with adequate space and with minimal intrusion of security staff), more positive first contacts via phone or in person, better lighting in hallways and outdoors, and more private intake procedures—among many others—are examples of the sorts of changes organizations have made in efforts to create safer and more welcoming environments.

Once this process is completed, we ask organizational workgroups to follow the same procedure, this time with a focus on the staff’s experiences of safety, trustworthiness, choice, collaboration, and empowerment. We have seen this “parallel process” with regard to trauma-related concerns played out repeatedly in a wide variety of settings. Simply put, only when staff members’ experiences of physical and emotional safety, of trustworthy relationships (with their co-workers and with supervisors and administrators), of choice in how they go about their daily work, of collaborative power-sharing with administrators and supervisors (so that staff input is weighed significantly), and of empowerment (so that staff members have the resources they need to do their jobs well) are in place is the staff able to create similar experiences for consumers.

Trauma-informed cultures of care develop over time with the collaboration and support of administrators who recognize the invaluable

perspectives of both staff and consumers. We have gathered qualitative data in support of this shift in organizational cultures. Consumers report that they feel more accepted. One woman said, for example, “Before this initiative, I had to leave an important part of myself on the doorstep to this agency; now I can bring my whole self inside.” Consumers, staff, and administrators frequently comment that the initiative fostered more collaborative relationships among them. Built on safety and trustworthiness and supported by valuing choice and empowerment, the capacity to share power meaningfully has become a hallmark of trauma-informed care.

As a values-based context strongly supportive of evidence-based trauma-specific interventions, trauma-informed organizational cultures represent a powerful source of engagement for women and their children who have been exposed to violence (Cocozza et al., 2005; Morrissey et al., 2005). (Also see the Substance Abuse and Mental Health Services Administration’s Women, Co-Occurring Disorders, and Violence Study for related discussions and findings. 7 ) To the extent that secondary and tertiary prevention of such violence relies on creating settings that are welcoming and engaging for individuals with complex histories of violent victimization, trauma-informed care is an increasingly central requirement for programs designed to assist women and children.

ENHANCING EMOTION REGULATION: A FRAMEWORK FOR PSYCHOLOGICAL EMPOWERMENT OF WOMEN AND CHILDREN EXPOSED TO VIOLENCE

Julian d. ford, ph.d. university of connecticut school of medicine.

The health care and social service professions tend to approach the question of how to assist women and children who are victims of violence by doing research on, and developing practice guidelines for, the treatment of posttraumatic stress disorder (PTSD) (Forbes et al., 2010). Extensive surveys of scientifically validated and clinically promising PTSD treatments have been compiled by the International Society for Traumatic Stress Studies, the U.S. Department of Veterans Affairs, the Clinical Resource Efficiency Support Team (part of the Northern Ireland Health Service), the American Psychiatric Association, the British National Institute for Clinical Excellence, the Institute of Medicine, and the Australian Centre for Posttraumatic Mental Health at the University of Melbourne (CREST, 2003; APA, 2004; VA, 2004; NICE, 2005; IOM, 2006; Australian Centre

7 Available at http://pathprogram.samhsa.gov/Resource/Women-Co-Occurring-Disordersand-Violence-Study-Program-Summary-21101.aspx .

for Posttraumatic Mental Health, 2007; Foa et al., 2009). These guidelines were developed to address diagnostic criteria for PTSD in the Diagnostic and Statistical Manual (APA, 1997).

Although laudable in that they have made the possible benefits of carefully developed therapies for PTSD increasingly known to professionals who treat victims of violence, this medicalized approach to helping victims recover from violence has several key limitations. First, the very terms, “victim” and “treatment” suggest a degree of passivity and deficiency that does a grave injustice to the typically extremely courageous and resilient survivors of violence. Violence temporarily disempowers those who must survive it, but even prolonged and horrific violence does not strip the survivor of the capacity to be empowered. Being viewed as broken or defective and therefore in need of corrective treatment as a result of having suffered violence adds injury (as well as insult) to injury. Although therapeutic treatments can be empowering, this is the case only to the extent that they emphasize helping the violence survivor restore or build their strengths. PTSD therapies definitely have been shown through both scientific and clinical research to empower children and adults who have experienced violence (Courtois et al., 2009; Ford and Cloitre, 2009). However, PTSD treatments tend to provide education and therapy based primarily on a view of PTSD as a breakdown of courage (i.e., avoidance of trauma reminders or memories) or deficits in arousal and anxiety management (i.e., hyperarousal, hypervigilance).

Recent research provides a basis for a paradigm shift from a pathology/deficit perspective to a framework of psychological empowerment for interventions for survivors of violence. Women and children who have been exposed to violence often suffer from aftereffects that either do not fit the criteria for PTSD or that involve symptoms and difficulties in daily living that go well beyond PTSD (Rayburn et al., 2005; Schumm et al., 2006; Ford et al., 2008, 2009, 2010, in press-b; Gill et al., 2008; Mongillo et al., 2009; Briggs-Gowan et al., 2010; Seng et al., in review). Although these sequelae might at first glance seem to be consistent with the pathology perspective (e.g., depression, panic, dissociation, addiction, oppositional–defiance, eating disorders, personality disorders, guilt, shame, complicated bereavement), in fact what they demonstrate is the extreme degree of biological, psychological, and interpersonal adaptation required to survive violence (Ford, 2005; Ford and Cloitre, 2009; Ford et al., 2009). These adaptations require substantial strength and resilience, rather than being markers for or the results of pathology or deficiencies (Herman, 1992; Courtois et al., 2009).

As a result of this paradigm shift, in the past decade an impressive array of psychological empowerment interventions has been developed for children and adults who have experienced violence and related forms of complex trauma (Courtois et al., 2009; Ford and Cloitre, 2009). As summarized

by Courtois and colleagues, psychological empowerment interventions are built upon the following two central philosophical foundations:

• Recognizing the uniqueness of the individual . The model is organized around recognition of the primacy and uniqueness of the individual and the maintenance of his/her welfare. Treatment is not one-size-fits-all; rather, each client is assessed, and treatment is planned differentially according to the specific needs of the individual. This is a phenomenological approach…. A “whole person” philosophy prevails: Although symptoms, deficits, and distress are reasons for seeking treatment and generally become the targets for intervention, the individual’s strengths, resources, resilience, personalized needs, values, and contexts are identified and reinforced.
• Personal empowerment. A strengths- and resilience-based philosophy of personal empowerment and self-determination encourages the therapist to seek to understand the individual’s unique phenomenological experience and its specific meaning and its relationship to symptoms, distress, and treatment goals. The individual has authority over the meaning and interpretation of his/her personal life history, current needs and preferences, and goals for the future. The therapist functions as an active, empathic, and responsive listener and a guide to enable the client to openly voice, examine, and therapeutically work through feelings of confusion, shame, or other emotions that have been suppressed or forbidden. The therapist seeks to create relational conditions where the client is emotionally validated and is “seen” and appreciated, to counter the invalidiation experiences typically associated with attachment trauma and subsequent victimization and to encourage emotional expression and development. The therapist strives to create conditions within the treatment that are as egalitarian as possible and that encourage collaboration with and empowerment of the client; however, the responsibilities and inherent power differences in the treatment relationship are explicitly acknowledged. The therapist seeks to use power effectively on the individual’s behalf while simultaneously encouraging the client’s development and autonomy. Importantly, the therapist conveys an openness to the client’s questioning of authority (including that of the therapist) and supports the client’s ultimate authority over his/her life, memories, and therapeutic engagement and progress. Moreover, the therapist is careful to maintain appropriate boundaries and limitations and is responsible for avoiding dual relationships and situations in which the client might be subject to pressure, coercion, or exploitation intentionally or inadvertently by the therapist. Treatment should be based in a shared plan that is systematic (not laissez-faire), utilizes effective strategies … organized around a careful assessment and a planned sequence of interventions that are hierarchically ordered and sequenced (86-87; italics in original).

A recent meta-analysis of therapy outcome studies with adult survivors of childhood sexual abuse found that cognitive behavior therapy was superior to other modalities for anxiety, depression, and other internalizing problems but not for problems more specifically related to emotion dysregulation (e.g., externalizing or interpersonal problems) (Taylor and Harvey, 2010). Thus, some violence survivors, particularly those with extensive victimization histories, may respond best to therapy focused on enhancing emotion regulation. Survivors who have severe difficulties with emotion regulation and their therapists also may prefer not to engage in trauma memory processing or to not do so until the client has acquired emotion regulation skills (Cook et al., 2004; Cloitre et al., 2010). Three manualized psychosocial intervention models that do not include trauma memory processing have been designed to enhance skills for emotion regulation, anxiety management, and interpersonal functioning. Skills Training for Emotion and Interpersonal Regulation (STAIR) has shown promise in reducing PTSD and depression symptoms and in enhancing emotion regulation with women survivors of violence (Cloitre et al., 2010). Seeking Safety has shown promise in reducing PTSD and substance use problems with girls and women (Najavits et al., 2006; Zlotnick et al., 2009). Although STAIR and Seeking Safety address emotion regulation, they emphasize becoming more assertively aware and expressive of emotions as a way to overcome excessively negative emotion states and dysfunctional avoidance of trauma memories or reminders of those memories.

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) acknowledges the extreme emotional distress (e.g., depression, anxiety, anger, guilt, shame, and grief) or emotionally numbed and shutdown feelings (e.g., dissociation) that violence survivors often suffer (Ford and Russo, 2006). However, these PTSD or trauma-related “symptoms” are currently viewed as adaptive, rather than maladaptive or dysfunctional, reactions which reflect a change in the stress response system in the body that is protective of the individual. TARGET teaches a single sequential skill set described by the mnemonic FREEDOM, designed based on research showing that emotion regulation involves recognizing, modulating, and recovering from negative emotion states as well as accessing and sustaining positive emotion states (Eisner et al., 2009; Kessler and Staudinger, 2009). Restoring affect regulation is described as requiring seven practical steps or skills denoted by FREEDOM: Focusing the mind on one thought at a time; Recognizing current triggers for emotional reactions; distinguishing dysregulated (“reactive”) versus adaptive (“main”) Emotions; Evaluations (thoughts); goal Definitions; behavioral Options; and self-statements affirming that taking responsibility for recovering from intense emotions is crucial not only to one’s own personal well-being but also to Making a positive contribution to primary relationships (e.g., as a parent) and the community.

TARGET has been evaluated in a series of real-world effectiveness studies as a group therapy for women and men in substance abuse treatment as well as for incarcerated women, as a one-to-one therapy for low-income women with complex trauma histories and girls involved in delinquency, and as a combined group and milieu intervention for girls and boys placed in juvenile detention centers (Frisman et al., 2008, Ford et al., in press-b, in preparation; Ford and Hawke, in review). Group and milieu interventions enable participants to provide one another with peer modeling, support, and guidance as well as potentially enabling the program or community in which they take place to become “trauma informed” (Fallot and Harris, 2008). Consistent with this view, TARGET was found to enable women and men recovering from substance abuse to maintain a sense of realistic confidence and optimism (“sobriety self-efficacy”), where others who received substance abuse treatment as usual showed a marked decline in this important resilience factor (Frisman et al., 2008). The benefits to the entire setting were evident in findings from the evaluation of TARGET in youth detention centers, in which every session of TARGET received by a girl or boy was associated with a reduction in the number of behavioral incidents and punitive sanctions imposed by staff during the first two weeks of youths’ stay in the facilities (Ford and Hawke, in review). On the other hand, many girls or women who have experienced violence may prefer the privacy of a one-to-one therapy intervention, and TARGET showed evidence of helping both underserved women and girls to not only reduce their PTSD symptoms but also to increase their ability to regulate emotions (Ford et al., in press-a, in press-b).

Implications of a Psychological Empowerment Approach for Violence Survivors

To the extent that knowledge is power, providing women and children who have experienced violence with de-stigmatizing explanations of why they are struggling with persistent emotional distress and how they can draw upon their inherent personal strengths to regain their emotional balance is a very direct and essential form of psychological empowerment. Equally, if not more, important is bringing this same knowledge to the many professionals, advocates, policy makers, funders, jurists, and regulators who determine how scarce societal resources will be allocated both to prevent violence and to restore the lives and well-being of survivors of violence. If violence changes how survivors’ bodies respond to subsequent stressors (non-violent as well as violent), then traumatic stress disorders such as PTSD and its more complex variants are simply extreme versions of the out-of-balance emotional states that everyone experiences. Therefore, if recovery from the aftereffects of violence involves regaining or restoring

innate capacities for re-setting the body’s stress reaction systems—and, in so doing, regaining or restoring the innate ability to regulate emotions and maintain a generally healthy balanced emotional state despite expectable perturbations—it is essential that not only violence survivors but also the public at large (including those key determiners and providers of services) are informed about why and how emotion regulation is essential not only for survivors of violence but also on a larger scale to prevent violence. With this perspective, it becomes possible to understand not only the aftereffects of violence but also violence itself as resulting at least in part from emotion dysregulation on a broad scale (e.g., uncivil discourse in politics or extreme economic and social disparities). Knowledge and skills regarding emotion regulation are essential not just for violence survivors, but for everyone.

Adegoke, T. G., and D. Oladeji. 2008. Community norms and cultural attitudes and beliefs factors influencing violence against women of reproductive age in Nigeria. European Journal of Scientific Research 20:265-273.

Adi, Y., A. Killoran, K. Janmohamed, and S. Stewart-Brown. 2007. Systematic review of the effectiveness of interventions to promote mental wellbeing in children in primary education. Report 1: Universal approaches: non-violence related outcomes. London: National Institute for Health and Clinical Excellence.

Ahmed, S. M. 2005. Intimate partner violence against women: Experiences from a woman-focused development programme in Matlab, Bangladesh. Journal of Health, Population and Nutrition 23(1):95-101.

Amaro, H. 2011. The Boston Consortium Model: Treatment of trauma among women with substance use disorders. Paper presented at Workshop on Preventing Violence against Women and Children, Institute of Medicine, Washington, DC. January 28.

Amoakohene, M. I. 2004. Violence against women in Ghana: A look at women’s perceptions and review of policy and social responses. Social Science and Medicine 59:2373-2385.

Anderson, L. A., and S. C. Whiston. 2005. Sexual assault education programs: A meta-analytic examination of their effectiveness. Psychology of Women Quarterly 29:374-388.

Anderson, P., D. Chisholm, and D. C. Fuhr. 2009. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. The Lancet 373(9682):2234-2246.

APA (American Psychiatric Association). 1997. Diagnostic and statistical manual of mental disorders (DSM), fourth edition . Washington, DC: American Psychiatric Association.

APA. 2004. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Washington, DC: American Psychiatric Association.

Australian Centre for Posttraumatic Mental Health. 2007. Australian guidelines for the treatment of adults with acute stress disorder and posttraumatic stress disorder. Melbourne, Australia: Australian Centre for Posttraumatic Mental Health.

Bacon, H., and S. Richardson. 2001. Attachment theory and child abuse: An overview of the literature for practitioners. Child Abuse Review 10:377-397.

Bair-Merritt, M. H., J. M. Jennings, R. Chen, L. Burrell, E. MacFarlane, L. Fuddy, and A. K. Duggan. 2010. Reducing maternal intimate partner violence after the birth of a child: A randomized controlled trial of the Hawaii Healthy Start home visitation program. Archives of Pediatrics & Adolescent Medicine 164(1):16-23.

Baldry, A. C., and D. P. Farrington. 2007. Effectiveness of programs to prevent school bullying. Victims and Offenders 2(2):183-204.

Bandura, A. 1977. Social learning theory . Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. 1986. Social foundations of thought and action: A social cognitive theory . Upper Saddle River, NJ: Prentice Hall.

Barker, G., C. Ricardo, and M. Nascimento. 2007. Engaging men and boys in changing gender based inequity in health: Evidence from programme interventions. Geneva, Switzerland: World Health Organization.

Basile, K. C., M. F. Hertz, and S. E. Back. 2009. Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings: Version 1. Atlanta, GA: Centers for Disease Control and Prevention.

Bilukha, O., R. A. Hahn, A. Crosby, M. T. Fullilove, A. Liberman, E. Moscicki, S. Snyder, F. Tuma, P. Corso, A. Schofield, P. A. Briss, and Task Force on Community Preventive Services. 2005. The effectiveness of early childhood home visitation in preventing violence: A systematic review. American Journal of Preventive Medicine 28:11-39.

Bloom, S., and B. Farragher. 2010. Destroying sanctuary: The crisis in human service delivery systems . New York: Oxford University Press.

Bowlby, J. 1980. Attachment and loss . New York: Basic.

Bowlby, J. 1990. A secure base: Parent-child attachment and healthy human development . London: Routledge.

Breitenbecher, K. H., and C. A. Gidycz. 1998. Empirical evaluation of a program designed to reduce the risk of multiple sexual victimization. Journal of Interpersonal Violence 13:472-488.

Breitenbecher, K. H., and M. Scarce. 2001. An evaluation of the effectiveness of a sexual assault education program focusing on psychological barriers to resistance. Journal of Interpersonal Violence 16:387-407.

Briggs-Gowan, M. J., J. D. Ford, L. Fraleigh, K. McCarthy, and A. S. Carter. 2010. Prevalence of exposure to potentially traumatic events in a healthy birth cohort of very young children in the northeastern United States. Journal of Traumatic Stress 23(6):725-733.

Bruce, S. 2002. The “A Man” campaign: Marketing social norms to men to prevent sexual assualt. The Report on Social Norms, Working paper, No. 5 . Little Falls, NJ: PaperClip Communications.

Campbell, J. C. 2005. Assessing dangerousness in domestic violence cases: History, challenges, and opportunities. Criminology & Public Policy 4:653-672.

Chaffin, M., J. F. Silovsky, B. Funderburk, L. A. Valle, E. V. Brestan, T. Balachova, S. Jackson, J. Lensgraf, and B. L. Bonner. 2004. Parent–child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology 72(3):500-510.

Chaloupka, F. J., M. Grossman, and H. Saffer. 2002. The effects of price on alcohol consumption and alcohol-related problems. Alcohol Research and Health 26(1):22-34.

Champion, H. L., and R. H. Durant. 2001. Exposure to violence and victimization and the use of violence by adolescents in the United States. Minerva Pediatrics 53:189-197.

Cloitre, M., K. C. Stovall-McClough, K. Nooner, P. Zorbas, S. Cherry, C. L. Jackson, W. Gan, and E. Petkova. 2010. Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry 167(8):915-924.

Cocozza, J. J., E. W. Jackson, K. Hennigan, J. P. Morrissey, B. G. Reed, R. D. Fallot, and S. Banks. 2005. Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment 28(2):109-119.

Cook, J. M., P. P. Schnurr, and E. B. Foa. 2004. Bridging the gap between posttraumatic stress disorder research and clinical practice. Psychotherapy: Theory, Research, Practice, Training 41:374-387.

Courtois, C. A., J. D. Ford, and M. Cloitre. 2009. Best practices in psychotherapy for adults. In C. A. Courtois and J. D. Ford, eds., Treating complex traumatic stress disorders: An evidence-based guide (pp. 82-103). New York: Guilford Press.

Covington, S. 2003. Beyond trauma: A healing journey for women . City Center, MN: Hazelden.

Covington, S. 2007. Women and addiction: A gender-responsive approach . Clinical innovators series. City Center, MN: Hazelden.

CREST. 2003. The management of post traumatic stress disorder in adults. Belfast, Ireland: Clinical Resource Efficiency Support Team.

Crooks, C. V. 2011. Cycles of violence. Paper presented at Workshop on Preventing Violence Against Women and Children, Institute of Medicine, Washington, DC. January 28.

Crooks, C. V., K. L. Scott, D. A. Wolfe, D. Chiodo, and S. Killip. 2007. Understanding the link between childhood maltreatment and violent delinquency: What do schools have to add? Child Maltreatment 12(3):269-280.

Dahlberg, L. L., and A. Butchart. 2005. State of the science: Violence prevention efforts in developing and developed countries. International Journal of Injury Control and Safety Promotion 12(2):93-104.

Dias, M. A., K. Smith, K. deGuehery, P. Mazur, V. Li, and M. L. Shaffer. 2005. Preventing abusive head trauma among infants and young children: A hospital-based, parent education program. Pediatrics 115:e470-477.

Dodge, K. A., J. D. Coie, G. S. Pettit, and J. M. Price. 1990. Peer status and aggression in boys’ groups: Developmental and contextual analyses. Child Development 61(5):1289-1309.

Dodge, K. A., G. S. Pettit, and J. E. Bates. 1994. Effects of physical maltreatment on the development of peer relations. Development and Psychopathology 6:43-55.

Douglas, M. 1998. Restriction of the hours of sale of alcohol in a small community: A beneficial impact. Australian and New Zealand Journal of Public Health 22:714-719.

Du Mont, J., and D. Parnis. 2000. Sexual assault and legal resolution: Querying the medical collection of forensic evidence. Medicine and Law 19:779-792.

Duailibi, S., W. Ponicki, J. Grube, I. Pinsky, R. Laranjeira, and M. Raw. 2007. The effect of restricting opening hours on alcohol-related violence. American Journal of Public Health 97:2276-2280.

Dusenbury, L., M. Falco, A. Lake, R. Brannigan, and K. Bosworth. 1997. Nine critical elements of promising violence prevention programs. Journal of School Health 67:409-414.

Eckenrode, J., B. Ganzel, C. R. Henderson, Jr., E. Smith, D. L. Olds, J. Powers, R. Cole, H. Kitzman, and K. Sidora. 2000. Preventing child abuse and neglect with a program of nurse home visitation: The limiting effects of domestic violence. JAMA 284(11):1385-1391.

Ehrensaft, M. K., P. Cohen, J. Brown, E. Smailes, H. Chen, and J. G. Johnson. 2001. Intergenerational transmission of partner violence: A 20-year prospective study. Journal of Consulting and Clinical Psychology 71:741-753.

Eisner, L. R., S. L. Johnson, and C. S. Carver. 2009. Positive affect regulation in anxiety disorders. Journal of Anxiety Disorders 23(5):645-649.

Ellsberg, M., J. Liljestrand, and A. Winkwist. 1997. The Nicaraguan Network of Women Against Violence: Using research and action for change. Reproductive Health Matters, 5(10):82-92.

Fabiano, P., H. W. Perkins, A. Berkowitz, J. Linkenbach, and C. Stark. 2003. Engaging men as social justice allies in ending violence against women: Evidence for a social norms approach. Journal of American College Health 52:105-112.

Fagan, J., and A. Browne. 1994. Violence between spouses and intimates: Physical aggression between women and men in intimate relationships. In A. J. Reiss, Jr., and J. A. Roth, eds. Understanding and preventing violence, Volume 3: Social Influences (pp. 115-292). Washington, DC: National Academy Press.

Fallot, R. D., and M. Harris. 2008. Trauma-informed services. In G. Reyes, J. D. Elhai and J. D. Ford, eds. The Encyclopedia of Psychological Trauma . Hoboken, NJ: John Wiley.

Fallot, R. D., and M. Harris. 2009. Creating cultures of trauma-informed care: A self-assessment and planning protocol . Washington, DC: Community Connections.

Farkas, M., C. Gagne, W. Anthony, and J. Chamberlin. 2005. Implementing recovery oriented evidence based programs: Identifying the critical dimensions. Community Mental Health Journal 41(2):141-158.

Farrington, D. P., and M. M. Ttofi. 2009. School-based programs to reduce bullying and victimization. Campbell Systematic Reviews. Oslo, Norway: Campbell Collaboration.

Finkelhor, D. 2009. The prevention of childhood sexual abuse. The Future of Children 19(2):169-194.

Finkelhor, D., N. Asdigian, and J. Dziuba-Leatherman. 1995. The effectiveness of victimization prevention instruction: An evaluation of children’s responses to actual threats and assaults. Child Abuse and Neglect 19:141-153.

Finkelhor, D., R. K. Ormrod, and H. A. Turner. 2009. Lifetime assessment of poly-victimization in a national sample of children and youth. Child Abuse and Neglect 33(7):403-411.

Finnish Foundation for Alcohol Studies. 2003. Alcohol in developing societies: A public health approach. Helsinki and Geneva: Finnish Foundation for Alcohol Studies and World Health Organization.

Fisher, G. J. 1986. College student attitudes toward forcible date rape: Changes after taking a human sexuality course. Journal of Sex Education and Therapy 12:42-46.

Foa, E. B., T. Keane, M. J. Friedman, and J. A. Cohen, eds. 2009. Effective treatments for PTSD, 2nd ed. New York: Guilford.

Fontaine, R. G. 2010. New developments in developmental research on social information processing and antisocial behavior. Journal of Abnormal Child Psychology 38(5):569-573.

Forbes, D., M. Creamer, J. I. Bisson, J. A. Cohen, B. E. Crow, E. B. Foa, M. J. Friedman, T. M. Keane, H. S. Kudler, and R. J. Ursano. 2010. A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress 23(5):537-552.

Ford, J. D. 2005. Treatment implications of altered neurobiology, emotion regulation and information processing following child maltreatment. Psychiatric Annals 35:410-419.

Ford, J. D., and M. Cloitre. 2009. Best practices in psychotherapy for children and adolescents. In C. Courtois and J. D. Ford, eds., Treating complex traumatic stress disorders: An evidence-based guide (pp. 59-81). New York: Guilford.

Ford, J. D., D. F. Connor, and J. Hawke. 2009. Complex trauma among psychiatrically impaired children: A cross-sectional, chart-review study. Journal of Clinical Psychiatry 70(8):1155-1163.

Ford, J. D., J. D. Elhai, D. F. Connor, and B. C. Frueh. 2010. Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and involvement in delinquency in a national sample of adolescents. Journal of Adolescent Health 46(6):545-552.

Ford, J. D., J. K. Hartman, J. Hawke, and J. Chapman. 2008. Traumatic victimization, posttraumatic stress disorder, suicidal ideation, and substance abuse risk among juvenile justice-involved youths. Journal of Child and Adolescent Trauma 1:75-92.

Ford, J. D., and J. Hawke. In review. Trauma emotion regulation psychoeducation group attendance is associated with reduced disciplinary incidents and sanctions in juvenile detention facilities. Journal of Child and Adolescent Trauma .

Ford, J. D., and E. Russo. 2006. Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET). American Journal of Psychotherapy 60(4):335-355.

Ford, J. D., K. Steinberg, J. Hawke, J. Levine, and W. Zhang. In press-a. Evaluation of trauma emotion regulation—Guide for education and therapy (TARGET) with traumatized girls involved in delinquency. Journal of Clinical Child and Adolescent Psychology .

Ford, J. D., K. Steinberg, and W. Zhang. In press-b. Emotion regulation and social problem-solving psychotherapies for high-risk mothers with PTSD. Behavior Therapy .

Foshee, V. A., G. F. Linder, K. E. Bauman, S. A. Langwick, X. B. Arriaga, J. L. Health, P. M. McMahon, and S. Bangdiwala. 1996. The Safe Dates project: Theoretical basis, evaluation design, and selected baseline findings. American Journal of Preventive Medicine 12(5):39-47.

Foshee, V. A., K. E. Bauman, X. B. Arriaga, R. W. Helms, G. G. Koch, and G. F. Linder. 1998. An evaluation of Safe Dates, an adolescent dating violence prevention program. American Journal of Public Health 88(1):45-50.

Foshee, V. A., K. E. Bauman, W. F. Greene, G. G. Koch, G. F. Linder, and J. E. MacDougall. 2000. The Safe Dates program: 1-year follow-up results. American Journal of Public Health 90(10):1619-1622.

Foshee, V. A., K. E. Bauman, S. T. Ennett, G. F. Linder, T. Benefield, and C. Suchindran. 2004. Assessing the long-term effects of the Safe Dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration. American Journal of Public Health 94(4):619-624.

Foshee, V. A., K. E. Bauman, S. T. Ennett, C. Suchindran, T. Benefield, and G. F. Linder. 2005. Assessing the effects of the dating violence prevention program “Safe Dates” using random coefficient regression modeling. Prevention Science 6:245-258.

Foshee, V. A., K. J. Karriker–Jaffe, H. L. Reyes, S. T. Ennett, C. Suchindran, K. E. Bauman, and T. Benefield. 2008. What accounts for demographic differences in trajectories of adolescent dating violence? An examination of intrapersonal and contextual mediators. Journal of Adolescent Health 42(6):596-604.

Foshee, V. A., M. L. Reyes, and S. Wyckoff. 2009. Approaches to preventing psychological, physical, and sexual partner abuse. In D. O’Leary and E. Woodin, eds., Psychological and physical aggression in couples: Causes and interventions (pp. 165-190). Washington, DC: American Psychological Association.

Fox A. M., S. S. Jackson, N. B. Hansen, N. Gasa, M. Crewe, and K. J. Sikkema. 2007. In their own voices: A qualitative study of women’s risk for intimate partner violence and HIV in South Africa. Violence Against Women 13:583-602.

FPH (U.K. Faculty of Public Health). 2008. Alcohol and public health. Faculty of Public Health position statement: U.K. Faculty of Public Health.

Frisman, L., J. D. Ford, H. Lin, S. Mallon, and R. Chang. 2008. Outcomes of trauma treatment using the TARGET model. Journal of Groups in Addiction and Recovery 3:285-303.

Garbarino, J. 1999. Lost boys: Why our sons turn violent and how we can save them . New York: The Free Press.

Garner, J., J. Fagan, and C. Maxwell. 1995. Published findings from the Spouse Assault Replication Program: A critical review. Journal of Quantitative Criminology 11:3-28.

Gibson, L. E., and H. Leitemberg. 2000. Child sexual abuse prevention programs: Do they decrease the occurrence of child sexual abuse? Child Abuse & Neglect 24:1115-1125.

Gill, J. M., G. G. Page, P. Sharps, and J. C. Campbell. 2008. Experiences of traumatic events and associations with PTSD and depression development in urban health care-seeking women. Journal of Urban Health 85(5):693-706.

Go, V. F., S. C. Johnson, M. E. Bentley, S. Sivaram, A. K. Srikrishnan, D. D. Celentano, and S. Solomon. 2003. Crossing the threshold: Engendered definitions of socially acceptable domestic violence in Chennai, India. Culture, Health and Sexuality 5:393-408.

Hahn, R., D. Fuqua-Whitley, H. Wethington, J. Lowy, A. Crosby, M. Fullilove, R. Johnson, A. Liberman, E. Moscicki, L. Price, S. Snyder, F. Tuma, S. Cory, G. Stone, K. Mukhopadhaya, S. Chattopadhyay, and L. Dahlberg. 2007. Effectiveness of universal school-based programs to prevent violent and aggressive behavior: A systematic review. American Journal of Preventive Medicine 33(2 Suppl):S114-S129.

Harris, M. 1998. Trauma recovery and empowerment: A clinician’s guide for working with women in groups . New York: The New Press.

Harris, M., and R. D. Fallot, eds. 2001. Using trauma theory to design service systems . San Francisco: Jossey-Bass.

Heise, L., and C. García-Moreno. 2002. Violence by intimate partners. In E. G. Krug, ed., World report on violence and health (pp. 87-121). Geneva, Switzerland: World Health Organization.

Herman, J. L. 1992. Trauma and recovery . New York: Basic Books.

Herrenkohl, T. I., C. Sousa, E. A. Tajima, R. C. Herrenkohl, and C. A. Moylan. 2008. Intersection of child abuse and children’s exposure to domestic violence. Trauma Violence Abuse 9(2):84-99.

Hussain, R., and A. Khan. 2008. Women’s perceptions and experiences of sexual violence in marital relationships and its effect on reproductive health. Health Care for Women International 29:468-483.

Ilika, A. L. 2005. Women’s perception of partner violence in a rural Igbo community. African Journal of Reproductive Health 9:77-88.

IOM (Institute of Medicine). 2006. Posttraumatic stress disorder: Diagnosis and assessment . Washington, DC: The National Academies Press.

Jaffe, P. G., and M. Juodis. 2006. Children as victims and witnesses of domestic homicide: Lessons learned from domestic violence death review committees. Juvenile and Family Court Journal 57(3):13-28.

Jaffe, P. G., N. K. D. Lemon, and S. E. Poisson. 2003. Child custody and domestic violence: A call for safety and accountability . Thousand Oaks, CA: Sage.

Jennings, A. 1998. On being invisible in the mental health system. In B. L. Levin, A. K. Blanch, and A. Jennings, eds. Women’s mental health services: A public health perspective (pp. 326-347). Thousand Oaks, CA: Sage Publications.

Jewkes, R., M. Nduna, J. Levin, N. Jama, K. Dunkle, A. Puren, and N. Duwury. 2008. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. British Medical Journal 337:383-387.

Jewkes, R., P. Sen, and C. García-Moreno. 2002. Sexual violence. In E. G. Krug, ed. World report on violence and health (pp. 149-181). Geneva, Switzerland: World Health Organization.

Kabeer, N. 2001. Conflicts over credit: Re-evaluating the empowerment potential of loans to women in rural Bangladesh. World Development 29(1):63-84.

Katz, J. 2006. The macho paradox: Why some men hurt women and how all men can help . Napierville, IL: Sourcebooks.

Kessler, E. M., and U. M. Staudinger. 2009. Affective experience in adulthood and old age: The role of affective arousal and perceived affect regulation. Psychology and Aging 24(2):349-362.

Kim, J. C., G. Ferrari, T. Abramsky, C. H. Watts, J. R. Hargreaves, L. A. Morison, G. Phetla, J. D. H. Porter, and P. Pronyk. 2009. Assessing the incremental benefits of combining health and economic interventions: Experience from the IMAGE study in rural South Africa. Bulletin of the World Health Organization 87:824-832.

Knox K. L., D. A. Litts, G. W. Talcott, J. C. Feig, and E. D. Caine. 2003. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Cohort study. British Medical Journal 327:1376-1381.

Koenig, M. A., A. Saifuddin, H. Mian Bazle, and A. B. M. Khorshed-Alam-Mozumder. 2003. Women’s status and domestic violence in rural Bangladesh: Individual- and community-level effects. Demography 40(2):269-288.

Lankester, T. 1992. Setting up community health programmes: A practical manual for use in developing countries . London: Macmillan Press.

Laranjeira, R., and D. Hinkly. 2002. Evaluation of alcohol outlet density and its relation with violence. Revista de Saude Publica 36(4):455-461.

Liu, M., and C. Chan. 1999. Enduring violence and staying in marriage: Stories of battered women in rural China. Violence Against Women 5:1469-1492.

Lösel, F., and A. Beelmann. 2003. Effects of child skills training in preventing antisocial behaviour: A systematic review of randomized evaluations. Annals of the American Academy of Political and Social Science 587:84-109.

Macmillan, H. L., C. N. Wathen, J. Barlow, D. M. Fergusson, J. M. Leventhal, and H. N. Taussig. 2009. Interventions to prevent child maltreatment and associated impairment. Lancet 373(9659):250-266.

Markowitz, S. 2000. The price of alcohol, wife abuse, and husband abuse. Southern Economic Journal 67:279-303.

Meltzer, H., R. Gatward, T. Corbin, R. Goodman, and T. Ford. 2003. Persistence, onset, risk factors and outcomes of childhood mental disorders . London: Office for National Statistics, HMSO.

Mikton, C., and A. Butchart. 2009. Child maltreatment prevention: A systematic review of reviews. Bulletin of the World Health Organization 87(5):353-361.

Mitra, A., and P. Singh. 2007. Human capital attainment and gender empowerment: The Kerala paradox. Social Science Quarterly 88:1227-1242.

Mongillo, E. A., M. Briggs-Gowan, J. D. Ford, and A. S. Carter. 2009. Impact of traumatic life events in a community sample of toddlers. Journal of Abnormal Child Psychology 37(4):455-468.

Morrison, A., M. Ellsberg, and S. Bott. 2004. Addressing gender-based violence in the Latin American and Caribbean region: A critical review of interventions. Washington, DC: World Bank Policy Research.

Morrissey, J. P., E. W. Jackson, A. R. Ellis, H. Amaro, V. B. Brown, and L. M. Najavits. 2005. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56(10):1213-1222.

Mueser, K. T., S. D. Rosenberg, H. Xie, M. K. Jankowski, E. E. Bolton, W. Lu, J. L. Hamblen, H. J. Rosenberg, G. J. McHugo, and R. Wolfe. 2008. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology 76(2):259-271.

Najavits, L. M. 2002. Seeking safety: A treatment manual for PTSD and substance abuse . New York: Guilford Press.

Najavits, L. M., R. J. Gallop, and R. D. Weiss. 2006. Seeking safety therapy for adolescent girls with PTSD and substance use disorder: A randomized controlled trial. Jounal of Behavioral Health Services and Research 33(4):453-463.

National Collaborating Centre for Mental Health. 2007. Antenatal and postnatal mental health. NICE Clinical Guideline No 45 . London: National Institute for Clinical Excellence.

NICE (National Institute for Clinical Excellence.). 2005. Posttraumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. London, UK: National Institute for Clinical Excellence.

Oliver, J. E. 1993. Intergenerational transmission of child abuse: Rates, research, and clinical implications. American Journal of Psychiatry 150(9):1315-1324.

Paine, K., G. Hart, M. Jawo, S. Ceesay, M. Jallow, L. Morison, G. Walraven, K. McAdam, and M. Shaw. 2002. Before we were sleeping, now we are awake: Preliminary evaluation of the Stepping Stones sexual health programme in the Gambia. African Journal of AIDS Research 1(1):39-40.

Petersen, I., A. Bhana, and M. McKay. 2005. Sexual violence and youth in South Africa: The need for community based prevention interventions. Child Abuse & Neglect 29:1233-1248.

Powers, M. B., J. M. Halpern, M. P. Ferenschak, S. J. Gillihan, and E. B. Foa. 2010. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review 30(6):635-641.

Prinz, R. J., M. R. Sanders, C. J. Shapiro, D. J. Whitaker, and J. R. Lutzker. 2009. Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science 10(1):1-12.

Rahman, A. 1999. Women and microcredit in rural Bangladesh: Anthropological study of the rhetoric and realities of Grameen Bank lending . Boulder, CO: Westview Press.

Rayburn, N. R., S. L. Wenzel, M. N. Elliott, K. Hambarsoomians, G. N. Marshall, and J. S. Tucker. 2005. Trauma, depression, coping, and mental health service seeking among impoverished women. Journal of Consulting and Clinical Psychology 73(4):667-677.

Resick, P. A., T. E. Galovski, M. O’Brien Uhlmansiek, C. D. Scher, G. A. Clum, and Y. Young-Xu. 2008. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology 76(2):243-258.

Rhyne, E. 2001. Mainstreaming microfinance: How lending to the poor began, grew, and came of age in Bolivia . Green Haven, CT: Kumarian Press.

Robins, C. S., J. A. Sauvageot, K. J. Cusack, S. Suffoletta-Maierle, and B. C. Frueh. 2005. Consumers’ perceptions of negative experiences and “sanctuary harm” in psychiatric settings. Psychiatric Services 56(9):1134-1138.

Schecter, S., and J. Edleson. 1999. Effective intervention in domestic violence and child maltreatment cases: Guidelines for policy and practice. Reno, NV: National Council of Juvenile and Family Court Judges.

Schewe, P. A. 2007. Interventions to prevent sexual violence. In L. Doll, ed. Handbook of injury and violence prevention (pp. 183-201). New York: Springer.

Schopper, D., J.-D. Lormand, and R. Waxweiler. 2006. Developing policies to prevent injuries and violence: Guidelines for policy-makers and planners. Geneva, Switzerland: World Health Organization.

Schuler, S. R., S. M. Hashemi, A. P. Riley, and S. Akhter. 1996. Credit programs, patriarchy and men’s violence against women in rural Bangladesh. Social Science and Medicine 43(12):1729-1742.

Schumm, J. A., M. Briggs-Phillips, and S. E. Hobfoll. 2006. Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women. Journal of Traumatic Stress 19(6):825-836.

Scott, K. L., and C. V. Crooks. 2004. Effecting change in maltreating fathers: Critical principles for intervention planning. Clinical Psychology: Science and Practice 11:95-111.

Seng, J., W. D’Andrea, and J. D. Ford. In review. Psychological trauma history and empirically derived psychiatric syndromes in a community sample of women in prenatal care. Psychological Trauma .

Sheehan, D. 2008. Alcohol, health and wider social impact. SE Regional Public Health Group Information Series No. 1. London: Department of Health.

Skowron, E. A., and D. H. S. Reinemann. 2005. Psychological interventions for child maltreatment: A meta-analysis. Psychotherapy: Theory, Research, Practice, and Training 42:52-71.

Slovak, K., C. Carlson, and L. Helm. 2007. The influence of family violence on youth attitudes. Child and Adolescent Social Work Journal 24:77-99.

Smith, J. D., B. H. Schneider, P. K. Smith, and K. Ananiadou. 2004. The effectiveness of whole-school antibullying programs: A synthesis of evaluation research. School Psychology Review 33:548-561.

Smith, P. H., J. W. White, and L. J. Holland. 2003. A longitudinal perspective on dating violence among adolescent and college-age women. American Journal of Public Health 93(7):1104-1109.

Solórzano, I., H. Abaunza, and C. Molina. 2000. Evaluación de impacto de la campaña contra las mujeres un desastre que los hombres si podemos evitar [impact evaluation of the campaign violence against women: A disaster we can prevent as men]. Managua: CANTERA.

Sousa, C., T. I. Herrenkohl, C. A. Moylan, E. A. Tajima, J. B. Klika, R. C. Herrenkohl, and M. J. Russo. 2011. Longitudinal study on the effects of child abuse and children’s exposure to domestic violence, parent-child attachments, and antisocial behavior in adolescence. Journal of Interpersonal Violence 26(1):111-136.

Stuart, G. L., S. E. Ramsey, T. M. Moore, C. W. Kahler, L. E. Farrell, P. R. Recupero, and R. A. Brown. 2003. Reductions in marital violence following treatment for alcohol dependence. Journal of Interpersonal Violence 18:1113-1131.

Taylor, J. E., and S. T. Harvey. 2010. A meta-analysis of the effects of psychotherapy with adults sexually abused in childhood. Clinical Psychology Review 30(6):749-767.

Usdin, S., E. Scheepers, S. Goldstein, and G. Japhet. 2005. Achieving social change on gender-based violence: A report on the impact evaluation of Soul City’s fourth series. Social Science and Medicine 61(11):2434-2445.

VA (U.S. Department of Veterans Affairs). 2004. Management of posttraumatic stress . Washington, DC: Department of Veterans Affairs.

van der Kolk, B. A., and M. S. Greenberg. 1987. The psychobiology of the trauma response: Hyperarousal, constriction, and addition to traumatic reexposure. In B. A. van der Kolk, ed. Psychological trauma (pp. 63-87). Arlington, VA: American Psychiatric Publishing.

van Lier, P., F. Vitaro, E. Barker, H. Koot, and R. Tremblay. 2009. Developmental links between trajectories of physical violence, vandalism, theft, and alcohol-drug use from childhood to adolescence. Journal of Abnormal Child Psychology 37(4):481-492.

Welbourn, A. 2009. Stepping Stones—List of surveys and reports to 2006 and some quotes from Stepping Stones users around the world. Some brief notes prepared for the UNAIDS pre-think tank meeting on Evaluation Strategies for Prevention Interventions, Geneva. Available at http://www.steppingstonesfeedback.org/resources/22/Welbourn_Quotes_UNAIDS_Presentation_2009.pdf (accessed April 29, 2011).

Welsh, P. 1997. Hacia una masculinidad sin violencia en las relaciones de pareja [toward masculinity without partner violence]. Managua: CANTERA.

Whitaker, D. J., C. K. Baker, and I. Arias. 2007a. Interventions to prevent intimate partner violence. In L. Doll, ed., Handbook of injury and violence prevention (pp. 203-223). New York: Springer.

Whitaker, D. J., C. K. Baker, C. Pratt, E. Reed, S. Suri, C. Pavlos, B. J. Nagy, and J. Silverman. 2007b. A network model for providing culturally competent services for intimate partner violence and sexual violence. Violence Against Women 13(2):190-209.

Whitaker, D. J., S. Morrison, C. Lindquist, S. R. Hawkins, J. A. O’Neil, and A. M. Nesius. 2006. A critical review of interventions for the primary prevention of perpetration of partner violence. Aggression and Violent Behavior 11(2):151-166.

Whitfield, C. L., R. F. Anda, S. R. Dube, and V. J. Felitti. 2003. Violent childhood experiences and the risk of intimate partners violence in adults: Assessment in a large health maintenance organization. Journal of Interpersonal Violence 18:166-185.

Wolfe, D. A., C. Crooks, P. Jaffe, D. Chiodo, R. Hughes, W. Ellis, L. Stitt, and A. Donner. 2009. A school-based program to prevent adolescent dating violence: A cluster randomized trial. Archives of Paediatrics & Adolescent Medicine 163(8):692-699.

Wolfe, D. A., C. Wekerle, K. Scott, A. L. Straatman, C. Grasley, and D. Reitzel-Jaffe. 2003. Dating violence prevention with at-risk youth: A controlled outcome evaluation. Journal of Consulting and Clinical Psychology 71(2):279-291.

WHO (World Health Organization) and International Society for Prevention of Child Abuse and Neglect. 2006. Preventing child maltreatment: A guide to taking action and generating evidence Geneva, Switzerland: World Health Organization.

WHO and LSHTM (London School of Hygiene and Tropical Medicine). 2010a. The nature, magnitude and consequences of intimate partner and sexual violence. In Preventing intimate partner and sexual violence against women: Taking action and generating evidence . Geneva, Switzerland: World Health Organization.

WHO and LSHTM. 2010b. Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: World Health Organization.

WHO and LSHTM. 2010c. Risk and protective factors for intimate partner and sexual violence. In Preventing intimate partner and sexual violence against women: Taking action and generating evidence . Geneva, Switzerland: World Health Organization.

Zlotnick, C., J. Johnson, and L. M. Najavits. 2009. Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. Behavior Therapy 40(4):325-336.

Analysis and Conclusion on Gender Violence Research Paper

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Understanding Structural Roots of Gender Violence

Consequences of structural violence, human trafficking and displacement, women trends in war, conclusions and recommendations, works cited.

In 1993, the Canadian Panel on violence against Women coined one of the greatest statements on violence and intimidation against women. To this panel, violence against women in the society draws inspiration from inequality structures in the patriarchal nature of many societies. Therefore, developing a sustainable solution to this ill depends on the ability of leading elites to develop adequate equality and equity structures between men and women in the society. Until then, gender violence will remain elusive.

In the Eastern Europe’s case, there exists a link to detach to gender violence against women in the post war error from the real drivers of the vice (Hepburn and Simon 57). More emphasis seems to get diversion towards the structural rooting of violence in the society. During and after the war, women suffered in the hands of men as sex pets, and commercial sex workers.

Much focused aimed at clearing men of the vices committed rather than seeking justice for the women in question. The root driver of this school of thought draws inspiration from the conservative societies that believe women lack equal position in the society and should play a subordinate role to men.

In similarity to the universality and pervasiveness of conflicts and wars, gender violence spreads out across geographical, cultural, social, and ethnic borders. Even though the international community and human right watchdogs continue to play a vital role in fighting gender violence, the intensity of its persistence remains high (Andrijasevic 42).

Gender violence across these boundaries harbors relatively similarly consequences and trends with women as the major casualties. Such an observation, based on the historical manifestations of violence, draws inspiration from the socio-economic and political contexts within which women exist. Social stratification and male-dominated societies produce these gender discrimination tendencies within class, caste, and patriarchal social relations in which male individuals enjoy super power over female counterparts.

Even though direct and physical violence against women lead to physical injury and physiological trauma, use of women as sex pets and commercial sex workers during the disintegration of the Soviet Union created a social and psychological damage to the vulnerable women during and after the wars.

In the Bosnia and Serbia conflict, women used as sex slave remained in psychological trauma giving up their desire to fight for dignity and self-esteem. This violence, coupled with the embedment social gender stratification normalized the violence leading to loss of dignity in women (Gallagher 72).

In war and post war economies, women and children often represent the casualties. The consequences of war on women are far reaching ranging from physical injury to psychological traumatic situations (Wilson, Friedman, and Lindy 91).

Since inequality sustained the during the fall of Soviet Union and the Bosnian-Serbian conflict, the cumulative impacts of these conflicts stemmed inequality within the society with women. Denial of fundamental human rights and exploitation of sex values in women remained the great drivers of violence during these two conflicts.

Violence set up within societies with conservative opinions about the roles of women presented great impact on the women suffrage especially in mental, sexual, and reproductive health (Dudley, Silove, and Gale 33). Forced sex led to unwanted pregnancies and sexually transmitted infections.

The worst part of this violence occurs during the pregnancy stages of a victim with injuries on fetus and infants. Fatal situations during this war caused miscarriage among women leading trauma and other mental health problems such as depression, fear, anxiety, and obsessive behaviors.

According to statistics at the United Nations, conservative estimates indicate that more than two million people are victims of human trafficking. Among the casualties of the vice are migrants and refugees.

War refugees and other individual fleeing their countries for safety often land in the hands of greedy and egocentric individual ready to earn some money from the desperate state of the affected individuals. Women and children represent the social groups suffering from this vice. Soldiers and other corrupt security officers in the immigration and security sectors act as the ambassador of human trafficking (Downe 65).

At the United Nations, data on human on human trafficking indicate that sexual exploitation of women and young girls from war torn regions are high. According to the Norwegian discourse on the sex purchase law, human trafficking becomes rampant in areas of war in which gender and social structures in which women serve as subordinates to their male counterparts in the society.

Dang and Suphang (77), in their analysis of wartime sexual violence argue that sexual orientation in the society plays a role in in human displacement and sexual abuse of women. In the piece, they maintain that in societies with conservative opinions about the role of women in relation to those of the male counterparts, stands high chances of women and girl child exploitation in times of war compared to societies with relative equality between the two genders. During the fall of Soviet Union and the post-integration conflicts, women and girl in the region suffered not only physical and emotional problems, but also trans-locational effects.

Several young girls and women, on the run for safety, landed on the hand of human trafficking leading to more damage.it is also important to note that women and girls presented the highest number of casualties of the refugees in the Bosnian war with Serbia.

The role of men in the military and the militia groups partly explains the gender distribution in many refugee camps. In a setting where women and girls congest a given refugee camps, limited resources cause a state of disparity. For this reason, women become desperate to earn a living from any activity. For this reason, human trafficking often takes an easy course as some women willingly move into the activity for the sake of leaving a congested camp (Yakushko 173).

In the wake of globalization and technological advancements, the demands for resources continue to rise. Several conflicts over natural resources and other factor arise across the world forcing a large number of people into displacement. For this reason, there has been an increase in the number of refugee camps. As communism ended, the demand for control of resources to serve the rising independent states set precedence for increased number of conflicts (Tepfenhart 89).

Several countries broke out together but disintegrated due to lack of agreement over control of resources. As the number of international conflicts increased, several vices occur within the displacement facets of the affected populations. With little disregard to the plight of the displaced refugees, there exists a disconnect between the human rights group striving to serve and rehabilitate the depressed refugees and the unscrupulous soldiers and other institutional officials seeking to earn few bucks from the desperate situations of the refugees.

In the Bosnia war with Serbia, several women displaced from their original homes based on ethnicity and violence got refuge in the camps under military protection. In such camps, some soldiers not only subjected them to sexual exploitation but also engaged in further displaced through human trafficking. The trauma resulting from loss of family during war and conflict coupled with the separation of women from their cultures offered a prerequisite for trauma and depression (Tepfenhart 93).

In the history development of wars, women and girls as casualties stand out as one of the uniform phenomenon. Smock (23) in her analysis of the plight women and young girls argue that media, and political leaders continue to unravel the relatively quiet and unexplored tragic stories of rape during wars. Even though rape exists in the society with or without wars, in the war context it takes a relatively traumatic course as victims often suffer without any legal proceedings against the perpetrators.

Apart from the absence of judicial proceedings against the perpetrators of this vice, nepotism, favoritism, and tribalism sets out as a factor of rape and sex slavery in many war camps (Downie 63). Women in each society have a culture and way of life. In the war camps the war camps, things change. It remains a norm for women to play subordinate roles to the soldiers and serve as slaves.

Women with relatively masculine and stronger genes get better treatment and service in order to sire children with abilities to serve in the military. Women with weak and unwanted traits on the other hand act as sex pets and customers to the human trafficking syndicate with the camps.

In the Bosnia-Serbian war, there existed not only rape but also forced reproduction of perpetrators genes to eliminate the genes considered inferior in the society (Kourvetaris 163). Despite the biological believes and facts about children being a balance of the genes from the biological parents, the Serbian perpetrators of rape and gender violence in this war believed that the genes from the perpetrators dominated the child’s biological characteristics. The Serbians therefore, in their superiority complex’ war with the Bosnians, exploited this fact on Muslim women in the war camps with the aim of cleansing the inferior Muslim minority.

In the refugee camps during this war, the Serbian soldiers raped and abused women refugees until death or conception. The victims who conceived were further concentrated in the camps to ensure zero abortion procurement (Marchak 16). Through these inhumane acts, the Serbian soldiers aimed at increasing their ethnicity and eliminating the Bosnians. On the Bosnian side, more than two thousand women from the Serbian communities underwent the same activities during the war (Vlachova and Biason 63).

Sexual objectification theory remains evident in this explanation of rape and ethnic cleansing in the refugee camps during the Bosnia-Serbia war. Evidence show that soldiers from both camps used the women as an object of developing a new and superior identity irrespective of the traumatic problems the women went through.

As objects of developing a new and superior identity, the soldiers raped, maimed, and in some cases killed women who failed to conceive. As described the objectification theory that sees women as objects and means to an end for the male in the society, the Bosnia-Serbian war presents a great example in which this theory stands out as the leading school of thought especially among the soldiers (Fairchild and Rudman 347).

Structural rooting of gender violence in the society plays a vital role in the culture and bearing of women roles in the society. In order to develop a society devoid of gender violence, the change towards equality and equity among the gender remains overdue.

Gender empowering and creation of social cultures that appreciate the role and differences in the gender act as a basis for stemming out gender violence (Bronstein 71). In times of war and conflict, human rights and social activists need highly developed systems of monitoring the military activities taking place in the refugee camps to ensure protection of women and vulnerable person living in the camps.

Structural and cultural violence towards women remains evident in many societies. Inequalities and discrimination against women in the education, employment, and leadership opportunities presents an ample environment increased violence and gender disparities. Given the patriarchal nature of many societies, there is need for sensitized women focused development to stem out the culture of discrimination.

Developing and in depth understanding of the root drivers of gender and violence against women offer the opportunities for unmasking the gruesome patriarchal structures which encourage women victimization (Schumacher and Slep 235). In the objectification theory, scholars need to develop adequate points against such a school of thought and encourage women to embrace their dignity and live in equality with the male counterparts. Offering women equal opportunities with the male counterparts improves their abilities to withstand violence and the traumatic problems associated with war and effects of war.

In the social empowerment and capacity building perspective, women need to develop sustainable income earning activities to reduce overdependence on their male counterparts. Economic independence offers basis for social independence thus reducing vulnerability of women during war (Smolak and Murnen 510).

As some organization and international non-governmental organization continue to develop women empowerment programs through community groups’ investment and small business enterprises, there remains a need for improved funding of women empowerment initiates to reduce the level of women dependency on male earnings.

Andrijasevic, Rutvica. “Beautiful Dead Bodies: Gender, Migration And Representation In Anti-trafficking Campaigns.” Feminist Review 86 (2007): 24-44. Palgrave Macmillan . Web.

Bronstein, Carolyn. Battling Pornography: The American Feminist Anti-Pornography Movement, 1976-1986 . Cambridge: Cambridge UP, 2011. Print.

Dang, Nguyen, and Chanthawanit Suphang. Uprooting People for Their Own Good?: Human Displacement, Resettlement and Trafficking in the Greater Mekong Sub-Region . Hanoi: Social Sciences Pub. House, 2004. Print.

Downie, Pamela. “Two Stories of Migrant Sex Work, Cross Border Movement and Violence.” Canadian Women Studies 25.2 (2006): 61-66. Print.

Dudley, Michael, Derrick Silove, and Fran Gale. Mental Health and Human Rights: Vision, Praxis, and Courage . Oxford: Oxford UP, 2012. Print.

Fairchild, Kimberly, and Laurie Rudman. “Everyday Stranger Harassment and Women’s Objectification.” Social Justice Research 21.3 (2008): 338-357. Print.

Gallagher, Tom. The Balkans in the New Millennium: In the Shadow of War and Peace . London: Routledge, 2005. Print.

Hepburn, Stephanie, and Rita Simon. Human Trafficking Around the World: Hidden in Plain Sight . New York: Columbia University press, 2013. Print.

Kourvetaris, George. “Ethnonationalism and subnationalism: The case of former Yugoslavia.” Journal of Political and Military Sociology 24.2 (1996): 163. Print.

Marchak, Patricia. No Easy Fix: Global Responses to Internal Wars and Crimes against Humanity . Montreal: McGill-Queen’s UP, 2008. Print.

Schumacher, Julie, and Amy Slep. “Attitudes and Dating Aggression: A Cognitive Dissonance Approach.” Prevention Science 5.4 (2004): 231-243. Print.

Smock, David R. Teaching About the Religious Other . Washington: United States Institute of Peace, 2005. Print.

Smolak, Linda, and Sarah Murnen. “Gender, Self-Objectification and Pubic Hair Removal.” Sex Roles 65.7/8 (2011): 506-517. Print.

Tepfenhart, Mariana. “The Causes of Ethnic Conflicts.” Comparative Civilizations Review 68.2 (2013): 84-97. Print.

Vlachova, Marie, and Lea Biason. Making the World a More Secure Place: Combating Violence against Women . Geneva: DCAF, 2004. Print.

Wilson, John, Matthew Friedman, and Jacob Lindy. Treating Psychological Trauma and Ptsd . New York: Guilford Press, 2001. Print.

Yakushko, Oksana, Megan Watson, and Sarah Thompson. “Stress and Coping in the Lives of Recent Immigrants and Refugees: Considerations for Counseling.” International Journal for The Advancement of Counselling 30.3 (2008): 167-178. Print.

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Essays on Domestic Violence

Domestic violence essay topics and outline examples.

Domestic violence is a critical and complex issue that affects individuals and families across all demographics. Writing essays on this topic can help raise awareness, promote understanding, and inspire action to combat this pervasive problem. When selecting domestic violence essay topics, consider focusing on different aspects such as the psychological impact on victims, legal responses, and societal attitudes.

Essay Title 1: Unveiling the Shadows: Understanding the Causes, Effects, and Prevention of Domestic Violence

Thesis Statement: This essay sheds light on the complex issue of domestic violence by examining its root causes, the devastating effects on victims and society, and strategies for prevention and intervention.

• Introduction
• Defining Domestic Violence: Types and Prevalence
• Causes of Domestic Violence: Analyzing Societal, Psychological, and Cultural Factors
• Impact on Victims: Physical, Emotional, and Psychological Consequences
• Children and Domestic Violence: The Far-Reaching Effects on Youth
• Legal Framework: Laws and Policies Addressing Domestic Violence
• Prevention and Intervention: Support Services, Shelters, and Community Outreach
• Conclusion: Breaking the Cycle of Domestic Violence for a Safer Society

Essay Title 2: Behind Closed Doors: The Cycle of Abuse, Power Dynamics, and Empowering Survivors of Domestic Violence

Thesis Statement: This essay explores the cycle of abuse, the power dynamics within abusive relationships, and strategies to empower survivors of domestic violence to break free from the cycle.

• The Cycle of Abuse: Tensions, Violence, and Reconciliation
• Power and Control: Understanding the Dynamics of Abusive Relationships
• Barriers to Leaving: Factors That Keep Victims in Abusive Situations
• Supporting Survivors: Advocacy, Counseling, and Safe Havens
• Legal Remedies: Restraining Orders, Prosecution, and Victim Protection
• Education and Awareness: Preventing Domestic Violence Through Knowledge
• Conclusion: Empowering Survivors to Reclaim Their Lives

Essay Title 3: The Role of Education and Societal Change in Eradicating Domestic Violence

Thesis Statement: This essay discusses the pivotal role of education and societal change in eradicating domestic violence, emphasizing the importance of promoting healthy relationships and challenging harmful norms and stereotypes.

• Educational Initiatives: Teaching Healthy Relationships and Consent
• Media Influence: Portrayals of Domestic Violence and Their Impact
• Community Engagement: Grassroots Movements and Support Networks
• Breaking Stereotypes: Challenging Gender Norms and Toxic Masculinity
• Preventive Measures: Recognizing Early Warning Signs and Providing Resources
• International Perspectives: Global Efforts to Combat Domestic Violence
• Conclusion: Building a Safer and More Respectful Society for All

Domestic Violence Topics for Research Paper

• The Long-Term Psychological Effects of Domestic Violence on Victims
• The Efficacy of Restraining Orders in Preventing Domestic Violence
• The Impact of Domestic Violence on Children’s Development and Behavior
• Comparative Analysis of Domestic Violence Laws in Different Countries
• Domestic Violence and Substance Abuse: Understanding the Connection
• The Role of Social Services in Supporting Domestic Violence Survivors
• The Influence of Cultural Norms and Beliefs on Domestic Violence
• Gender Differences in Domestic Violence: Perpetrators and Victims
• The Role of Healthcare Providers in Identifying and Responding to Domestic Violence
• Domestic Violence in Same-Sex Relationships: Unique Challenges and Solutions
• Exploring the Cycle of Abuse: Patterns and Interventions
• The Economic Consequences of Domestic Violence on Victims and Society
• The Role of Education in Preventing Domestic Violence
• Legal Challenges in Prosecuting Domestic Violence Cases
• The Effectiveness of Domestic Violence Shelters and Safe Houses
• The Impact of Domestic Violence on Workplace Productivity and Employment
• The Role of Technology in Perpetrating and Preventing Domestic Violence
• Barriers to Reporting Domestic Violence: Understanding Victims’ Reluctance
• The Impact of Media Representation on Public Perception of Domestic Violence
• Strategies for Supporting Domestic Violence Survivors in Legal Proceedings

Exploring domestic violence essay topics is vital for understanding and addressing a pervasive social issue that impacts millions of lives. These topics enable deep dives into the psychological, legal, social, and economic aspects of domestic violence, fostering a comprehensive understanding of the issue. By researching and writing about domestic violence, we can raise awareness, advocate for stronger support systems, and influence policy changes that protect and empower victims. Addressing this topic in academic and public discourse is crucial for creating a safer and more just society. Through continued education and advocacy, we can work towards ending the cycle of abuse and ensuring a brighter future for all affected.

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The Issues of Domestic Violence and Stalking in The United States

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Domestic violence refers to a pattern of abusive behaviors, physical, emotional, psychological, or sexual, occurring within a domestic or intimate relationship. It involves the exertion of power and control by one person over another, typically perpetrated by a current or former partner, spouse, or family member.

• Physical Abuse: the use of physical force that causes bodily harm or injury to a partner or family member.
• Emotional or Psychological Abuse: this form of abuse aims to control, manipulate, or undermine the victim's emotional well-being.
• Sexual Abuse: any non-consensual sexual activity or coercion within an intimate relationship.
• Financial Abuse: this form of abuse entails controlling or limiting the victim's access to financial resources.
• Verbal Abuse: it includes the use of words, insults, threats, or derogatory language to demean, belittle, or intimidate the victim.

Domestic violence affects individuals of all genders, ages, races, and backgrounds in the United States. Approximately 1 in 4 women and 1 in 9 men experience severe intimate partner violence. This issue has profound physical, emotional, and psychological consequences, perpetuating a cycle of violence that impacts families and communities. Encouragingly, more survivors are reporting abuse and seeking help from shelters, hotlines, and support groups, which offer safety planning, counseling, and legal support. Raising awareness and implementing effective strategies are crucial in combating this pervasive problem.

Domestic violence has historical roots across cultures, often seen as a private matter and neglected by legal systems. Historically, women were viewed as property, perpetuating violence in relationships. The feminist movement in the 1960s and 1970s highlighted domestic violence, leading to shelters, hotlines, and support services. Legislation like the Violence Against Women Act (VAWA) of 1994 provided resources and legal protections in the U.S. Despite progress, domestic violence persists, requiring ongoing efforts to address root causes, promote gender equality, and ensure a violence-free society for all.

• Dr. Ellen Pence: Co-founder of the Duluth Model, an influential approach to addressing domestic violence. Her work focused on changing societal perceptions of domestic violence and promoting accountability for perpetrators.
• Tarana Burke: Activist and author who created the "Me Too" movement. Initially aimed at raising awareness about sexual assault, it has since expanded to address various forms of abuse, including domestic violence. Her advocacy has sparked a global conversation and empowered countless survivors to share their experiences.
• Rihanna: Celebrity who has used her platform to speak out against domestic violence and support organizations that assist survivors. Her visibility has helped generate widespread attention and funding for initiatives combating domestic violence.
• Halle Berry: Another celebrity who has actively spoken out against domestic violence and supported related organizations. Her advocacy has raised awareness and provided crucial support for survivors and related initiatives.

Public opinion on domestic violence has significantly evolved. Historically marked by silence and victim-blaming, awareness and open conversations have shifted perspectives. Today, there is widespread condemnation of domestic violence, recognition of its seriousness, and acknowledgment of the need for action. People understand it affects all demographics and support survivors while holding perpetrators accountable, viewing it as a public health issue requiring comprehensive responses.

• Power and Control
• Socioeconomic Factors
• Cultural and Social Norms
• Substance Abuse
• Childhood Experiences
• Lack of Education and Awareness
• Psychological and Emotional Trauma
• Social and Interpersonal Impact
• Impact on Children
• Physical Injuries
• Cycle of Violence
• According to the World Health Organization (WHO), approximately one in three women worldwide has experienced physical or sexual violence from an intimate partner in their lifetime.
• Domestic violence is often underreported, making it challenging to fully understand the scope of the problem. Studies indicate that a significant number of domestic violence incidents go unreported due to fear, shame, economic dependence, or lack of awareness about available resources.
• Domestic violence can perpetuate across generations. Children who witness domestic violence in their homes are more likely to become victims or abusers themselves as adults. Breaking this inter-generational cycle requires effective intervention and support to prevent the normalization of violence within families.

The topic of domestic violence is critical because it sheds light on a pervasive issue that affects millions of people worldwide. By exploring domestic violence essay topics, we can better understand the underlying causes, effects, and solutions to this problem. This knowledge can inform policies, improve support systems, and promote societal change, ultimately helping to protect and empower victims while working to prevent future abuse. Writing about domestic violence also raises awareness, fosters empathy, and encourages action to combat this serious social issue.

1. Anderson, K. L. (2017). Gender, power, and violence: Responding to intimate partner violence in South African households. Gender & Society, 31(6), 743-768. 2. Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National Intimate Partner and Sexual Violence Survey, United States, 2011. Morbidity and Mortality Weekly Report, 63(8), 1-18. 3. Coker, A. L., Smith, P. H., Thompson, M. P., McKeown, R. E., Bethea, L., & Davis, K. E. (2002). Social support protects against the negative effects of partner violence on mental health. Journal of Women's Health & Gender-Based Medicine, 11(5), 465-476. 4. Ellsberg, M., Jansen, H. A., Heise, L., Watts, C. H., & Garcia-Moreno, C. (2008). Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study. The Lancet, 371(9619), 1165-1172. 5. Fisher, B. S., Cullen, F. T., & Turner, M. G. (2000). The sexual victimization of college women (NCJ 182369). Bureau of Justice Statistics. 6. García-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., & Watts, C. H. (2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women's health and domestic violence. The Lancet, 368(9543), 1260-1269. 7. Hegarty, K., O'Doherty, L., & Taft, A. (2013). Challenging the biomedical model: Toward a more nuanced understanding of violence against women. Violence Against Women, 19(11), 1419-1437. 8. Jewkes, R. (2002). Intimate partner violence: Causes and prevention. The Lancet, 359(9315), 1423-1429. 9. Johnson, M. P. (2008). A typology of domestic violence: Intimate terrorism, violent resistance, and situational couple violence. Northeastern University Press. 10. World Health Organization. (2013). Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. World Health Organization.

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In conclusion, I would like emphasize that sexual violence poses an obstacle ...

In conclusion, I would like emphasize that sexual violence poses an obstacle to peace and security. It impedes women from participating in peace and democratic processes and in post-conflict reconstruction and reconciliation. As a tool of war it can become a way of life: once entrenched in the fabric of society, it lingers long after the guns have fallen silent. Many women lose their health, livelihoods, husbands, families and support networks as a result of rape. This, in turn, can shatter the structures that anchor community values, and with that disrupt their transmission to future generations. Children accustomed to acts of rape can grow into adults who accept such acts as the norm. This vicious cycle must stop, as we cannot accept a selective zero-tolerance policy. Today's adoption of resolution 1960 (2010), on sexual violence, is an important step in that direction. It is for that reason that Slovenia joined in co-sponsoring it.

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Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience

• Miao Chen 1 ,
• Hao Xie 2 ,
• Xiaoli Liao 3 &
• Juan Ni 4  

BMC Public Health volume  24 , Article number:  2437 ( 2024 ) Cite this article

Metrics details

Workplace violence is a global public health issue and a major occupational hazard cross borders and environments. Nurses are the primary victims of workplace violence due to their frontline roles and continuous interactions.

The present study aimed to investigate the status of workplace violence, turnover intention, compassion fatigue, and psychological resilience among Chinese nurses, and explore the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses.

A cross-sectional study was conducted among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China. Data was collected through an online questionnaire, which included a demographic information form, the Workplace Violence Scale (WVS), the Turnover Intention Questionnaire (TIQ), the Compassion Fatigue Scale (CF-CN), and the Connor-Davidson Resilience Scale (CD-RISC). Descriptive statistics and correlation analysis were employed to examine the relationships among the main variables. A moderated mediation analysis was further conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience.

The present survey recruited a convenience sample of 1,141 clinical registered nurses, who reported experiencing multiple types of workplace violence during the past year. Correlation analysis revealed significant positive correlations between workplace violence and turnover intention ( r  = 0.466, P  < 0.01) as well as compassion fatigue ( r  = 0.452, P  < 0.01), while negative correlation between workplace violence and psychological resilience ( r =-0.414, P  < 0.01). Moderated mediation analysis revealed that compassion fatigue mediated, while psychological resilience moderated, the positive relationship between workplace violence and turnover intention (all P  < 0.05).

This study underscores the mediating effect of compassion fatigue and the moderating role of psychological resilience in the relationship between workplace violence and turnover intention among Chinese nurses. Future efforts should be undertaken to develop effective preventive measures and intervention strategies at individual, organizational, and national levels to mitigate workplace violence and foster supportive work environment.

Clinical trial number

Not applicable.

Peer Review reports

Introduction

Workplace violence refers to any type of acts, incidents, or behaviors where staffs are attacked, threatened, or humiliated in professional circumstances [ 1 , 2 ], which takes in forms of physical violence and psychological violence. World Health Organization (WHO) has identified workplace violence towards healthcare workers as a significant concern within the healthcare systems [ 3 ]. Workplace violence is one of the most complex occupational hazards in healthcare environment around the world. An umbrella review of meta-analysis examined the prevalence of workplace violence against healthcare workers, which reported a prevalence of 58.7% for overall workplace violence, a prevalence of 20.8% for physical violence, a prevalence of 66.8% for verbal violence, and a prevalence of 10.5% for sexual harassment against healthcare workers [ 4 ]. Nurses is one of the professional groups most exposed to workplace violence due to the nature of their professions and the characteristics of their work environments [ 5 , 6 , 7 ]. The prevalence of workplace violence against nurses remains high around the world, and the estimate was 43% in United States (US) [ 8 ], 44% in Japan [ 9 ], and 67% in Italy [ 10 ]. In addition, a meta-analysis of cross-sectional studies examined the prevalence of workplace violence against Chinese nurses, which reported an incidence of 71% for overall workplace violence, an incidence of 63% for verbal violence, an incidence of 14% for physical violence, and an incidence of 6% for sexual harassment among these Chinese nurses during the last year [ 11 ]. International Council of Nurses (ICN) has issued a position statement to condemn all forms of workplace violence against nurses [ 12 ]. Nurses witnessing or experiencing workplace violence can threaten their health and safety as well as impair their work performance and professional attitudes [ 13 , 14 ]. ICN has stated that workplace violence in the healthcare sectors can impair the delivery of patient services and the assurance of patient safety [ 15 ]. Specifically, a cross-sectional study indicated workplace violence as a major occupational hazard, since the experience of such violence impaired the health status and career satisfaction of victims [ 16 ]. Additionally, other study implicated workplace violence as the main cause of occupational stress, as the experience of such violence increased psychological stress and damaged health status of nurses [ 17 ].

Turnover intention refers to an employee’s tendency to leave the current profession and seek an alternative occupation within a certain timeframe [ 18 ]. Turnover intention represents the final stage of turnover perception, and can serve as an excellent indicator for actual turnover [ 18 ]. The turnover rates among nurses remain high around the word, reaching 18.7% in the US [ 19 ] and 12.3% in the United Kingdom (UK) [ 20 ]. The shortage of nurses is a prevalent challenge encountered by healthcare systems worldwide, with the WHO estimating a deficit of over 9 million nurses by 2030 [ 21 ]. China also faces high turnover rates among nurses, a cross-sectional survey of 12,291 nurses across 23 hospitals found that 9.82% of Chinese nurses exhibited strong turnover intention [ 22 ]. Studies have converged to examine the antecedents of turnover intention among nurses, with workplace violence emerging as a strong predictor of turnover intention [ 23 ]. For example, a longitudinal survey with data gathered from 2006 to 2010 examined the relationship between turnover intention and workplace violence among 1,515 Finnish physicians, revealed that workplace violence was positively associated with turnover intention [ 24 ]. In addition, a cross-sectional study investigated the relationship between turnover intention and workplace violence among Chinese nurses, which involved 1,761 nurses among 9 public tertiary hospitals across 4 provinces, indicated that workplace violence was positively associated with turnover intention [ 25 ]. Exposure to workplace violence can make nurses to doubt their own occupational value and professional status, which further causes nurses dissatisfaction with job and intention to leave job [ 26 , 27 ]. While previous studies have primarily examined the occurrence rate and risk assessment of workplace violence, few studies have investigated the consequences and mechanisms of workplace violence on work outcomes [ 28 ]. Therefore, the present study aims to further explore the impacts of workplace violence on turnover intention, and uncover the mechanism behind this correlation among Chinese nurses.

Compassion fatigue refers to a state of physiological dysfunction and emotional exhaustion, which can induce emotional stress and psychological distress in affected individuals [ 29 , 30 ]. Compassion fatigue is a synonymous term for various occupational stresses, encompassing dimensions of both occupational burnout and secondary traumatic stress. Occupational burnout is defined as a sense of exhaustion, frustration, and fatigue resulting from work pressure, while secondary traumatic stress is defined as a syndrome of intrusion, avoidance, and arousal stemming from indirect exposure to traumatic events. Nurses are recognized as the healthcare professionals who struggle the most with compassion fatigue, with reported prevalence ranging from 7.3 to 44.8% among this population [ 31 ]. Compassion fatigue is considered an occupational hazard within healthcare sectors, posing serious consequences for nurses, patients, and organizations alike. Studies have indicated that exposure to workplace violence can decrease compassion satisfaction and evoke compassion fatigue among victimized nurses [ 32 ]. Evidence has also implicated that the presence of compassion fatigue decreased the quality of occupational life and increased the risk of turnover intention among nurses [ 33 ]. Given the relationship between workplace violence and compassion fatigue as well as the association between compassion fatigue and turnover intention, compassion fatigue may act as a critical mediator through which workplace violence impacts turnover intention.

Psychological resilience represents a personality attribute which enables individuals to cope successfully with and recover quickly from adverse circumstances [ 34 ]. Psychological resilience constitutes a protective factor that helps nurses transform adverse events into positive experiences, thus enhancing retention intentions of nurses and stabilizing human resources of healthcare organizations. Previous studies have identified psychological resilience as a protective factor that can alleviate the adverse impacts of workplace violence on affected nurses [ 32 ]. Meanwhile, current evidence also demonstrated that psychological resilience constituted a personal resource to maintain positive professional attitudes and reduce turnover intentions among nurses [ 35 ]. In addition, previous studies have linked both compassion fatigue and psychological resilience to turnover intention, where higher level of compassion fatigue and lower level of psychological resilience predicted stronger turnover intention among nurses [ 36 ]. As psychological resilience can mitigate the negative impact of adverse events and foster professional growth after negative experiences, psychological resilience may act as a protective factor to moderate the impact of workplace violence on turnover intention.

Despite the recognized correlations among these variables, the underlying mechanisms driving these correlations merits further elucidations. Therefore, this study was performed to verify the correlations between these variables and to explore the mechanisms behind these correlations. The stressor-strain-outcome (SSO) model delineates a process between the stressors and the outcomes under the mediating role of strain, where stressors are environmental stimulus, strains are personal emotions, and outcomes are behavioral responses [ 37 , 38 ]. The present study adopts the SSO model as the theoretical framework, where the stressor is workplace violence, the strains are compassion fatigue and psychological resilience, and the outcome is turnover intention. Thus, this study aims to examine the relationship between workplace violence and turnover intention, and to explore the mediating role of compassion fatigue and the moderating effect of psychological resilience in this relationship.

The present study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies.

A cross-sectional study was undertaken among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China.

Participants

A convenience sampling method was adopted to recruit clinical registered nurses as study participants.

Inclusion criteria were set as: nurses who work in local public hospitals, obtained a Chinese registered nurse license, engaged in clinical patient care at least one year, and provided informed consent to participate.

Exclusion criteria were set as: nurse not employed by hospitals, such as training nurses and nursing interns.

Sample size

The equation n = Z 2 α/2 P(1-P)/δ 2 was used to calculate the sample size. The type I error α was set as 0.05, the Z α/2 was set as 1.96, and the absolute error δ was set as 0.03. With a reference prevalence of workplace violence set at 65.8% [ 39 ], the initial sample size was calculated to be 961. To account for a 10% allowance for invalid responses, the minimum required sample size was determined to be 1,058.

Recruitment

Wenjuanxing, the most popular online survey platform in China, was utilized to create the anonymous online questionnaires. WeChat, the largest social communication platform in China, was used to distribute the online questionnaire. The online questionnaire comprised four parts, the first part was an information sheet and the informed consent form, the second part was the inclusion and exclusion criteria, the third part was an instruction about questionnaire contents and response requirements, and the fourth part was the specific questionnaire items. The web link and a quick response (QR) code for accessing the online questionnaire were then distributed to nurses through WeChat. Head nurses on each unit were asked to share the access information with the nurses on their respective units, allowing participating nurses to conveniently complete the survey using their mobile phones or computers. A rule was set as one internet protocol address could only submit the questionnaire once to avoid duplicate submissions.

The first part of the online questionnaire presented an information sheet and the informed consent form. Nurses were required to carefully review the relevant content and then click either “Yes” or “No” to indicate whether they fully understood the research details and were willing to provide their consent to participate. Only nurses who clicked “Yes” to signify their informed consent were then able to proceed to the next part of the survey. The second part of the online questionnaire presented the inclusion and exclusion criteria. Nurses were required to carefully review the relevant content and then click either “Yes” or “No” to confirm that they fully understood the participation requirements and met the eligibility criteria. Only nurses who clicked “Yes” to affirm their eligibility were then able to advance to the next part of the survey. The third part of the online questionnaire provided an instruction about questionnaire contents and response requirements. Nurses were required to carefully review this relevant information and then click either “Yes” or “No” to indicate their readiness to begin completing the questionnaire. Only nurses who clicked “Yes” to confirm their understanding and willingness to proceed were then able to advance to the next part of the survey. Nurses were then guided to the part of specific questionnaire items where they could complete the survey at their own pace. The confidentiality of questionnaire data was strictly maintained to guarantee the anonymity of participation.

Variables and measurements

Data was collected through an online questionnaire, comprising demographic information form, Workplace Violence Scale (WVS), Turnover Intention Questionnaire (TIQ), Compassion Fatigue Scale (CF-CN), and Connor-Davidsion Resilience Scale (CD-RISC).

Demographic information form

A demographic information form was constructed to collect general information, including gender, age, ethnicity, occupational department, and professional title. Gender was categorized as “Male” and “Female”. Ethnicity was categorized as “Han nationality” and “Other nationality”. Occupational department was classified into “Internal medicine department”, “Surgery department”, “Emergency medicine department”, and “Intensive care unit department”. Professional title was divided into “Primary title”, “Intermediate title”, and “Senior title”.

Workplace Violence Scale

The Chinese version of Workplace Violence Scale (WVS) was used to measure nurses’ experiences of workplace violence over the past year [ 40 , 41 ]. The WVS has been widely utilized to assess workplace violence against healthcare workers in China, demonstrating favorable validity and reliability across diverse samples [ 42 ]. This scale consisted of 5 dimensions measuring physical assault (PA), emotional abuse (EA), threats (T), verbal sexual harassment (VSH), and sexual abuse (SA). Each item was rated on a 4-point scale ranging from “0 = none” to “3 = more than 3 times”. The total score of the scale was the sum of the responses of each item, with higher scores indicating higher frequencies of workplace violences. A total score of 0 indicated that the nurse did not experience workplace violence, and a total score of 1–15 indicated that the nurse experienced some level of workplace violence. The Cronbach’s α coefficient for the scale was 0.62, indicating acceptable internal consistency of this scale.

Turnover Intention Questionnaire

The Chinese version of Turnover Intention Questionnaire (TIQ) was used to measure nurses’ turnover intention [ 43 , 44 ]. The TIQ has been widely applied to assess turnover intention among nurses, exhibiting high reliability and validity across different samples [ 45 ]. This scale consisted of 6 items across 3 dimensions, including the likelihood of quitting the current job (item 1 and 6), the motivation of finding another job (item 2 and 3), and the possibility of getting another job (item 4 and 5). Each item was rated on a 4-point scale ranging from “1 = never” to “4 = always”. The total score of the scale was the sum of the responses of each item (6–24), with higher scores indicating greater turnover intention. The Cronbach’s α coefficient for the scale was 0.71, indicating favorable internal consistency of this scale.

Compassion fatigue scale

The Chinese version of the Compassion Fatigue Scale (CF-CN) was adopted to measure nurses’ compassion fatigue [ 46 ]. The CF-CN has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [ 47 , 48 ]. This scale comprised 30 items across 3 dimensions, including compassion satisfaction (10 items), occupational burnout (10 items), and secondary traumatic stress (10 items). Each item was scored on a 5-point scale ranging from “1 = never” to “5 = always”, with items 1, 4, 15, 17, and 29 designated as reverse scoring questions. The present study used two subscales, occupational burnout and secondary traumatic stress, to measure compassion fatigue among nurses [ 47 ]. The test-retest reliability coefficients for each dimension ranged from 0.76 to 0.86, and the Cronbach’s α coefficients of each subscale ranged from 0.75 to 0.82, indicating acceptable reliability and internal consistency of the instrument.

Connor-davidsion resilience scale

The Chinese version of Connor-Davidson Resilience Scale (CD-RISC) was used to measure nurses’ psychological resilience [ 49 ]. The CD-RISC has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [ 50 , 51 ]. This scale comprised 25 self-rated items across 3 dimensions, including optimism (4 items), strength (8 items), and tenacity (13 items). Each item was scored on a 5-point scale ranging from “0 = not true at all” to “4 = true nearly all the time”. The total score of the scale was the sum of the responses of each item, with higher scores indicating better resilience capacity. The Cronbach’s α coefficients of optimism subscale, strength subscale, and tenacity subscale was 0.60, 0.78, and 0.82, respectively. The CD-RISC exhibited high internal consistency, with a Cronbach’s α coefficient of 0.90 for the total scale in this study.

Data analysis

Data analyses were conducted using SPSS V.25.0 for Windows. The threshold for statistical significance was set at P  < 0.05 for all analyses. Descriptive analysis was performed to calculate means and standard deviations for quantitative variables as well as frequencies and percentages for categorical variables. The normality of the quantitative data distribution was assessed using the Shapiro-Wilk test or the Kolmogorov-Smirnov test. For quantitative data that followed a normal distribution, independent samples t-tests and one-way Analysis of Variance (ANOVA) were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that did not follow a normal distribution, Wilcoxon Mann-Whitney (U-test) and Kruskal-Wallis H-tests were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that followed a normal distribution, Pearson’s correlation coefficient was conducted to examine the relationships between the main variables. For quantitative data that did not follow a normal distribution, Spearman’s rank correlation coefficient was conducted to examine the relationships between the main variables.

A moderated mediation analysis was conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience. Mediation analysis was performed using Model 4 in the PROCESS macro to examine whether compassion fatigue (mediator) mediated the relationship between workplace violence (independent variable) and turnover intention (dependent variable). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the indirect effect. If the 95% CI did not contain 0, it indicated a significant mediating effect of compassion fatigue. Moderated mediation analysis was conducted using Model 8 in the PROCESS macro to investigate whether the mediating effect of compassion fatigue (mediator) varied depending on the level of psychological resilience (moderator). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the conditional indirect effects at different levels of psychological resilience (-1 SD, mean, + 1 SD). If the 95% CI did not contain 0, it indicated a significant moderated mediation effect, suggesting that the mediating effect of compassion fatigue was influenced by the level of psychological resilience.

Ethical considerations

This study obtained ethic approval from the institutional review board of the Third Xiangya Hospital, Central South University (Reference number: kuai 23773). All procedures were conducted in accordance with the provisions of the Declaration of Helsinki. The informed consent was obtained from all participants before they completed the questionnaire. As the questionnaire was distributed and collected anonymously online, this study did not collect handwritten informed consent forms from the participants. The submission of the completed questionnaire was considered as evidence of the participants’ informed consent and voluntary agreement to take part in the study.

A total of 1,324 questionnaires were received, yielding 1,141 valid responses and achieving an effective response rate of 86.17%.

Demographic characteristics

Table  1 presents the demographic characteristics of the study participants. The sample was predominantly female, with 95.18% women and 4.82% men. The age of participants ranged from 21 to 54 years, with a mean age of 32.45 ± 6.80 years. With regard to ethnicity, the majority of participants (99.21%) identified as Han Chinese, while 0.79% belonged to other ethnic groups. In relation to occupational department, 53.46% of the participants were affiliated with the internal medicine department, 38.74% with the surgery department, 4.21% with the emergency medicine department, and 3.59% with the intensive care unit department. With respect to professional titles, 38.47% of the participants held a primary title, 36.54% held an intermediate title, and 24.99% held a senior title.

Descriptive statistics

Table  2 presents the scores of the different variables measured for these nurses. The mean total score of the WVS was 1.43 ± 1.72, the mean total score of the TIQ scale was 10.65 ± 2.39, the mean score of the CF-CN was 41.69 ± 4.01, and the mean score of the CD-RISC was 64.01 ± 11.99.

Table  3 present the mean total score of the WVS and the TIQ across demographic characteristics. Given the non-normal distribution of the data, the Mann-Whitney test was used to compare two groups while the Kruskal-Wallis test was employed to compare multiple groups. The results indicated that there were no significant differences in the mean total scores of the WVS and the TIQ across gender, age, ethnicity, occupational department, and professional title (all P  > 0.05).

Correlation analysis

Table 4 presents the results of correlation analysis between different variables measured for these nurses. Spearman’s correlation analysis revealed significant positive correlations between workplace violence and turnover intention ( r  = 0.466, P  < 0.01), as well as compassion fatigue ( r  = 0.452, P  < 0.01), while negative correlations between workplace violence and psychological resilience ( r =-0.414, P  < 0.01)

Moderated mediation analysis

The PROCESS macro for SPSS was used to perform a moderated mediation analysis, Model 4 was used to examine the mediating role of compassion fatigue, and Model 8 was used to explore the moderating role of psychological resilience. The mediation analysis using Model 4 of the PROCESS macro examined the mediating role of compassion fatigue in the relationship between workplace violence (independent variable) and turnover intention (dependent variable). The direct effect of workplace violence on compassion fatigue was significant (β = 0.923, t = 14.432), indicating that workplace violence significantly influenced the mediation variable compassion fatigue. The direct effect of workplace violence on turnover intention was also significant (β = 0.567, t = 15.090), showing that workplace violence significantly influenced the dependent variable turnover intention. When the effects of both workplace violence and compassion fatigue were examined on turnover intention, the results showed that workplace violence (β = 0.165, t = 6.015) and compassion fatigue (β = 0.436, t = 37.238) both significantly influenced turnover intention. This suggested that compassion fatigue played a partial mediating role in the relationship between workplace violence and turnover intention. The bootstrap 95% confidence interval for the indirect effect of workplace violence on turnover intention through compassion fatigue did not include 0, further confirming the existence of this mediation effect (as shown in Tables  5 and 6 ).

The moderated mediation analysis using Model 8 of the PROCESS macro examined the moderating role of psychological resilience on the mediating effect of compassion fatigue. At the low level of psychological resilience (-SD), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue had a significant mediating effect with an effect size of 0.097. At the average level of psychological resilience (mean), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue also had a significant mediating effect with an effect size of 0.071. At the high level of psychological resilience (+ SD), the bootstrap 95% confidence interval included 0, indicating that compassion fatigue did not have a significant mediating effect. These results suggested that the mediating effect of compassion fatigue was contingent on the level of psychological resilience, with the mediating effect being stronger at lower levels of psychological resilience and being weaker at higher levels of psychological resilience. This finding demonstrated the moderating role of psychological resilience in the mediation process (as shown in Tables  7 and 8 ).

Workplace violence represents an occupational hazard cross borders, occupations, and cultures, drawing attention from organizations, researchers, and media [ 52 ]. Nurses, who constitute a majority of healthcare personnel, are recognized as the group most susceptible to workplace violence in healthcare circumstances [ 53 ]. The prevalence and seriousness of workplace violence against nurses highlight the characterization of consequences and mechanisms. Despite the established correlation between workplace violence and nurse outcome, the relationship and mechanism between workplace violence and turnover intention warrant further elaboration. Therefore, the present cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and to clarify the mediating role of compassion fatigue and the moderating effect of psychological resilience within this link.

Nurses face a high risk of workplace violence due to the nature of their occupation and the characteristics of their work environment. This study found that nurses experienced various forms of workplace violence in the past year, with emotional abuse and physical assault being the two most common types. The high prevalence of workplace violence observed in this study was similar to findings from previous studies conducted in China and other countries. For instance, a cross-sectional study involving 266 nurses from 165 hospitals in China observed that 64.7% of nurses experienced at least one type of workplace violence in the previous year, with verbal abuse being the most frequent form [ 54 ]. Furthermore, a cross-sectional study involving 599 mental healthcare nurses in Japan revealed that over 40% of nurses experienced workplace violence in the past year [ 9 ]. In addition, a cross-sectional study examining the prevalence of workplace violence among nurses in five European countries found that 54% experienced non-physical violence, 20% experienced physical violence, and 15% experienced both forms [ 55 ]. The types and incidences of workplace violence against nurses vary across geographic locations and hospital environments [ 56 ]; however, studies around the world converge to support a high prevalence of workplace violence against nurses. Notably, the rates of workplace violence against nurses remain underreported, as nurses often rationalize violent incidents as a regrettable part of their professions and accept violent events as an inevitable hazard of their occupations [ 57 ]. For example, a cross-sectional survey of 692 nurses in Slovenia concluded that only a portion of nurses reported violent incidents in formal written form, with the reporting rate being 6.5% for psychological violence and 10.9% for physical violence [ 58 ]. Furthermore, a whole-population survey of 411 nurses in the UK indicated that while 74.7% of nurses experienced workplace violence, only 18.2% of nurses reported all violent incidents [ 59 ]. Workplace violence is a professional hazard of nurses, inflicting not only physical injuries but also psychological harms on victimized nurses. The prevalence and seriousness of workplace violence against nurses underscore the urgency for healthcare institutions and systems to implement legislative measures and procedural frameworks preventing such occurrences and ensuring workplace safety. This study supports the prevalence of workplace violence against nurses and emphasize the characterization of consequence and mechanism of workplace violence among nurses.

Turnover intention refers to a behavioral tendency wherein staffs intend to leave their current professions. Turnover intention is a strong predictor of actual turnover, acting as both a proxy for and a predictor of actual turnover. This study was consistent with the results of previous studies, indicating the presence of turnover intention among significant proportion of nurses. For instance, a meta-analysis examining the prevalence of turnover intention among 37,672 primary health workers in China found that 30.4% of these primary health workers exhibited turnover intention to their current jobs [ 60 ]. Furthermore, a nationwide study of 11,942 nurses from 87 hospitals in China found that 22.93% of nurses exhibited strong turnover intention to their current positions [ 61 ]. Meanwhile, a cross-sectional study of 506 novice nurses from 5 hospitals in China reported an even higher prevalence of 51.9% for turnover intention among this population [ 62 ]. In addition, Dall’Ora et al. (2015) investigated the prevalence of turnover intention among a sample of 31,627 registered nurses in 488 hospitals across 12 European countries, found that 33% of nurses demonstrated turnover intention to their current jobs [ 63 ]. Nurses, as the largest sector of healthcare workers, are the foundation and guarantee for the development and sustainability of hospitals. The presence of high turnover intention among nurses not only impairs the professional identity and growth of nurses but also affects the workforce and development of hospitals. The global shortage of nurses combined with the high rates of turnover intention emphasizes the imperative for healthcare institutions and systems to take implement prevention measures and intervention strategies bolstering organizational commitment and promoting occupational retention among nurses. This study indicates the presence of high turnover intention among nurses, which highlight the identification of antecedents of turnover intention among nurses.

This study identified a positive correlation between workplace violence and turnover intention among these nurses, implying that exposure to workplace violence increased turnover intention within this population. This finding was in line with previous studies, which observed that the experience of workplace violence decreased the quality of occupational life and induced the emergence of turnover intention among nurses [ 64 ]. Specifically, a cross-sectional survey of 1,024 nurses from 26 cities in China found that workplace violence was positively related to turnover intention among this sample [ 65 ]. Additionally, a cross-sectional study of 415 emergency nurses in China reported a positive association between workplace violence and turnover intention among this group [ 66 ]. This study aligned with previous studies support the adverse impact of workplace violence on turnover intention, underscoring the exploration of mechanisms behind this correlation. Evidence indicated that exposure to workplace violence provoked negative professional attitudes and decreased job satisfaction, thus impaired occupational commitment and elicited turnover intention among nurses [ 67 ].

This study revealed that compassion fatigue mediated the positive correlation between workplace violence and turnover intention among nurses. Nurses, who work on the frontlines of healthcare, face both physical challenges and emotional pressures in their daily duties. Compassion fatigue refers to a state of holistic exhaustion and deprivation, manifesting as physical decline in energetic endurance, emotional decline in empathetic ability, and spiritual decline in recovery capability [ 68 , 69 ]. Compassion fatigue arisen from chronic exposure to patient distress, work pressure, occupational devotion, lack of personal-professional boundaries, and absence of self-care measures [ 68 , 69 ]. The findings of this study suggested that the experience of workplace violence caused the presence of compassion fatigue, which further induced the emergence turnover intention among nurses. Exposure to workplace violence originates compassion discomfort, progresses to compassion stress, and culminates in compassion fatigue, ultimately eliciting job dissatisfaction, occupational burnout, and turnover intention among nurses. Numerous studies have demonstrated the detrimental consequences of compassion fatigue on nurse outcomes and the deleterious influences of workplace violence on compassion fatigue. This study was consistent with previous studies to confirm the mediating role of compassion fatigue in the link between workplace violence and turnover intention. Specifically, Chen et al. (2022) performed a cross-sectional survey of 4,520 psychiatrists among 41 tertiary psychiatric hospitals in China, found a positive relationship between workplace violence and turnover intention under the mediation effect of job burnout and occupational stress [ 70 ]. Additionally, Choi and Lee (2017) conducted a cross-sectional study among 358 nurses in Korea, found that workplace violence increased compassion fatigue, which in turn fueled turnover intention [ 64 ]. Evidence indicated that exposure to workplace violence caused compassion fatigue, which elicited job dissatisfaction, decreased organizational loyalty, and stimulated turnover intention among nurses [ 71 ]. Since mediating role of compassion fatigue proposed in this study, preventive measures and intervention strategies should aim to alleviate compassion fatigue and promote compassion satisfaction among nurses, mitigating the detrimental effects of workplace violence and preventing the emergence of turnover intention. Hospital administrators and nurse managers should formulate policies and provide opportunities for nurses to participate in group psychological debriefing or individual psychological counseling, thereby alleviating occupational burnout and traumatic stress.

This study identified that psychological resilience moderated the positive correlation between workplace violence and turnover intention among nurses. Resilience represents a personality attribute which enables nurses to cope with challenges, adaptation to adversity, and recover from setbacks [ 72 , 73 ]. Resilience allows nurses to copy with pressure events and adapt to stressful environments, further enhance supportive systems and personal abilities [ 72 , 73 ]. Resilience helps nurses to build professional relationships, enhance emotional insights, and achieve life spirituality, which enables nurses to buffer, mitigate, and resist the detrimental effects of workplace violence. Studies supported the protective effects of psychological resilience on nurse outcomes and the buffer roles of psychological resilience on workplace violence. While previous studies did not directly illustrate the moderating role of psychological resilience in the link between workplace violence and turnover intention, they have jointly indicated the negative impact of workplace violence on turnover intention and the protective effect of psychological resilience on turnover intention [ 74 ]. Other positive psychological indicators, similar to psychological resilience, have also been shown to play a moderating role in the relationship between workplace violence and turnover intention. For instance, a cross-sectional survey of 1,063 Chinese healthcare workers found that workplace violence was positively associated with turnover intention, and perceived social support and mental health mediated the relationship between workplace violence and turnover intention [ 75 ]. In addition, a longitudinal survey of 1,515 Finnish physicians found that workplace violence was positively associated with turnover intention, and job control moderated the relationship between workplace violence and turnover intention [ 26 ]. Evidence implicated psychological resilience as a psychological resources and personal attributes which enabled nurses to perceive workplace violence as a solvable problem and stimulate an adaptation process to workplace violence, thus buffered the fluctuation of job satisfaction and inhibited the emergence of turnover intention among nurses [ 76 ]. Given the moderating role of psychological resilience confirmed in this study, preventive measures and intervention strategies should aim to foster psychological resilience among nurses, alleviating the adverse effects of workplace violence and preventing the emergence of turnover intention. Preventive measures and intervention strategies should, therefore, focus on fostering psychological resilience among nurses to alleviate the adverse effects of workplace violence and mitigate the emergence of turnover intentions. Institutions or hospitals can implement positive psychology workshops and professional development programs to equip nurses with emotion regulation strategies and stress management techniques, thereby overcoming workplace violence and fostering occupational commitment.

The present study has several limitations that should be acknowledged. First, the cross-sectional design of this study precluded any causal inferences about the relationships between the study variables. Future research should employ longitudinal designs to clarify temporal precedence necessary to infer causality. Second, the self-reported nature of this study introduced the potential for common method bias to inflate the observed relationships. Future research should incorporate objective measures, such as incident reports or observational data, to corroborate the findings. Third, the sample was drawn from public hospitals in a specific geographic region, which may limit the generalizability of the findings. Future research should replicate this study in more diverse samples to strengthen the external validity of the results.

Despite the promotion of “zero tolerance” policies, the incidence of workplace violence against healthcare workers, particularly nurses, remains a persistent issue [ 77 ]. The prevalence and seriousness of workplace violence against nurses underscore the characterization of consequence and mechanism behind this phenomenon. Therefore, this cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and further explore the mediating role of compassion fatigue and the moderating role of psychological resilience on this link among Chinese nurses. The findings of this study supported the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses. Nurses represent the primary victims of workplace violence in healthcare sectors, facing a higher risk of such incidents than other types of healthcare staffs. Nurses witnessing and experiencing workplace violence not only impacts their health and safety but also impairs their work performance and job productivity [ 78 , 79 ]. Various countries around the world have initiated coordinated strategies such as “zero tolerance zone” to prevent workplace violence in health sectors. National Health Commission of China established the “safe hospital” policy to build safe work environments and maintain medical orders in health institutions. Future research and practical efforts should be directed toward developing effective preventive measures and intervention strategies at the individual, organizational, and national levels to mitigate workplace violence and cultivate harmonious work atmosphere for nurses and other healthcare professionals. These efforts could mitigate the adverse effects of workplace violence and prevent the emergence of turnover intention by addressing compassion fatigue and fostering psychological resilience.

Data availability

Data that support the findings of this study are available from the corresponding author Xiaoli Liao upon reasonable request.

Abbreviations

World Health Organization

International Council of Nurses

Compassion Fatigue Scale

Connor-Davidson Resilience Scale

Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet. 2002;360(9339):1083–8.

Article   PubMed   Google Scholar  

Al-Qadi MM. Workplace violence in nursing: a concept analysis. J Occup Health. 2021;63(1):e12226.

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization. Workplace violence. 2002. Available at: http://www.who.int/violence_injury_prevention/injury/work9/en/print.html . Accessed April 2, 2024.

Sahebi A, Golitaleb M, Moayedi S et al. Prevalence of workplace violence against health care workers in hospital and pre-hospital settings: An umbrella review of meta-analyses. Front Public Health. 2022;10: 895818.

Rodwell J, Demir D. Oppression and exposure as differentiating predictors of types of workplace violence for nurses. J Clin Nurs. 2012;21(15–16):2296–305.

Park M, Cho SH, Hong HJ. Prevalence and perpetrators of workplace violence by nursing unit and the relationship between violence and the perceived work environment. J Nurs Scholarsh. 2015;47(1):87–95.

Havaei F, Astivia OLO, MacPhee M. The impact of workplace violence on medical-surgical nurses’ health outcome: a moderated mediation model of work environment conditions and burnout using secondary data. Int J Nurs Stud. 2020;109:103666.

Potera C. Violence against nurses in the Workplace. Am J Nurs. 2016;116(6):20–1.

Kobayashi Y, Oe M, Ishida T, Matsuoka M, Chiba H, Uchimura N. Workplace Violence and its effects on Burnout and secondary traumatic stress among Mental Healthcare Nurses in Japan. Int J Environ Res Public Health. 2020;17(8):2747.

Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychol Res Behav Manag. 2016;9:263–75.

Liu X, Yang H, Hu Y, et al. Incidence of workplace violence against nurses among Chinese hospitals: a meta-analysis. J Nurs Manag. 2022;30(6):1490–501.

International Council of Nurses. Abuse and Violence Against Nursing Personnel ICN Position Statement.2006. http://www.icn.ch/psviolence00.htm

Najafi F, Fallahi-Khoshknab M, Ahmadi F, Dalvandi A, Rahgozar M. Antecedents and consequences of workplace violence against nurses: a qualitative study. J Clin Nurs. 2018;27(1–2):e116–28.

PubMed   Google Scholar  

Pariona-Cabrera P, Cavanagh J, Bartram T. Workplace violence against nurses in health care and the role of human resource management: a systematic review of the literature. J Adv Nurs. 2020;76(7):1581–93.

International Council of Nurses. Abuse and Violence Against Nursing Personnel. 2000. http://www.icn.ch/psviolence00.htm

Han X, Jiang F, Shen L, et al. Workplace Violence, Workforce Stability, and well-being in China’s Psychiatric hospitals. Am J Prev Med. 2022;62(4):e265–73.

Zhang SE, Liu W, Wang J, et al. Impact of workplace violence and compassionate behaviour in hospitals on stress, sleep quality and subjective health status among Chinese nurses: a cross-sectional survey. BMJ Open. 2018;8(10):e019373.

Fernet C, Trépanier SG, Demers M, et al. Motivational pathways of occupational and organizational turnover intention among newly registered nurses in Canada. Nurs Outlook. 2017;65(4):444–54.

NSI Nursing Solutions. 2021 NSI national health care retention & RN staffing report.

Royal College of Nursing. The UK nursing labour market review 2020.

World Health Organization. Global strategy on human resources for health: Workforce 2030. https://www.who.int/publications/i/item/9789241511131 . Accessed April 2, 2024.

Cao J, Jia Z, Zhu C, et al. Nurses’ turnover intention and associated factors in general hospitals in China: a cross-sectional study. J Nurs Manag. 2021;29(6):1613–22.

Zhang Y, Yin R, Lu J, et al. Association between horizontal violence and turnover intention in nurses: a systematic review and meta-analysis. Front Public Health. 2022;10:964629.

Liu W, Zhao S, Shi L, et al. Workplace violence, job satisfaction, burnout, perceived organisational support and their effects on turnover intention among Chinese nurses in tertiary hospitals: a cross-sectional study. BMJ Open. 2018;8(6):e019525.

Heponiemi T, Kouvonen A, Virtanen M, et al. The prospective effects of workplace violence on physicians’ job satisfaction and turnover intentions: the buffering effect of job control. BMC Health Serv Res. 2014;14:19.

Chang YP, Lee DC, Wang HH. Violence-prevention climate in the turnover intention of nurses experiencing workplace violence and work frustration. J Nurs Manag. 2018;26(8):961–71.

Chang YP, Lee DC, Chang SC, et al. Influence of work excitement and workplace violence on professional commitment and turnover intention among hospital nurses. J Clin Nurs. 2019;28(11–12):2171–80.

d’Ettorre G, Pellicani V. Workplace Violence toward Mental Healthcare Workers Employed in Psychiatric wards. Saf Health Work. 2017;8(4):337–42.

Yu H, Jiang A, Shen J. Prevalence and predictors of compassion fatigue, burnout and compassion satisfaction among oncology nurses: a cross-sectional survey. Int J Nurs Stud. 2016;57:28–38.

Ledoux K. Understanding compassion fatigue: understanding compassion. J Adv Nurs. 2015;71(9):2041–50.

Xie W, Chen L, Feng F, et al. The prevalence of compassion satisfaction and compassion fatigue among nurses: a systematic review and meta-analysis. Int J Nurs Stud. 2021;120:103973.

Li L, Liao X, Ni J. A cross-sectional survey on the relationship between workplace psychological violence and empathy among Chinese nurses: the mediation role of resilience. BMC Nurs. 2024;23(1):85.

Pang Y, Dan H, Jung H, Bae N, Kim O. Depressive symptoms, professional quality of life and turnover intention in Korean nurses. Int Nurs Rev. 2020;67(3):387–394 Cao & Chen, 2021.

Aburn G, Gott M, Hoare K. What is resilience? An integrative review of the empirical literature. J Adv Nurs. 2016;72(5):980–1000.

Zhao Y, Wang H, Sun D, et al. Job satisfaction, resilience and social support in relation to nurses’ turnover intention based on the theory of planned behaviour: a structural equation modelling approach. Int J Nurs Pract. 2021;27(6):e12941.

Cao X, Chen L. Relationships between resilience, empathy, compassion fatigue, work engagement and turnover intention in haemodialysis nurses: a cross-sectional study. J Nurs Manag. 2021;29(5):1054–63.

Koeske GF, Koeske RD. A preliminary test of a stress-strain-outcome model for reconceptualizing the burnout phenomenon. J Soc Serv Res. 1993;17:107–35.

Article   Google Scholar  

Um MY, Harrison DF. Role stressors, burnout, mediators, and job satisfaction: a stress-strain-outcome model and an empirical test. Soc Work Res. 1998;22:100–15.

Shi L, Zhang D, Zhou C, et al. A cross-sectional study on the prevalence and associated risk factors for workplace violence against Chinese nurses. BMJ Open. 2017;7(6):e013105.

Schat AC, Kelloway EK. Reducing the adverse consequences of workplace aggression and violence: the buffering effects of organizational support. J Occup Health Psychol. 2003;8(2):110–22.

Wang PX. Study on Medical Workplace Violence and Theory Model. Sichuan University; 2006.

Xiao Y, Chen TT, Zhu SY, Li CY, Zong L. Factors associated with workplace violence against Chinese healthcare workers: an online cross-sectional survey. Front Public Health. 2024;12:1295975.

Michaels CE, Spector PE. Causes of employee turnover: a test of the Mobley, Griffeth, Hand, and Meglino model. J Appl Psycho. 1982;67(1):53.

Zheng X, Yang M, Gao W, Chen F. The Chinese version Professional Quality of Life Scale: testing of reliability and validity in nurses. J Nurs Sci. 2013;28(5):13–5.

Google Scholar  

Li X, Guo Y, Zhao T, Zhang S, Yue X, Liu Y. Cluster analysis of self-concept and job satisfaction in Chinese nurses with master’s degree to identify their turnover intention: a cross-sectional study. J Clin Nurs. 2021;30(13–14):2057–67.

Chen HY, Wang WH. Reliability and validity of the Chinese version of the Compassion fatigue scale. Chin Nurs Manag. 2013;13(4):39–41.

CAS   Google Scholar  

Cong SN, Zhang AX, Liu Y, et al. Analysis of influencing factors and impact path of compassion fatigue in nurses from maternity hospitals in Jiangsu. Chin J Nurs. 2022;57(8):977–84.

Yu H, Gui L. Compassion fatigue, burnout and compassion satisfaction among emergency nurses: a path analysis. J Adv Nurs. 2022;78(5):1294–304.

Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82.

Han BR, Chen X, Xu FX, et al. Correlation analysis between resilience and career development of nurses. Chin Nurs Manage. 2020;20(12):1845–9.

Ren Y, Zhou Y, Wang S, Luo T, Huang M, Zeng Y. Exploratory study on resilience and its influencing factors among hospital nurses in Guangzhou, China. Int J Nurs Sci. 2017;5(1):57–62.

PubMed   PubMed Central   Google Scholar  

Ramacciati N, Ceccagnoli A, Addey B. Violence against nurses in the triage area: an Italian qualitative study. Int Emerg Nurs. 2015;23(4):274–80.

Fu C, Ren Y, Wang G, Shi X, Cao F. Fear of future workplace violence and its influencing factors among nurses in Shandong, China: a cross-sectional study. BMC Nurs. 2021;20(1):123.

Song C, Wang G, Wu H. Frequency and barriers of reporting workplace violence in nurses: an online survey in China. Int J Nurs Sci. 2020;8(1):65–70.

Babiarczyk B, Turbiarz A, Tomagová M, et al. Reporting of workplace violence towards nurses in 5 European countries - a cross-sectional study. Int J Occup Med Environ Health. 2020;33(3):325–38.

Zhang J, Zheng J, Cai Y, et al. Nurses’ experiences and support needs following workplace violence: a qualitative systematic review. J Clin Nurs. 2021;30(1–2):28–43.

Boafo IM. The effects of workplace respect and violence on nurses’ job satisfaction in Ghana: a cross-sectional survey. Hum Resour Health. 2018;16(1):6.

Kvas A, Seljak J. Unreported workplace violence in nursing. Int Nurs Rev. 2014;61(3):344–51.

Article   PubMed   CAS   Google Scholar  

Lovell A, Skellern J, Mason T. Violence and under-reporting: learning disability nursing and the impact of environment, experience and banding. J Clin Nurs. 2011;20(23–24):3304–12.

He R, Liu J, Zhang WH, et al. Turnover intention among primary health workers in China: a systematic review and meta-analysis. BMJ Open. 2020;10(10):e037117.

Xu YM, Wu Y, Zhang Y, et al. Investigation of nursing work status in Chinese hospitals. Chin J Nurs. 2016;51(8):947–50.

Ren L, Kim H. Serial multiple mediation of psychological empowerment and job burnout in the relationship between workplace bullying and turnover intention among Chinese novice nurses. Nurs Open. 2023;10(6):3687–95.

Dall’Ora C, Griffiths P, Ball J, Simon M, Aiken LH. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open. 2015;5(9):e008331.

Choi SH, Lee H. Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention. J Nurs Manag. 2017;25(7):508–18.

Zhao SH, Shi Y, Sun ZN, et al. Impact of workplace violence against nurses’ thriving at work, job satisfaction and turnover intention: a cross-sectional study. J Clin Nurs. 2018;27(13–14):2620–32.

Li N, Zhang L, Xiao G, et al. Effects of organizational commitment, job satisfaction and workplace violence on turnover intention of emergency nurses: a cross-sectional study. Int J Nurs Pract. 2020;26(6):e12854.

Arnetz JE, Hamblin L, Essenmacher L, Upfal MJ, Ager J, Luborsky M. Understanding patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports. J Adv Nurs. 2015;71(2):338–48.

Peters E. Compassion fatigue in nursing: a concept analysis. Nurs Forum. 2018;53(4):466–80.

Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: a concept analysis. Nurs Health Sci. 2010;12(2):235–43.

Chen Y, Wang P, Zhao L, et al. Workplace Violence and turnover intention among psychiatrists in a National Sample in China: the Mediating effects of Mental Health. Front Psychiatry. 2022;13:855584.

Kim Y, Lee E, Lee H. Association between workplace bullying and burnout, professional quality of life, and turnover intention among clinical nurses. PLoS ONE. 2019;14(12):e0226506.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Cooper AL, Brown JA, Leslie GD. Nurse resilience for clinical practice: an integrative review. J Adv Nurs. 2021;77(6):2623–40.

Cooper AL, Brown JA, Rees CS, et al. Nurse resilience: a concept analysis. Int J Ment Health Nurs. 2020;29(4):553–75.

Park JE, Song MR. Effects of Emergency nurses’ experiences of Violence, Resilience, and nursing work environment on turnover intention: a cross-sectional survey. J Emerg Nurs. 2023;49(3):461–9.

Yang Y, Wang P, Kelifa MO, et al. How workplace violence correlates turnover intention among Chinese health care workers in COVID-19 context: the mediating role of perceived social support and mental health. J Nurs Manag. 2022;30(6):1407–14.

Li JH, Chen TW, Lee HF, Shih WM. The effects of Emergency Room Violence toward Nurse’s intention to leave-resilience as a Mediator. Healthc (Basel). 2021;9(5):507.

Holmes CA. Violence, zero tolerance and the subversion of professional practice. Contemp Nurse. 2006;21(2):212–27.

Edward KL, Ousey K, Warelow P, et al. Nursing and aggression in the workplace: a systematic review. Br J Nurs. 2014;23(12):653–9.

Hassankhani H, Parizad N, Gacki-Smith J, et al. The consequences of violence against nurses working in the emergency department: a qualitative study. Int Emerg Nurs. 2018;39:20–5.

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Acknowledgements

The authors would like to express their gratitude to all the participants and researchers involved in this study.

The authors did not receive any financial support for the research, authorship, or publication of this article.

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Xiaoli Liao

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All authors have reviewed and approved the final manuscript. Miao Chen: Designed questionnaire, collected data, performed data reanalysis, revised the manuscript. Hao Xie: Collected data, and reviewed the manuscript.Xiaoli Liao: Conceptualized proposal, designed questionnaire, performed initial data analyses, and wrote the original manuscript draft.Juan Ni: Collected data, and reviewed the manuscript.All authors reviewed the manuscript.

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Correspondence to Xiaoli Liao .

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Chen, M., Xie, H., Liao, X. et al. Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience. BMC Public Health 24 , 2437 (2024). https://doi.org/10.1186/s12889-024-19964-y

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Received : 23 February 2024

Accepted : 02 September 2024

Published : 07 September 2024

DOI : https://doi.org/10.1186/s12889-024-19964-y

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