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Preventing Violence Against Women and Children: Workshop Summary
Preventing Violence
Against Women
and Children
Workshop Summary
Deepali M. Patel, Rapporteur
Forum on Global Violence Prevention

Board on Global Health
Copyright National Academy of Sciences. All rights reserved.

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Disease Control and Prevention; Department of Education: Office of Safe and
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PLANNING COMMITTEE ON PREVENTING VIOLENCE

AGAINST WOMEN AND CHILDREN WORKSHOP1
JACQUELYN C. CAMPBELL (Chair), Anna D. Wolf Chair and Professor, Johns
Hopkins University School of Nursing
CLARE ANDERSON, Deputy Commissioner, Administration on Children, Youth
and Families, Department of Health and Human Services
GARY BARKER, International Director, Promundo-DC
JEFFREY EDLESON, Professor and Director of Research, University of
Minnesota School of Social Work
CLAUDIA GARCÍA-MORENO, Coordinator, Department of Gender, Women,
and Health, World Health Organization
JOANNE LACROIX, Manager, Family Violence Prevention Unit, Public Health
Agency of Canada
SUSAN SALASIN, Director, Trauma and Trauma-Informed Care Program,
Substance Abuse and Mental Health Services Administration
Consultant
ELENA NIGHTINGALE, Scholar-in-Residence, Institute of Medicine
1 Institute of Medicine planning committees are solely responsible for organizing the work-
shop, identifying topics, and choosing speakers. The responsibility for the published workshop
summary rests with the workshop rapporteur and the institution.

FORUM ON GLOBAL VIOLENCE PREVENTION

JACQUELYN C. CAMPBELL (Co-chair), Anna D. Wolf Chair and Professor,
Johns Hopkins University School of Nursing
MARK ROSENBERG (Co-chair), President and CEO, The Task Force for Global
Health
CLARE ANDERSON, Deputy Commissioner, Administration on Children, Youth
and Families, Department of Health and Human Services
FRANCES ASHE-GOINS, Acting Director, Office on Women’s Health, U.S.
Department of Health and Human Services
KATRINA BAUM, Division Director, Violence & Victimization Research,
National Institute of Justice, Department of Justice
SUSAN BISSELL, Associate Director, Child Protection Section, UNICEF
ARTURO CERVANTES TREJO, Director General, National Center for Injury
Prevention, Ministry of Health, Mexico
XINQI DONG, Associate Professor of Medicine, Behavioral Sciences and
Nursing, Rush Institute for Healthy Aging, Rush University Medical Center
AMIE GIANINO, Global Director, Beer & Better World, Anheuser-Busch InBev
KATHY GREENLEE, Assistant Secretary for Aging, Administration on Aging,
U.S. Department of Health and Human Services
RODRIGO V. GUERRERO, City Counselor, Cali, Colombia
JOHN R. HAYES, Global Strategy Leader for Neuroscience, Medical Affairs, Eli
Lilly and Company
DAVID HEMENWAY, Director, Injury Control Research Center and the Youth
Violence Prevention Center, Harvard University
FRANCES HENRY, Advisor, F. Felix Foundation
MERCEDES S. HINTON, Program Officer, Initiative on Confronting Violent
Crime, Open Society Institute
LARKE NAHME HUANG, Senior Advisor, Office of the Administrator,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services
L. ROWELL HUESMANN, Amos N. Tversky Collegiate Professor of Psychology
and Communication Studies Director, Research Center for Group Dynamics,
Institute for Social Research, The University of Michigan
KEVIN JENNINGS, Assistant Deputy Secretary of Education, Office of Safe and
Drug Free Schools, Department of Education
CAROL M. KURZIG, President, Avon Foundation for Women
JOANNE LACROIX, Manager, Family Violence Prevention Unit, Public Health
Agency of Canada
JACQUELINE LLOYD, Health Scientist Administrator, Prevention Research
Branch, Division of Epidemiology, Services and Prevention Research,
National Institute on Drug Abuse
BRIGID McCAW, Medical Director, NCal Family Violence Prevention Program,
Kaiser Permanente
JAMES A. MERCY, Special Advisor for Strategic Directions, Division of Violence
Prevention, National Center for Injury Prevention and Control, Centers for
Disease Prevention and Control
vi

PEGGY MURRAY, Senior Advisor for International Research, Office of the

Director, National Institute for Alcohol Abuse and Alcoholism
MICHAEL PHILLIPS, Director, Suicide Research and Prevention Center,
Shanghai Jiao Tong University School of Medicine
COLLEEN SCANLON, Senior Vice President, Advocacy, Catholic Health
Initiatives
KRISTIN SCHUBERT, Program Officer, Vulnerable Populations Portfolio, The
Robert Wood Johnson Foundation
EVELYN TOMASZEWSKI, Senior Policy Advisor, Human Rights and
International Affairs, National Association of Social Workers
ELIZABETH WARD, Chairman, Violence Prevention Alliance, University of the
West Indies, Mona Campus
Staff
DEEPALI M. PATEL, Program Officer
RACHEL M. TAYLOR, Research Associate
RACHEL E. PITTLUCK, Senior Program Assistant
BRANDON J. STRATFORD, Christine Mirzayan Fellow (January
2011-April 2011)
ELENA NIGHTINGALE, Scholar-in-Residence
KATE BURNS, Intern
JULIE WILTSHIRE, Financial Officer
PATRICK KELLEY, Board Director
vii


Reviewers
This report has been reviewed in draft form by individuals chosen

for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the process. We wish to thank the following individuals for
their review of this report:
NAEEMAH ABRAHAMS, Senior Researcher, Gender & Health Research

Unit, Medical Research Council of South Africa
MANUEL CONTRERAS, Gender and Public Health Specialist,
International Center for Research on Women
LISA NAJAVITS, Professor of Psychiatry, Boston University School of
Medicine
AGNES TIWARI, Associate Professor and Assistant Dean, School of
Nursing, Li Ka Shing Faculty of Medicine of the University of
Hong Kong
Although the reviewers listed above have provided many constructive

comments and suggestions, they were not asked to endorse the final draft
ix

x REVIEWERS
of the report before its release. The review of this report was overseen by
Richard Krugman, Vice Chancellor for Health Affairs and Dean, Univer-
sity of Colorado at Denver. Appointed by the Institute of Medicine they
were responsible for making certain that an independent examination of
this report was carried out in accordance with institutional procedures and
that all review comments were carefully considered. Responsibility for the
final content of this report rests entirely with the author and the institution.

Contents
1 Introduction 1
PART I
2 The Co-Occurrence of Child Maltreatment and Intimate

Partner Violence 9
3 Paradigm Shifts and Changing Social Norms

in Violence Prevention 20
4 The State of Prevention Research in Low- and

Middle-Income Countries 32
5 Violence Prevention Among Multiple Sectors 42
PART II
6 Papers on Research in Preventing Violence Against

Women and Children 49
Preventing Intimate Partner and Sexual Violence Against Women:

Primary Prevention Strategies 50
WHO
xi

xii CONTENTS
International Men and Gender Equality Survey 79

Gary Barker, Juan Manuel Contreras, Brian Heilman,
Ajay Singh, Ravi Verma, and Marcos Nascimento

The Science of Prevention/Interrupting the Cycle of Violence 87
Claire Crooks

Trauma-Informed Care: A Values-Based Context for
Psychosocial Empowerment 97
Roger D. Fallot
Enhancing Emotion Regulation: A Framework for

Psychological Empowerment of Women and Children
Exposed to Violence 102
Julian D. Ford
7 Papers on Global Partnerships and Government Initiatives 117
The InterCambios Alliance 118

Margarita Quintanilla
Global Partnerships on Domestic Violence Legal Reform 123

Cheryl A. Thomas
New Zealand’s Efforts to Address Violence Against

Women and Children 136
Denise Wilson
8 Papers on Preventive Interventions 144
The IMAGE Program: Summary 145

Julia Kim
Innovative Prevention Interventions: Addressing IPV

and Potential Child Abuse at Prenatal Care 148
Agnes Tiwari
The Fourth R: A School-Based Strategy to Prevent

Adolescent Dating Violence 157
David A. Wolfe

CONTENTS xiii
The Community Advocacy Project: An Evidence-Based

Psychosocial Intervention for Women with Abusive Partners 163
Cris M. Sullivan
Using a Systems-Model Approach to Improving IPV Services

in a Large Health-Care Organization 169
Brigid McCaw
APPENDIXES
A Workshop Agenda 185

B Speaker Biographical Sketches 192
C Planning Committee Biographical Sketches 205
D Forum Member Biographical Sketches 209


Introduction
Violence against women and children is a serious public health con-

cern, with costs at multiple levels of society. Although violence is a threat
to everyone, women and children are particularly susceptible to victimiza-
tion because they often have fewer rights or lack appropriate means of
protection. In some societies certain types of violence are deemed socially
or legally acceptable, thereby contributing further to the risk to women
and children.
In the past decade research has documented the growing magnitude of
such violence, but gaps in the data still remain. Victims of violence of any
type fear stigmatization or societal condemnation and thus often hesitate
to report crimes. The issue is compounded by the fact that for women and
children the perpetrators are often people they know and because some
countries lack laws or regulations protecting victims. Some of the data that
have been collected suggest that rates of violence against women range from
15 to 71 percent in some countries and that rates of violence against chil-
dren top 80 percent (García-Moreno et al., 2005; Pinheiro, 2006). These
data demonstrate that violence poses a high burden on global health and
that violence against women and children is common and universal.
On January 27-28, 2011, the Institute of Medicine’s Forum on Global
Violence Prevention convened its first workshop to explore the prevention
of violence against women and children. Part of the forum’s mandate is
to engage in multisectoral, multidirectional dialogue that explores cross-
cutting approaches to violence prevention. To that end, the workshop
was designed to examine these approaches from multiple perspectives and
at multiple levels of society. In particular, the workshop was focused on

2 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
exploring the successes and challenges presented by evidence-based preven-

tive interventions and examining the possibilities of scaling up or translat-
ing such work in other settings. Speakers were invited to share the progress
and outcomes of their work and to engage in dialogue exploring gaps and
opportunities in the field.
The workshop was planned by a formally appointed committee of
the Institute of Medicine (IOM), the members of which created an agenda
and identified relevant speakers. Because the topic is large and the field is
broad, presentations at this event represent only a sample of the research
currently being undertaken. Speakers were chosen to present a global, bal-
anced perspective, but by no means a comprehensive one. The agenda for
this workshop can be found in Appendix A.
ORGANIZATION OF THE REPORT

This summary provides a factual account of the presentations given at
the workshop. Opinions expressed within this summary are not those of
the Institute of Medicine, the forum, or its agents, but rather of the present-
ers themselves. Statements are the views of the speakers and do not reflect
conclusions or recommendations of a formally appointed committee. This
summary was authored by a designated rapporteur based on the workshop
presentations and discussions and does not represent the views of the in-
stitution, nor does it constitute a full or exhaustive overview of the field.
The workshop summary is organized thematically, covering the major
topics that arose during the two-day workshop, so as to provide a larger
context for these issues in a more compelling and comprehensive way. As
well, the thematic organization allows the summary to serve as an overview
resource of important issues in the field. The themes were chosen as the
most frequent, cross-cutting, and essential elements that arose from the
workshop, but do not represent the views of the IOM or a formal consen-
sus process.
The summary begins with a brief introduction of the issue, followed by
two parts and an appendix. The first part consists of four chapters that pro-
vide the summary of the workshop; the second part of the report consists of
submitted papers and commentary from speakers regarding the substance
of the work they presented at the workshop. These papers were solicited
from speakers to provide further information of their work. The appendix
contains additional information regarding the agenda and participants.
DEFINITIONS AND CONTEXT

Violence is defined by the World Health Organization as “the inten-
tional use of physical force or power, threatened or actual, against oneself,

INTRODUCTION 3
another person, or against a group or community that either results in or

has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation” (WHO, 2002). When directed against
women or children, this violence can take a number of forms, including,
but not limited to, sexual violence, intimate partner violence, child abuse
and neglect, bullying, teen dating violence, trafficking, and elder abuse. The
majority of violence against women and children is perpetrated by partners,
family members, friends, or acquaintances, so that most violence against
women and children takes place in the form of intimate partner violence,
family violence, or school violence (WHO and LSHTM, 2010).
These three types of violence, which are interconnected, are commonly
referred to as being part of a “cycle of violence,” in which victims become
perpetrators. The workshop’s scope was narrowed to focus on these ele-
ments of the cycle as they relate to interrupting this transmission of vio-
lence. Intervention strategies include preventing violence before it starts as
well as preventing recurrence, preventing adverse effects (such as trauma
or the consequences of trauma), and preventing the spread of violence to
the next generation or social level. Successful strategies consider the context
of the violence, such as family, school, community, national, or regional
settings, in order to determine the best programs. Thus, the workshop
operated in a multidimensional framework that integrated ecologic, public
health, and trauma-informed paradigms to explore a comprehensive ap-
proach to violence prevention.
The next four chapters examine the four major themes that arose
from participants’ presentations and discussions: advancing research on
co-occurrence of child maltreatment and intimate partner violence (Chap-
ter 2), paradigm shifts and changing social norms (Chapter 3), the state
of prevention research in low- and middle-income countries (Chapter 4),
and prevention among multiple sectors (Chapter 5). The three chapters in
Part 2 include the submitted papers, organized as (1) overviews of evidence,
(2) global partnerships and government initiatives, and (3) examples of
preventive interventions.
And finally the appendixes consist of the agenda (A), the speakers’
biographies (B), the planning committee members’ biographies (C), and the
Forum on Global Violence Prevention members’ biographies (D).
ACKNOWLEDGMENTS
The Forum on Global Violence Prevention was established to address a
need to develop multisectoral collaboration amongst stakeholders. Violence
prevention is a cross-disciplinary field, which could benefit from increased
dialogue between researchers, policy makers, funders, and practitioners.
The forum members chose the issue of violence against women and children

as the forum’s first workshop theme because there is a pressing need to

coordinate and collate the information in this area. As awareness of the
insidious and pervasive nature of these types of violence grows, so too does
the imperative to mitigate and prevent.
A number of individuals contributed to the successful development of
this workshop and report. These include a number of Institute of Medicine
staff: Tessa Burke, Marton Cavani, Rosemary Chalk, Kristen Danforth, Meg
Ginivan, Wendy Keenan, Patrick Kelley, Angela Mensah, Elena N ightingale,
Kenisha Peters, Lauren Tobias, Julie Wiltshire, and Jordan Wyndelts. The
forum staff, including Deepali Patel, Rachel Pittluck, and Rachel Taylor,
also put forth considerable effort to ensure this workshop’s success. The
staff at the Kaiser Family Foundation’s Barbara Jordan Conference Center
and Mind & Media provided excellent support for the live event and its
webcast.
The planning committee contributed several hours of service to develop
and execute the agenda, with the guidance of the forum membership.
Reviewers also provided thoughtful remarks in the reading of the draft
manuscript.
These efforts would not be possible without the work of the forum
membership itself, an esteemed body of individuals dedicated to the concept
that violence is preventable. Their names and biographies can be found in
Appendix D.
And finally, the overall successful functioning of the forum and its ac-
tivities rests on the foundation of its sponsorship. Financial support for the
Forum on Global Violence Prevention is provided by the U.S. Department
of Health and Human Services: Administration on Aging, Office of Women’s
Health; Anheuser-Busch InBev; Avon Foundation for Women; BD (Becton
Dickinson, and Company); Catholic Health Initiatives; Centers for Disease
Control and Prevention; Department of Education: Office of Safe and Drug-
Free Schools; Department of Justice: National Institute of Justice; Fetzer
Foundation; F. Felix Foundation; Foundation to Promote Open Society;
Kaiser Permanente; National Institutes of Health: National Institute on
Alcoholism and Alcohol Abuse, National Institute on Drug Abuse, Office of
Research on Women’s Health, John E. Fogarty International Center; Robert
Wood Johnson Foundation; and the Substance Abuse and Mental Health
Services Administration.
REFERENCES
García-Moreno, C., C. Watts, M. Ellsberg, L. Heise, and H. A. F. M. Jansen. 2005. WHO
Multi-country Study on Women’s Health and Domestic Violence against Women. Geneva,
Switzerland: World Health Organization.

INTRODUCTION 5
Pinheiro, P. S. 2006. Report of the independent expert for the United Nations study on vio-
lence against children. New York: United Nations.
WHO (World Health Organization). 2002. World report on violence and health. Geneva,
WHO and LSHTM (London School of Hygiene and Tropical Medicine). 2010. Preventing
intimate partner and sexual violence against women: Taking action and generating evi-
dence. Geneva, Switzerland: World Health Organization.


Part I
Workshop Overview


The Co-Occurrence of Child

Maltreatment and Intimate
Partner Violence
A number of speakers in this workshop noted that violence against

women and violence against children often occur together and share many
common risk factors. For example, Mary Ellsberg, from the International
Center for Research on Women, stated that “everything we know about
family and community life would suggest that the two issues are intricately
linked.”
Speakers estimated the prevalence of child maltreatment and intimate
partner violence using statistics from research in the United States, as much
of the most recent data on the intersection of child maltreatment and in-
timate partner violence has come from the United States. A recent study
using a nationally representative sample of children up to age 17 found
that children who had witnessed intimate partner violence in the previous
12 months were 3.88 times more likely to experience maltreatment during
those 12 months than children who had not witnessed intimate partner vio-
lence (Hamby et al., 2010). An earlier study found that approximately 35
percent of children in the United States between the ages of 14 and 17 have
been exposed to intimate partner violence and that 40 percent of all child
abuse victims report violence in the home between their parents (Finkelhor
et al., 2009). Although not every child who is exposed to intimate partner
violence is also a victim of maltreatment, or vice versa, the data from the
United States suggest a spectrum of violence that cannot be easily parsed
into its separate components.
Several presenters and workshop participants commented that his-
torically there has been a dearth of data from low- and middle-income
countries and that this dearth has begun to be addressed only recently.

International statistics for the co-occurrence of child maltreatment and inti-

mate partner violence that are comparable to those reported for the United
States and Europe are scarce. Indeed, most of the prevalence and incidence
data discussed during the workshop concerning violence against women
and children in low- and middle-income countries address the two issues
separately. Some speakers pointed to the World Report on Violence and
Health published by the World Health Organization (WHO) as a source
of international data on violence against children (Krug et al., 2002). In
particular, workshop speaker Claudia García-Moreno noted that this study
estimates that 21 percent of urban schoolchildren and 65 percent of rural
schoolchildren in Ethiopia report bruises or swelling due to parental beat-
ings. Dr. García-Moreno also cited data from the WHO Multi-Country
Study on Women’s Health and Domestic Violence against Women, a study
that she coordinated, which estimated the prevalence of intimate partner
violence to be between 15 and 71 percent among women in the countries
that were surveyed (García-Moreno et al., 2005). Although none of the
workshop speakers cited international data focusing on the co-occurrence
of violence against women and children, the sample statistics that were
provided suggest the need for understanding and addressing violence within
families rather than attempting to treat phenomena separately that are often
associated with one another.
In addition to discussing the lack of data available from low- and
middle-income countries, several speakers noted that efforts to understand
and address violence against women are often artificially separated from
similar efforts to understand and address violence against children. They
noted that programming and funding often target specific populations (e.g.,
women but not children, or vice versa) rather than using an integrated ap-
proach that focuses on common risk factors. Concerns were also voiced
about a lack of extant indicators that would allow researchers to collect
data to measure the health and well-being of families as a whole, rather
than breaking families down into component sub-groups of men, women,
and children. Claire Crooks, from the Centre for Addiction and Mental
Health, noted in her presentation that it is common practice to exclude
from studies children who are exposed to more than one type of violence,
as this polyvictimization is seen as a confounder. This presents an additional
problem when women who are experiencing intimate partner violence are
also perpetrating child maltreatment against their children. Dr. Crooks
remarked that the complicated nature of violence within families results
in very few programs and researchers “trying to understand the child and
mother’s exposure to violence together and figure out how to measure that,
how to intervene with that.”
A number of presenters spoke about efforts to address “family vio-
lence,” as an attempt to bridge the traditional divide between intimate

CHILD MALTREATMENT AND INTIMATE PARTNER VIOLENCE 11
partner violence and child maltreatment. Workshop speaker Denise W ilson

of the Auckland University of Technology noted that in New Zealand
family violence is defined as all violence and abuse occurring in close per-
sonal relationships. This can include child abuse and neglect, elder abuse,
child-to-parent violence, and sibling violence. Although this terminology
is less specific than violence against women and children, it speaks to the
interconnected nature of these two problems.
Another attempt to integrate these types of violence is through a multi
sectoral approach to violence prevention. One example of a multisectoral
approach on a national level is the Family Violence Initiative in Canada.
Workshop speaker David Butler-Jones, Chief Public Health Officer at the
Public Health Agency of Canada, described the Family Violence Initiative as
a federal-level collaboration among 15 departments. “It isn’t exclusively in-
volved in departments federally,” he added. “It engages provinces and territo-
ries, NGOs [nongovernmental organizations], and others at the same time.”
THE CYCLE OF VIOLENCE

A central concept that underlies many of the discussions at the work-
shop is the cyclical nature of violence. The concept is particularly important
in understanding the lifecourse implications as well as the intergenerational
intersection of violence against women and children. In particular, work-
shop participants referred to the cycle of violence when describing the
need to break down the silos that separate programming and funding for
the prevention of violence against women from those for the prevention of
violence against children. A number of speakers also referred to the cycle of
violence in describing the implications of early exposure to violence, either
directly or indirectly, throughout an individual’s life. These effects include
intergenerational transmission, in which individuals who experienced vio-
lence as children subject their own children to violence either through direct
means, such as maltreatment, or through indirect means, such as exposure
to intimate partner violence.
Dr. Crooks provided a graphic (Figure 2-1) duringher presentation that
depicted the cycle of violence. The understanding of violence illustrated in
that figure demonstrates how individuals who are exposed to violence dur-
ing various periods in their lives may eventually expose their own children
to violence, thus perpetuating the cycle. Dr. Crooks explained that an im-
portant point in the cycle of violence is when an individual who has expe-
rienced violence exposes his or her own children to violence, either through
perpetration or through exposure to intimate partner violence. However,
she stressed that there are multiple pathways by which an individual can
arrive at the point of intergenerational transmission of violence and that
factors related to violence exposure earlier in life can play a significant role.

Child
direct and
Adult IPV indirect
exposure
Bullying /
Dating
Peer
violence
aggression
FIGURE 2-1 The cycle of violence.

SOURCE: Crooks, 2011.
A number of workshop participants stressed that although men are the

primary perpetrators of violence against women and children, researchers
Figure 2-1 and 6-1
and policy makers cannot ignore the fact that there are also women who
abuse their children. Dr. Crooks also noted that not all children who are
exposed to violence become perpetrators, although most perpetrators of
violence were themselves victims of violence.
Dr. Crooks went on to describe a number of theories and frameworks
that are important in understanding the psychosocial mechanisms behind
the intergenerational transmission of violence. In particular, she highlighted
contributions from the fields of attachment and social learning research. She
explained that secure attachment is based on predictable, safe, and consistent
caregiving. She further noted that attachment research has demonstrated the
importance of very early relationship experiences, explaining that children
can develop ideas, which they carry forward with them into adolescence and
adulthood, about how safe the world is and about their place in relationships
with others. Dr. Crooks commented that this can help to explain why people
who experienced violence as children can grow up to do the same things to
people in their adult lives.
Dr. Crooks also mentioned social learning theory, which explains that
children learn unhealthy and coercive models about how to get their needs
met when they are exposed to violence, either as witnesses or as direct vic-
tims. Children create models concerning effective strategies for various situ-
ations, and when they see that somebody’s needs can be met in the family
through abuse and violence, they are more likely to adopt similar strategies

for getting their own needs met, rather than employing good communication
and problem-solving skills. The Fourth R curriculum, described by David
Wolfe from the Centre for Addiction and Mental Health, is an example of
a program that seeks to reduce violence by teaching conflict-resolution and
communication skills to middle-school and high-school students. Dr. Wolfe
reported that an analysis of the data found that the additional risk of vio-
lent delinquency that is normally associated with childhood maltreatment
was reduced for students in intervention schools. Additional information
on this program can be found in Chapter 8.
Dr. Crooks explained that as behaviors develop, attitudes develop to
match. This process can result in what she referred to as “hostile attribution
bias.” For example, if an individual is living with violence, chaos, and trauma,
that person learns to expect the very worst, and the worst-case scenario be-
comes the first thought because that is adaptive in dangerous situations. Even
when that individual is in a safer environment, such as a school, it is difficult
to suddenly disengage those adaptive behaviors. As a result, children with
hostile attribution bias may interpret accidents, such as someone bumping
into them, as attacks on their safety. They may eventually alienate their peers
and be identified as aggressive by teachers. Dr. Crooks noted that this way
of viewing the world can continue into adulthood and can contribute to the
violence that is perpetrated against children by parents, who see their child’s
behavior as hostile in nature.
Many speakers referred to individuals who have been victims of vio-
lence eventually exposing their own children to violence. One example of
data that have been interpreted as illustrating the cycle of violence came
from workshop presenter Gary Barker of both the International Center
for Research on Women and Instituto Promundo. According to an initial
analysis of data from the International Men and Gender Equality Survey
(IMAGES), which were collected from both rural and urban areas in a
number of countries, men who reported witnessing violence in their home
of origin are nearly twice as likely as other men to report using violence
against a female partner later in life (Barker et al., 2011). In addition to this
added propensity for violence perpetration and exposure later in life, Dr.
Ellsberg said, statistics from the Demographic and Health Surveys (DHS)
show that there are also physical health consequences for children whose
mothers experience intimate partner violence, such as an increased risk for
malnutrition and higher mortality rates.
COMMON RISK FACTORS FOR CHILD MALTREATMENT

AND INTIMATE PARTNER VIOLENCE
Many workshop presenters noted that child maltreatment and intimate
partner violence share a number of common risk factors. These comments

were often made in the context of discussions of efforts to prevent violence

against women and children. As noted earlier, many participants challenged
the wisdom of current violence prevention systems that maintain separate
programming and funding streams for different target populations rather
than making programming and funding decisions according to risk factors
associated with various negative outcomes including violence against both
women and children. As Dr. García-Moreno noted, “If we look at some of
the risk factors for child maltreatment . . . there is quite some overlap with
the [risk factors] that have been identified for intimate partner and sexual
violence.”
Two key types of risk factors emerged during discussions: social de-
terminants and individual factors. The WHO’s Commission on Social
Determinants of Health describes social determinants as “the structural
determinants and conditions of daily life” (Marmot et al., 2008). The par-
ticipants of this workshop discussed a number of risk factors that are as-
sociated with the ways that governments and societies distribute resources.
Hortensia Amaro, a workshop presenter from the Institute on Urban Health
Research, remarked on the importance of “thinking about upstream fac-
tors across cultures and countries that are associated with toxic stress that
children experience [and] are associated with highly strained communities
and families.” That statement captured a sentiment expressed by many
workshop participants that individuals who are exposed to violence within
their families tend to live in families that are experiencing a number of
stressors on multiple levels.
Many of the stressors that were noted result from economic conditions
and resource allocation at local, national, regional, and sometimes global
levels. Some risk factors mentioned in this category include inequitable edu-
cation systems, unemployment, marginalization of vulnerable populations,
and poverty. Dr Barker said that data from the IMAGES study indicates that
although, in aggregate, men often have power over women because of social
norms, “low-income men perceive themselves as not very powerful or power
less even as they may have and often have more power than their female
partners.” Workshop presenter Rachel Jewkes, from the Medical Research
Council of South Africa, offered a related remark. “Poorer men and women
are likely to abuse and be victims,” she said. “But it may be a manifesta-
tion of experiences from childhood.” Her comment expressed a common
sentiment—that risk factors, such as poverty, experienced in childhood are
not only risk factors for childhood exposure to violence but also can carry
through to adulthood and increase the risk of abuse and victimization.
Although many common risk factors are environmental in nature, a
number of them are also somewhat more individual and have more to
do with interactions among family and community members rather than
macro-level systems. Most of these factors cannot be divorced from the

systems that affect them, but they may be considered more proximal to
the individual who is either perpetrating violence or being victimized.
For example, several workshop participants noted that untreated mental
health conditions and substance abuse are strongly associated with vio-
lence exposure. Jacquelyn Campbell, co-chair of the forum, noted that the
U.S. Human Resources and Services Administration (HRSA) has begun to
incorporate intimate partner violence into its work on postpartum depres-
sion and depression during pregnancy interventions. Dr. Barker noted that
data from the IMAGES study show that men’s reports of feeling stressed or
depressed because of a perceived lack of sufficient income or work are more
strongly associated with the men engaging in intimate partner violence
than were their reports of actual household income or monthly income.
This speaks to the intersection between systems factors that contribute to
unemployment and poverty and individual factors, such as an individual’s
ability to cope with stressful circumstances.
Although many workshop speakers spoke of psychosocial risk factors, a
few participants also stressed recent advances in understanding of the bio-
logical mechanisms behind violence perpetration and the effects of violence
exposure. Michael Phillips, a forum member and workshop participant
from Shanghai Jiao Tong University, said, “There is a biological nature to
impulsiveness, to alcoholism, to suicide, and to aggressiveness.” And Julian
Ford, a workshop presenter from the University of Connecticut Health
Center Child Trauma Clinic, described some of the physiological compo-
nents to violence that are associated with trauma. In particular, he described
how, in situations that are perceived by an individual as life-threatening, an
“alarm goes off in the brain,” causing the brain to resort to a basic evalu-
ation of safety. When this alarm has been triggered on a regular basis, the
brain changes, creating a tendency to misperceive innocuous situations as
dangerous, resulting in a fight-or-flight response, Dr. Ford said. “Violence,
traumatic stress, life-threatening, life-changing experiences that are sudden,
horrifying, overwhelming, these don’t just change a person’s frame of refer-
ence or way of thinking—they change their body.”
Another risk factor that is a combination of environmental and indi-
vidual risk factors is gender socialization. This topic received a great deal of
attention from several presenters and was the focus of the presentation by
Dr. Jewkes. Gender socialization of children is, she said, “essentially a pro-
cess of learning social expectations about appropriate goals and practices
for men and boys and for women and girls and concomitant expectations
and experiences of power.” She added that sources of socialization include
social institutions, policies, and laws, as well as communities and families.
Dr. Jewkes noted that violence within the home can be particularly harmful
because it normalizes controlling and violent behaviors, which play a role
in violence against both women and children.

Dr. Jewkes illustrated some of the effects of the coercive enforcement of

gender norms with data from Julia Kim. Dr. Kim’s data indicate that a mi-
crofinance intervention for women combined with a structured curriculum
focused on women’s empowerment decreased poverty and violence expo-
sure, whereas the microfinance intervention alone had an effect on poverty
but no effect on violence exposure. Data from the IMAGES study presented
by Dr. Barker also spoke to the effects of gender norms. Those data indi-
cate that men whose fathers engaged in domestic work when the men were
growing up are more likely to engage in domestic work themselves once
they become adults than men whose fathers did not engage in domestic
work. Dr. Barker went on to explain that the significance of this finding, in
terms of risk factors for violence against women and children, is that we
can seek to help men change their behaviors in order to help them “pass
on ways that show gender equality, respect for others, and nonviolence.”
PROGRAMS TAKING AN INTEGRATED APPROACH

A number of speakers at the workshop had been asked to speak about
particular initiatives or programs with which they have been involved.
A number of those participants provided more detailed descriptions of
those programs in papers that are included in Chapter 8 of this summary.
Some of the programs specifically target violence against women and chil-
dren, whereas others focus on some of the risk factors that were listed
above and are therefore likely to reduce violence exposure among both
women and children.
Some of the programs described at the workshop can be characterized
as having been developed originally with a focus on preventing violence
against children but eventually having incorporated elements that address
violence against women, or vice versa. A number of the programs that
were discussed also focused on common risk factors that are known to
contribute to violence against both women and children. Most commonly,
these programs had a strong gender socialization component and targeted
social norms. These interventions seem to speak to the value of address-
ing power dynamics and societal norms around violence when working to
reduce violence in families.
High-Risk Domestic Violence Conferencing

Dr. Crooks described a new Canadian initiative that has been launched
by the Children’s Aid Society in London, Ontario, to implement what they
refer to as high-risk domestic violence conferencing. This is a significant
development because the Children’s Aid Society has historically been an
agency that has focused on child protective services, and it is now taking

the lead in organizing various individuals and organizations to provide sup-

port for high-risk cases. These conferences are designed to reduce multiple
risk factors, including those that might increase the risk for the batterer to
perpetrate violence in the future.
Parenting Training for Domestic Violence Workers

One workshop attendee discussed a curriculum that was developed to give
training in parenting strategies to individuals who work in intimate partner
violence programs. She explained that the goal is for these individuals, who
are working with women who have experienced intimate partner violence, to
learn to help support the parenting, attachment, and development capacities
of women and children who are in intimate partner violence programs.
Strengthening Families Program

Workshop speaker Judy Langford, from the Center for Study of Social
Policy, described the Strengthening Families Program, a program that is
based on resilience research and seeks to reduce child maltreatment. In
her discussion of the protective factors that are included in the program’s
framework, she noted that several of the factors also address intimate
partner violence. In particular, there is a focus on parental resilience, social
connections, and having access to intensive services that a family might
need when it is experiencing a crisis related to intimate partner violence,
substance abuse, or untreated mental illness.
Parenting Program to Promote Couples’ Communication Skills

Agnes Tiwari from the University of Hong Kong described a program
that was initially designed to address both intimate partner violence and
child maltreatment, although plans are under way for a cluster randomized
controlled trial that will evaluate the efficacy of the program in improving
couple relationship quality, enhancing parental sense of competence, and
reducing postnatal depressive symptoms. Of particular importance in this in-
tervention was the ability of the team that developed the curriculum to adapt
an established curriculum to meet the cultural needs of the target population
in China. This program used parent education, which was designed to be
very hands-on in order to encourage participation by the fathers as well as
the mothers, as a way to train parents about infant care and reduce the risk
of child maltreatment. Additionally, through discussions that were centered
around infant care and child rearing, the program’s administrators were able
to guide couples in improving their own communication skills and increasing
their understanding of their own relationship styles.

Sexto Sentido and Bell Bajao

Workshop speaker Dr. Ellsberg described two initiatives that have been
implemented in low- and middle-income countries, targeting permissive
norms around the use of violence. Sexto Sentido, a television program,
has become widely popular across Nicaragua. Storylines deal with issues
of violence and risky behaviors, and characters model the benefits of hav-
ing an open dialogue about the consequences of interpersonal violence
and challenging accepted societal norms. In India, an organization called
Breakthrough implemented the Bell Bajao campaign. The focus of this
campaign was to challenge permissive social norms related to violence and
to encourage people—especially men—to intervene when they see or hear
violence being perpetrated.
Intervention with Microfinance for AIDS and Gender Equity (IMAGE)

On behalf of Julia Kim from the United Nations Development Pro-
gramme, Dr. Jewkes discussed a microfinance program. In particular, she
described a research study that looked at the effects of a microfinance
intervention targeting women in a rural area of South Africa. Women in
some towns received only the microfinance intervention, while women in
other towns received the microfinance intervention as well as a women’s
empowerment curriculum. Women who received both reported lower rates
of poverty and fewer problems in their households during and after par-
ticipation in the program. Women who received the microfinance alone
experienced reductions in poverty but no change in household problems.
KEY MESSAGES
Although traditionally research in this area has focused on violence
against women and violence against children as separate issues, more re-
cently researchers and program designers are exploring ways of integrating
the two. In particular, a greater understanding of the intergenerational
transmission of violence could be beneficial in furthering the work in pre-
venting both these types of violence. As research becomes more plentiful
and shows a high correlation of child maltreatment and intimate partner
violence, as well as a number of common risk factors, emerging evidence
suggests that implementing programs that address both simultaneously
could yield greater results.

REFERENCES
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.
Available at http://www.icrw.org/publications/evolving-men (accessed April 26, 2011).
Crooks, C. V. 2011. Cycles of violence. Presented at IOM Workshop on Preventing Violence
Against Women and Children. Washington, DC: Institute of Medicine. January 28.
Finkelhor, D., H. Turner, R. Ormrod, and S. L. Hamby. 2009. Violence, abuse, and crime
exposure in a national sample of children and youth. Pediatrics 124(5):1411-1423.
Multi-country Study on Women’s Health and Domestic Violence against Women: Initial
results on prevalence, health outcomes and women’s responses. Geneva, Switzerland:
World Health Organization.
Hamby, S., D. Finkelhor, H. Turner, and R. Ormrod. 2010. The overlap of witnessing partner
violence with child maltreatment and other victimizations in a nationally representative
survey of youth. Child Abuse & Neglect 34(10):734-741.
Krug, E. G., J. A. Mercy, L. L. Dahlberg, and A. B. Zwi. 2002. World report on violence and
health. Biomedica 22 (Suppl 2):327-336.
Marmot, M., S. Friel, R. Bell, T. A. J. Houweling, and S. Taylor. 2008. Closing the gap in
a generation: Health equity through action on the social determinants of health. The
Lancet 372(9650):1661-1669.

Paradigm Shifts and

Changing Social Norms
in Violence Prevention
An important thread running through the workshop was the sense that
the attitudes and norms concerning violence against women and children
and its prevention are changing. There is a growing awareness of the mag-
nitude of the issue as well as of the potential value of early intervention.
Some of those intervention strategies involve the inclusion of men and boys
as part of the solution instead of seeing them only as perpetrators to be
punished. Speakers also felt that early intervention should include strate-
gies that bolster resilience or mitigate future violence. Finally, speakers
addressed the issue of complex stressors, the intersection of violence with
other inequities, and the importance of addressing violence within a larger
context.
Mary Ellsberg from the International Center for Research on Women
remarked that violence is taking its place not only on the human rights
agenda but also on the health and development agendas. As a result, efforts
to reduce violence against women and children are involving multiple sec-
tors and fields in bringing attention to the issue. Speaker James Lang from
Partners for Prevention thought that communications for social change
were an important part of the puzzle. Speaker Monique Widyono from
PATH agreed with this point and added that these communication tech-
niques can be harnessed to bring momentum to gender equity.
David Butler-Jones, the chief public health officer of Canada, said he
felt that change requires not only ending violence but also making a cultural
shift toward non-acceptance of violence. Dr. Ellsberg agreed, saying that
people should be empowered to stop violence when they see it occurring.
She referred to a program in Papua New Guinea in which women formed
20

PARADIGM SHIFTS AND CHANGING SOCIAL NORMS 21
a community policing group and created a safe haven for women and chil-
dren experiencing abuse.
Gail Wyatt and Michael Phillips both stated that cultural relativity and
sensitivity require particular attention: Norms and attitudes within cultures
shape issues such as gender equality and the rights of children, but they also
influence response. Rachel Jewkes agreed but added that nuances in what is
accepted versus what is normalized can be important. She highlighted the
importance of conversation with communities to understand what is truly
culturally valued.
On the workshop’s second day, speakers in the afternoon panel delved
into violence and its relationship to trauma and the importance of under-
standing the intersection of these issues. Roger Fallot said that an important
step in addressing violence is understanding trauma and bringing it into the
mainstream of public health.
GROWING ACCEPTANCE OF THE MAGNITUDE OF

VIOLENCE AGAINST WOMEN AND CHILDREN
Many speakers expressed the sense that violence against women and
children has become a mainstream issue over the past few decades. Claudia
García-Moreno of the World Health Organization said that when she first
began working in this field, she was informed that violence was not a health
issue but a social problem. Currently, researchers, particularly in public
health, have begun to recognize and document the magnitude of these types
of violence, though many gaps remain.
Only recently has evidence demonstrated that violence has an accu-
mulated effect, and in many cases it starts early and continues throughout
the lifespan. Little data exist from low- and middle-income countries, but
studies are under way, and preliminary findings show high rates of abuse.
In particular, Claudia García-Moreno mentioned a study in Swaziland con-
ducted by the Centers for Disease Control and Prevention, which found that
33 percent of girls had been victims of childhood sexual abuse. The WHO
Multi-Country Study shows that between 1 and 21 percent of women in
the 10 countries included in the study experienced abuse in childhood,
most commonly perpetrated by a family member (García-Moreno et al.,
2005). She also referred to a study by Jeff Edleson of children’s exposure to
violence; the study found that up to 83 percent of children had overheard
episodes of intimate partner violence (Edleson et al., 2003).
Dr. García-Moreno said that in the past 10 years the amount of data
on magnitude and consequences has increased significantly, although much
information is still missing on different types of violence against women
and children (García-Moreno et al., 2005). According to the current state
of knowledge, the majority of violence perpetrated against women is done

by an intimate partner, but the means and methods vary. Denise Wilson
of the Auckland University of Technology mentioned statistics from New
Zealand showing that 50 percent of homicides are related to family vio-
lence, and as many as 1 in 3 women in New Zealand experience some sort
of lifetime physical or sexual abuse. Indigenous populations such as the
Ma-ori are at highest risk; 47 percent of women seeking safety are Ma-ori,
although this group only makes up 15 percent of the population (Wilson,
2011). Agnes Tiwari said that intimate partner violence in Hong Kong is
relatively unrecognized, particularly as it tends to be emotional rather than
physical abuse, which makes it difficult to determine rates of prevalence. Dr.
García-Moreno added that the prevalence of other types of violence, such
as female genital mutilation, does not seem to be lessening.
Finally, Dr. García-Moreno noted that in addition to the increasing
body of knowledge concerning the prevalence of violence, there is also a
growing body of evidence about the long-term effects, with evidence show-
ing that consequences can continue for years after the violence itself.
GROWING ACCEPTANCE OF THE NEED FOR PREVENTION

Speakers generally felt that there was a growing recognition that pre-
vention of violence was useful to multiple sectors in addressing health and
social issues, and that this prevention included systemic changes in health
systems as well as in legal systems. Claudia García-Moreno asked rhe-
torically why those in the health sector should care, as violence prevention
efforts are often seen as competing with other interests. She felt that this
state of affairs indicated the need for system-wide changes. Similarly, Roger
Fallot talked about trauma-informed care as a new culture that has resulted
from a systemic approach to addressing trauma that seeks to provide safety,
address the potential for recurrence, and avoid replicating the violent situ-
ation. In addition, he said that a paradigm shift is needed in health service
organizations and settings that would focus on supporting victims, such
as an effort by health care providers to build trust with patients. Several
speakers reiterated this point and said that addressing issues of violence
and safety in communities and health-care systems would actually improve
health-care providers’ ability to provide services.
A number of speakers also spoke of the need for institutional, legal,
regulatory, and policy changes to address violence. Denise Wilson described
a number of pieces of legislation aimed at protecting women and children
in New Zealand: the Domestic Violence Act of 1995; the Children, Youth,
and Families Act in 1989; and the Care of Children Act in 2004. She also
discussed the New Zealand Health Strategy of 2000, which included reduc-
tion of interpersonal violence as a goal and included family violence as a
health problem.

Cheryl Thomas discussed the early stages of work performed in Cen-

tral Asia in the early 1990s by a group that she led; in particular, she said,
there were no provisions for domestic violence (no shelters, hotlines, or
service providers, for example) and no research and no political or social
will. In 1993 her group began work in Romania documenting domestic
violence, which opened the door to research in the area. Through this
work, she said, there has been a growing understanding that implement-
ing laws criminalizing violence against women is essential, and many
countries in Eastern Europe and Central Asia have begun to do so. In
particular, Advocates for Human Rights has highlighted the importance
of the role of an “order for protection.” Ms. Thomas also noted that in
Morocco the work of local implementing partners, particularly women’s
groups, has advanced the chances for implementation of a national do-
mestic violence law greatly.
Finally, speakers explored the need for nuanced research into develop-
ing prevention and intervention strategies. David Wolfe pointed out that
in self-reports of violence, girls state they hit as much as, if not more than,
boys do, and the rationalizations they use reflect familiar language from
men and boys from the 1980s (Wolfe et al., 2009). This is troublesome,
he said, because the girls will often still end up the victim because the boy
will often retaliate. Furthermore, the situation of girls-as-victims-only is less
prevalent in adolescent abusive relationships than at the adult level, perhaps
because adolescence is a training ground and teenage violence is somewhat
peer-sanctioned. Thus, he surmised, interventions that address girls solely
as victims miss a major piece of the growing understanding of adolescent
relationships and will not be as successful.
Monique Widyono offered another example with her description of a
tool called In Her Shoes, developed originally in Washington State, which
allows people to “walk in the shoes” of women experiencing violence. The
process allows policy makers, service providers, and others a chance to see
the consequences of such violence and to diminish stereotypes or expecta-
tions of survivors of violence.
ENGAGING MEN AND BOYS

Gender equality and violence against women and children are intri-
cately entwined, and advocates for reducing violence highlight the impor-
tance of increasing gender equality. Conversely, Kiersten Stewart discussed
the reverse, describing how addressing violence can address gender in-
equality. James Lang said that violence is a “constitutive element of gender
inequality” and that Partners for Prevention quickly became involved in
engaging men and boys because they are the “gatekeepers of power” and
primary prevention has to take that into account. However, Mr. Lang

warned against sliding into the paternalistic language of men and boys
“saving” women and girls from violence or thinking about males solely as
instruments of change.
Rachel Jewkes delved deeper into the nuances of gender equity, point-
ing out that simply involving more females in government is not enough;
relationships between men and women must be addressed as well. She
demonstrated the existence of a disconnect between gender equality and
a lack of violence by describing a study done in South Africa in which 90
percent of men said women should be treated equally, but 50 percent of
those surveyed admitted to committing physical violence against a female
partner (Gender Links and South African Medical Research Council, 2010).
Dr. García-Moreno also noted that there is a growing body of information
from men about their own perpetration of violence.
Dr. Jewkes explained that gender socialization is a process of learning
social expectations about the goals and practices of men and women as
well as about their experiences of power. Mary Ellsberg highlighted the
importance of social dynamics: Boys are raised to be “tough,” and girls are
raised to be pliant. Gender norms also influence the type of violence that
children experience, with boys more likely to experience bullying and fights
while girls are more likely to experience sexual and psychological violence
and exclusion.
Thus in the process of growing up children discover that going against
the dominant cultural model results in pressure, abuse, and violence. Dr.
Jewkes used the example of the rape of lesbians in South Africa as a “cor-
rective measure” to emphasize this point. Gary Barker agreed and suggested
that changing gender norms should mean not only redefining the roles of
men and women but also making people aware of the diversity of roles that
already exist in various cultures.
Therefore, Dr. Jewkes concluded, addressing violence against women
and children must include gender socialization. Various social institutions,
such as schools, help define gender, but the home and family life are some
of the earliest and strongest influences. If gender balances are unequal in the
home or if partner violence is occurring, boys and girls are at greater risk
of mimicking these models and finding themselves in abusive relationships
again and again. Gary Barker reiterated this, mentioning the stress on men
of being a provider, particularly during economic downturns, and suggested
that perhaps early gender socialization that included alternative roles for
men might reduce this stress. Dr. Jewkes, speaking for Julia Kim, said that
giving women increased roles as providers does not always help, particu-
larly if it is added to women’s responsibilities for taking care of the home,
because it can increase the stress on women. She noted that standards for
feminine behavior in the developing context are often constructed around
acquiescence to men’s demands and that social structures often reward

women who fit into socially acceptable roles despite the increased risk of
violence they must endure.
Dr. Jewkes referred to the hegemonic masculinity theory of Raewyn
Connell, which states that power is not exercised through use of force but
rather through the acquiescence of the powerless. A study in South Africa
found that while the vast majority of men and women believe in equality,
the majority of men and a smaller majority of women believe that a woman
should obey her husband. This was true across races. One of the factors
contributing to this situation is a lack of exposure to other culturally ap-
propriate ways of being a woman. Dr. Jewkes also pointed out that, ac-
cording to one study, women who strongly agree that a husband has a right
to beat his wife are more likely to be beaten and that women who believe
that beating is a sign of affection are also more likely to be beaten (Gender
Links and South African Medical Research Council, 2010).
The International Men and Gender Equality Survey (IMAGES) de-
scribed by Dr. Barker found that men report knowing about laws address-
ing gender-based violence but express sometimes contradicting views on
such laws. One consensus among interviewees across countries was the
feeling that the laws increase a sense of being observed or scrutinized,
which Dr. Barker described as not only a symptom of the gender power
balance being upset but also an indication that additional education might
be needed to explain how these laws are protective and not punitive. Claire
Crooks also expressed a concern about lack of services for men at risk of
perpetrating violence aimed at preventing either violence or the recurrence
of violence; most efforts are punitive instead of preventive.
To explain why some men experience similar risk factors but do not
perpetrate violence, Dr. Barker showed responses from IMAGES suggesting
that men are sensitive to positive cultural and social norms, including the
influence of a respected elder, reflection on past abuse (as victim or per-
petrator), and exposure to community spaces that promote non-violence.
Interventions that take into account these sensitivities often include
involving men in the care of family. Dr. Crooks said that it is important not
to assume that a program that works with mothers will work with fathers
and that more effort should be put into designing programs that include
men more actively.
Agnes Tiwari agreed, citing her work in including men in prevention
efforts as active participants rather than as passive partners. In her Hong
Kong study, men were included in a prenatal education intervention in
which the discussion around parenting skills was used as an entry point to
discussing couple relationships. This was more effective because the cultural
barrier to discussing romantic relationship skills could be overcome. In
particular, it was effective in reaching men and discussing both partner and
father roles in a way that didn’t seem “therapeutic.”

INTERSECTION WITH OTHER INEQUITIES

Recent research in the field of violence prevention shows that violence
does not occur in a vacuum; instead, it is highly co-occurring with certain
factors such as poverty, food insecurity, the presence of infectious and
chronic diseases, and lack of education. Addressing violence prevention in a
comprehensive way requires looking at these other issues as well. Dr. Butler-
Jones remarked that “poverty is a constellation” and can entail a lack not
only of economic resources but also of relationships as well. Having stabil-
ity, shelter, and adequate food means the difference between average health
and good health, all of which affect resiliency.
Thus investing in preventing violence against women and children
is not just about ending violence and promoting gender equality. As Dr.
Ellsberg said, “We cannot hope to make significant progress in achieving
the ambitious goals of ending poverty and hunger, achieving universal pri-
mary education, improving maternal and child health, and combating AIDS
and other infectious diseases unless we are able to end violence against
women and children.” Brigid McCaw also said that it is important to iden-
tify co-morbidities and inequities (poverty, substance abuse, and so forth)
because they may be more likely to bring the victim to the attention of the
provider than the violence itself. For example, as Claudia García-Moreno
pointed out, children experiencing violence at home often have difficulties,
such as behavior problems, at school, and understanding this link can lead
service providers to the violence even if no report is ever made.
These intersections are bi-directional: The increased risk of violence
creates a suspicion of legal and medical authorities, while unstable social
conditions can lead to an increased incidence of violence. Dr. Ellsberg
pointed out, for example, that poverty and lack of access to health care
prevent parents from accessing resources for addressing parenting and cop-
ing skills. Furthermore, those who fear the stigma of HIV and its associated
violence—of which women are most at risk—fail to seek screening and care.
Roger Fallot said that while violence increases the risk of homelessness,
incarceration, and substance abuse problems, those outcomes in turn place
people at risk of continued violence.
The context in which violence can occur is a major factor affecting
the risk and severity of violence. Dr. Amaro suggested it might be useful to
look further upstream at issues such as environmental factors and structural
violence, a topic that had been touched upon by an earlier audience member
who suggested that violence prevention efforts need to be incorporated into
social studies curriculum in schools. Dr. Crooks said that the more types
of violence a person experiences, the worse the outcome will be in terms
of both future perpetration and health and psychosocial outcomes. Poverty
and racism increase both the likelihood and the severity of violence and

also affect the impacts of violence. Denise Wilson underscored this point
by bringing up the example of the Ma-ori, who live in the most deprived
neighborhoods in urban centers of New Zealand and who still experience
barriers to access to health care and social services system because of racial
discrimination. The Ma-ori are disproportionately victims of violence, and
they account for 50 percent of women and children in shelters. Dr. Wilson
also described how the Ma-ori culture has seen huge shifts over the past
several decades, with the loss of traditional social structures that previously
supported women’s equality. Not all women have the same rights, Dr. Wyatt
said, and ethnic and racial differences play a large role in who is exposed
to or victimized by violence.
Promundo’s IMAGES study shows that one major factor in predict-
ing violence is whether men report feeling economic stress (as opposed to
reporting of actual income), which is related to the social norms of men’s
traditional roles as providers. Dr. Jewkes referred to a study from South
Africa in which women who report higher food insecurity report less eq-
uitable views of gender and men who report lower food security report
higher rates of violence against a partner. A similar outcome was found in
a study in India, which found that 49 percent of women who did not own
property reported violence, as compared with 7 percent of women who did
own property. In general, a lower ability to mobilize resources is correlated
with a higher acceptance of violence, greater likelihood of being a victim or
perpetrator, and lower likelihood of leaving a violent situation. This greater
risk of violence leads to a continued cycle of violence in which victims find
themselves re-victimized and sometimes become perpetrators themselves.
The context of violence also affects the severity of the outcomes. Julian
Ford and Claudia García-Moreno paid particular attention to the concept
of toxic stress and how continual exposure to violence both directly and
indirectly creates a climate of chronic stress, which has been shown to have
fundamental effects on cell growth in the brain. This is of particular impor-
tance for children, whose brain development can be significantly altered,
resulting in secondary outcomes throughout their lives. Exposure to chronic
stress affects language and communication ability and places an individual
at increased risk of substance abuse. The development of trauma as a long-
term outcome also has a complex relationship with violence, putting victims
at additional risk of re-victimization as well as at risk of other adverse
health outcomes. Dr. Amaro mentioned the high rates of co-occurrence of
alcohol- and drug-related disorders with trauma and post-traumatic stress
disorder (PTSD). Often the alcohol- and drug-related issues are methods of
self-medicating that are used to deal with trauma, but such use intensifies
the symptoms of PTSD, creating a cycle.
In the Boston Consortium study discussed by Dr. Amaro, an integrated
system was created to address trauma and substance abuse issues in women.

This included treatment for the trauma (psychotherapy and skills build-
ing) as well as substance abuse treatment, both clinical and residential.
The intervention involved careful attention to gender and racial linguistic
usage because the population was primarily African-American and Latina
women, and it paid close attention to addressing the roles of women in
society and their relationship to violence. The intervention also included
components to address integration with other services being provided,
because many of the women involved had other issues, such as the loss of
custody of children or a lack of economic empowerment.
Cris Sullivan applied her community advocacy model to discuss how
empowering women has a strong effect on whether abuse recurs and on
how capable women are of escaping the cycle of violence. She found
in her intervention that providing an advocate who would support the
woman with skills transfer and assistance empowered her to take control
of her life.
PREVENTION THROUGH PROMOTION

The speakers also agreed on the importance of primary prevention
and on moving even further upstream to address the environment in which
violence occurs. Researchers felt that promoting resilience and protec-
tive factors provides individuals with skills to deal with the conflict and
instability that breeds violence. Addressing many of the issues mentioned
previously, such as gender equality and co-morbidities and the chronic
stress on children, would be cost-effective and successful in the prevention
of violence against women and children. Speakers felt that mitigating the
climate of violence through social and legal programs often results in the
greatest success.
Some of these legal interventions would involve laws and regulations
that strengthen the rights of women and children, such as the interna-
tional and country-level policies mentioned by Cheryl Thomas and Kiersten
Stewart. Katrina Baum of the National Institute of Justice described the
paradigm shift that occurs when including criminal justice in prevention,
citing a case of a police chief referring to a stalking unit as a “homicide
prevention unit,” and Gary Barker noted that there is good evidence that
community policing can play a role in preventing violence.
Prevention can also be addressed in programs that strengthen individual
skills and family coping mechanisms. Bryan Samuels of the Administration
on Children, Youth, and Families referred to research undertaken to inform
program decision making that showed three important protective factors:
“young people who have the ability to self regulate, young people who
choose a particular way of coping with adversity, and young people who have
a level of self efficacy that leads them to the belief that they can avoid the

bad things that are going on around them, and that they have got a skill set
or a method for doing so.” Dr. Fallot talked about G-TRIM (Loving Life),
in which girls were given a space to talk about trauma, anger, and how to
move forward.
David Wolfe said that prevention is cheaper and easier than treatment
and noted that the Fourth R is designed around the promotion of healthy
relationships in adolescence. Learning to relate starts early, and adolescents
are curious and experimental, pushing at boundaries and becoming more
exposed to risk factors. The Fourth R addresses management of these
risk factors, strengthening the skills needed to make responsible choices
and teaching students to balance “pro-abuse” messages with healthy mes-
sages. An important component of the program is involving youth in their
own empowerment, particularly having older youth demonstrate the skills
learned through the program in videos or other activities. One major out-
come of the program is that boys who experienced maltreatment outside of
school were less likely to engage in dating violence after this intervention.
Risk factors are most noticeable at the middle school level, so addressing
troubling relationships then makes sense. However, it could potentially be
more effective to begin earlier with general information on the skills needed
to build healthy relationships.
Judy Langford discussed Strengthening Families, which targets all fami-
lies, not just those at risk, and aims to increase resilience and promote
strengths. To easily reach out to families, the program is carried out at
locations that they are likely to frequent. Strengthening Families is designed
to support five essential protective factors that were identified through re-
search and evaluation of successful programs. The first is parental resilience,
which aids a parent’s ability to maintain healthy relationships and handle
individual and parenting challenges. The second is social connections and
the ability to create a social network to prevent the damage caused by iso-
lation as a result of or a precursor to susceptibility to violence. The third
is knowledge of parenting and child development, which encompasses not
only “official” information from parenting guides but also the unofficial
information gleaned from family networks and cultural sources. The fourth
is concrete support in times of need, both the basic needs required to main-
tain a stable household, such as economic stability, and access to services
in crisis. The fifth protective factor is social and emotional development of
children, because children with developmental delays and cognitive disabili-
ties are more vulnerable to maltreatment than those with normal develop-
ment. The importance of this work, Ms. Langford said, is highlighted by the
number of states that expressed interest in learning about this framework,
which in turn resulted in a number of interdisciplinary approaches being
created and used in these states. Strengthening Families has been adopted by
national and international nongovernmental organizations, parent groups,

administrators, and state child welfare agencies as a means to reduce vio-

lence and improve family relationships.
Gary Barker discussed an intervention strategy, Program H, designed to
promote alternative masculine identities of non-violent or less violent men
and directed at both men and women. The program ran a campaign includ-
ing radio spots, TV ads, community theatre, and other media that high-
lighted positive aspects of masculinity. In Brazil the campaign resulted in
attitude change; in India, it resulted in lower reported rates of gender-based
violence. Preliminary data in the Balkans are being assessed, but one major
obstacle to success there was the ingrained violence in all-male schools, a
more difficult cultural context to overcome. A second intervention, Program
M, is looking at changing these attitudes within schools, not only among
students, but also among teachers as transmitters of these norms.
In the Intervention with Microfinance for AIDS and Gender Equity
study in South Africa, which was conducted by Julia Kim and described by
Rachel Jewkes, researchers sought to identify whether microfinance pro-
grams with added gender training elements resulted in women feeling more
empowered and in men and women reporting fewer violent events. Women
reported feeling more empowered collectively. There were also increases in
food security and household assets and a reduction in loan defaults. The
program also saw a 55 percent reduction in intimate partner violence two
years after the intervention, through shifts in attitudes, including greater
negotiating status of women, the ability of women to leave abusive relation-
ships, and fewer conflicts over finances. In a comparison group without the
gender training, there was no reduction in violence.
Finally, several speakers addressed the importance of education, given
that higher levels of education correlate to low violence. Dr. Barker referred
to cases in which the dropout rates for girls and boys in secondary school
are high, suggesting that while the focus is mostly on girls, consideration
should be given to addressing the issue with boys in order to keep them in
school, which in turn would increase earning potential, reduce economic
stress, and expose the boys to more positive gender role socialization.
KEY MESSAGES
The stigma of violence against women and children is diminishing, re-
vealing important cultural and contextual elements that could be addressed.
This paradigm shift involves increasing the evidence base, implementing
programs that move further upstream and address contextual factors, and
engaging men and boys, traditionally seen as perpetrators, as part of the
solution. As well, as the violence prevention community produces fur-
ther research and evidence of successful programs, the pervasive nature of

violence, and its relationship to other health and social inequities, continues
to be illuminated.
REFERENCES
Edleson, J. L., L. F. Mbilinyi, S. K. Beeman, and A. K. Hagemeister. 2003. How children are
involved in adult domestic violence: Results from a four-city telephone survey. Journal
of Interpersonal Violence 18(1):18-32.
Ellsberg, M., H. A. F. M. Jansen, L. Heise, C. H. Watts, C. Garcia-Moreno, and W. M. S. W.
Hlth. 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. Lancet 371(9619):1165-1172.
Gender Links and South African Medical Research Council. 2010. The war at home: Prelimi-
nary findings of the Gauteng Gender Violence Prevalence Study. Johannesburg, South
Africa: Gender Links.
Wilson, D. 2011. New Zealand’s efforts to prevent violence against women. Paper presented at
IOM Workshop on Preventing Violence Against Women and Children, Washington, DC.
Wolfe, D. A., C. V. 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 random-
ized trial. Archives of Pediatric Adolescent Medicine 163(8):692-699.

The State of Prevention

Research in Low- and
Middle-Income Countries
The state of research on prevention of violence against women and chil-

dren was a central theme of the workshop. A number of speakers referred
to advances in knowledge and practices while also pointing to various gaps
in knowledge—particularly in low- and middle-income countries—as well
as to challenges in the prevention research cycle. Figure 4-1, which is taken
from an Institute of Medicine (IOM) report published in 1994, illustrates
the five steps in the prevention intervention research cycle. As noted in
the report (IOM, 1994), while the feedback loop is shown as connecting
box 5 with box 1, in reality there should be a nearly continuous feedback
loop between researchers and practitioners at all stages of the prevention
research process. The illustration is provided in order to facilitate consis-
tency throughout this section and should not be construed as a product of
this workshop.
Discussion at the workshop focused mainly on data collection, trans-
lation, implementation, and dissemination efforts related to violence pre-
vention. This summary will refer to the activities listed in boxes 1 and 2
of Figure 4-1 as data collection. This includes data on the prevalence and
incidence of violence perpetration and victimization as well as similar infor-
mation related to risk and protective factors. The term translation will be
used to refer to the process by which research knowledge that is related to
violence prevention either directly or indirectly is used to inform violence
prevention activities and initiatives. This process is represented by the ar-
row connecting boxes 2 and 3. The term implementation refers to a specific
set of activities that are designed to put an intervention into practice. This
term will generally be used to refer to activities that have been described
32

RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES 33
Feedback Loop
1. Identify 2. With an 3. Design, 4. Design, 5. Facilitate

problem or emphasis on conduct, and conduct, and large-scale
disorder(s) and risk and analyze pilot analyze large- implementation
information to protective studies and scale trials of and ongoing
determine factors, review confirmatory the prevention evaluation of
extent relevant and replication intervention the preventive
information— trials of the program intervention
both from preventive program in the
fields outside intervention community
prevention and program
from existing
preventive
intervention
research
programs
FIGURE 4-1 Preventive intervention research cycle.

SOURCE: IOM, 1994.
Figure 4-1 redrawn

in sufficient detail that the intervention can be replicated as necessary, and
it is represented by the arrow that connects boxes 3 and 4. The term dis-
semination refers to a set of activities that is intended to expand the usage
of an intervention and is represented by box 5. The phrase “scaling up”
was used frequently by workshop participants and is interpreted within this
summary to refer to dissemination activities.
DATA FROM LOW- AND MIDDLE-INCOME COUNTRIES

The use of data was an important theme of the workshop, and a num-
ber of participants commented on the dearth of data available from low-
and middle-income countries. Workshop speaker Claudia García-Moreno
noted that the majority of the evidence base related to violence against
women and children comes from high-income countries. Another workshop
speaker, James Lang from the United Nations Development Programme,
commented that the currently available data have a number of problems
related to the methodologies and measurements used and the lack of longi-
tudinal data. Workshop participants mentioned a number of implications
that the limitations in data from low- and middle-income countries have
for successful prevention of violence against women and children. These
implications will be discussed later in this section.
Although workshop participants lamented the lack of data from low-
and middle-income countries, many speakers also noted that significant
progress has been made over the past decade. In particular, speakers men-
tioned a number of studies that have taken place in low- and middle-income
countries in recent years as examples of high-quality studies with a focus
on violence prevention, some of which were coordinated by the speakers
and participants at the workshop. Three studies that were frequently cited

when discussing the incidence and prevalence data related to violence

against women and children were the World Health Organization’s Multi-
country Study on Women’s Health and Domestic Violence against Women
(García-Moreno et al., 2005), which was coordinated by workshop speaker
Claudia García-Moreno; the World Health Organization’s World Report
on Violence and Health (Krug et al., 2002); and the International Men and
Gender Equality Survey IMAGES), conducted jointly by the International
Center for Research on Women (ICRW) and Instituto Promundo and coor-
dinated by workshop speaker Gary Barker (Barker et al., 2011).
A number of other high-quality studies in low- and middle-income
countries were mentioned during the workshop. In addition to the I MAGES
study, Dr. Ellsberg cited another ICRW study, Intimate Partner Violence:
High Costs to Households and Communities, which provides data from
Bangladesh, Morocco, and Uganda (Duvvury, 2009). She also noted that the
U.S. Centers for Disease Control and Prevention (CDC) has produced re-
ports on reproductive health in a number of low- and middle-income coun-
tries that have included data about violence against women and children. Dr.
García-Moreno specifically cited one of the CDC studies that examines the
health consequences of sexual violence against girls in Swaziland (Reza et
al., 2009). Dr. Ellsberg also pointed to the Demographic and Health Survey
(DHS) conducted by Macro International as an important source of data
related to the prevalence and consequences of different forms of violence
against women and children in low- and middle-income countries.
TRANSLATION
Another important step in the prevention research cycle that was dis-
cussed during the workshop is translation, which is the process of taking
research findings and making that information relevant to programs and
policies. This process is represented in Figure 4-1 as the arrow connect-
ing the first two boxes, which correspond to important data collection
activities, to box 3 which represents intervention development. Monique
Widyono, from the Program for Appropriate Technology in Health (PATH),
noted that translation is more effective when one understands what infor-
mation will be helpful for program and policy leaders before collecting the
data. In a similar vein, workshop participant and forum member Jim Mercy
discussed Together for Girls, a collaborative initiative of United Nations
agencies, the U.S. government, and the private sector aimed at addressing
sexual violence among girls. He noted that one of the three main pillars
of the program is to collect data that quantify and describe the problem
of sexual violence against girls and that can then guide action, while also
working with countries in translating that information to policies and
prevention programs. Judy Langford of the Center for Study of Social

Policy described the practical implications of translation research, stating

that facilitating high-quality programs that are based in research requires
researchers to do a better job of distilling the data to discover “the kernel
of truth” that is most central to the model that will be used to develop
programs and policies.
IMPLEMENTATION
Several workshop speakers discussed the importance of implementation
research and the implications that high-quality implementation efforts have
for the effectiveness of programs and policies that are based on scientifically
sound evidence. Workshop participant and forum chair Mark Rosenberg
said, “As we are trying to develop interventions that can travel well and
can be put in place in developing countries that don’t have big budgets, it
will become more and more important for us to move into this next stage of
research, looking at implementation and delivery.” As noted above, in this
report implementation refers to a specific set of activities that are designed
to put an intervention into practice and is represented in Figure 4-1 by the
arrow connecting boxes 3 and 4. Some participants spoke about different
aspects of implementation, while others gave specific examples based on
their experiences with particular programs and initiatives.
Dr. García-Moreno framed the issue of interventions targeting violence
against women and children with the statement, “We know that services
for victims work.” That point was emphasized by several workshop par-
ticipants who stressed that there are many very good programs that are
effective in reducing violence against women and children and in mitigat-
ing the negative health consequences that result from exposure to violence.
One of the most common themes related to implementation was the
need to ensure that programs are implemented in a way that is appropri-
ate for the particular communities that are being targeted. This issue is
particularly salient for efforts in low- and middle-income countries given
that, until very recently, most research on the prevention of violence against
women and children has been conducted in high-income countries such as
the United States. As Dr. Crooks commented, “When we talk about taking
programs to other communities or even other cultures and countries, we
can’t assume that [just because] a program has really strong evidence in one
setting [that it] is going to travel well.” Workshop speaker Rachel Jewkes
also commented that although a critical component of a program may be
relevant in many different settings, the best way to achieve that component
may differ from culture to culture. For example, she noted that although
an intervention may call for building social participation, the best way to
build social participation in a rural village in South Africa is likely to be
different from the best approach in an urban area. This fact that cultures

can vary both within countries and across countries was mentioned by a
number of workshop participants.
Several workshop participants and speakers described issues that are
important to consider when implementing an intervention originally devel-
oped in a different setting or cultural context. Dr. Amaro said that there
is very little scientific evidence that speaks to how to adapt interventions
to different cultures, and various participants cautioned against thinking
that simply translating the language in which the intervention is carried
out should be sufficient when adapting interventions to other settings. For
example, Dr. Ford noted during his presentation that the Trauma Affect
Regulation: Guide for Education and Treatment (TARGET) curriculum was
translated both in terms of language and in terms of culture in order to be
relevant to the communities for which it was being adapted. Dr. Crooks
echoed this point, noting that often “the manual gets changed in terms of
the pictures in it, or people throw in a few cultural teachings or stories and
think that is it, and it is essentially the same model.” She also commented
that people developing implementation efforts need to be open to identify-
ing totally different approaches that build on culturally relevant protective
factors in order to achieve the same ultimate outcomes. Discussing ways to
address this challenge, workshop participant and forum member Michael
Phillips said that there is a need for a more formalized approach to imple-
mentation that uses situation analysis to examine the various aspects of a
setting that will help identify how best to adapt a particular intervention.
A number of workshop speakers shared examples that illustrated the
importance of considering cultural values when implementing interventions,
particularly interventions that are being adapted for different populations.
Dr. Wilson offered an example of the consequences of failing to make sure
that an intervention is culturally relevant. An initiative in New Zealand to
address sudden infant death syndrome among the Ma-ori communities was
initially unsuccessful, she said, because the initiative had not incorporated
Ma-ori values. When the initiative was modified to take these values into
account, it was much more successful. Dr. Tiwari also provided an example
of cultural adaptation in her presentation. Describing two interventions
that were implemented in Hong Kong, she explained how she and her col-
leagues were able to take an assessment tool that was in use in the United
States and not only translate it but also take the time to validate the Chinese
version. She also described developing a parenting program for expecting
couples that addressed couple communication in the context of infant care
education, taking into account the fact that a therapeutic label could be
off-putting to Chinese couples while a focus on education was more in line
with their cultural values. Finally, she noted that incorporation of Chinese
health concepts and traditional stories was important because most of the
couples were living in a dual world. “Many of them are very Westernized,”

she said, “but at the same time they have to cope with the Chinese tradi-
tional beliefs that are passed down by their parents.”
In addition to Dr. Phillips’ comments about the use of situation analy-
sis as a tool to characterize communities more systematically in order to
develop more effective adaptations of interventions, a number of partici-
pants and speakers spoke of the importance of engaging with community
members. Dr. Jewkes said, “The best way of making sure you don’t make
mistakes over this is by using participatory methods.” Dr. Barker discussed
two initiatives in India and Brazil aimed at engaging men in efforts to re-
duce violence against women and children. He noted that participants in
both countries helped to develop a symbol that could identify them as men
who were questioning the use of violence against women and children. Dr.
Barker also noted that most of the activities used to raise public awareness
within their respective communities were developed by the group members,
which made it more likely that they would be relevant and reach their in-
tended audiences. Other examples of engaging with community members
and leaders came from North America and New Zealand. During Dr.
Wolfe’s presentation on the Fourth R (see Chapter 8 for more detailed infor-
mation on the program), he noted that schools and communities in North
America are asked to involve their youth and some of their local teachers in
modifying program implementation for their own communities. Dr. Wilson
described how focus groups in New Zealand with Ma-ori mental health
nurses were important in efforts to make sure an intervention designed to
provide women with resources related to intimate partner violence was ap-
propriate for the target population.
In addition to discussing these various cultural concerns, workshop
participants also noted that understanding the specific mechanisms that are
most effective in a given intervention is crucial in guiding the implemen-
tation of previously researched interventions in new settings. Dr. Amaro
said that there is a need for more research on the efficacy of interventions,
including more controlled studies, in order to understand the important
mediators and key program components. Dr. Edleson challenged partici-
pants to consider how to transport and diffuse evidence-based interventions
without losing the strength of the original models. One particular example
of this challenge was mentioned by a number of workshop participants: the
nurse home visiting program developed by Dr. David Olds. Dr. Crooks said,
“The original nurse visitation program developed by Olds has not necessar-
ily replicated well or traveled or adapted as well. When this same program
has been done using paraprofessionals, the outcomes have been more disap-
pointing.” Discussing replication challenges, Ms. Langford suggested that
the Strengthening Families framework has been broadly successful because
it provides a very simple research-based framework that is easy to apply
across many settings. She remarked that the “most interesting part to me

has been the way that parents, parent leaders, have taken the protective
factors framework and begun to create strategies to have conversations
among themselves.”
Bryan Samuels spoke of the need to evaluate program implementa-
tion efforts that involve modification to the original design. Much of the
implementation research leaves one “with an understanding of whether
a program worked or didn’t work, and the impact that it had.” How-
ever, he added, “What you don’t come away with is an understanding of
whether certain components of the program had a greater impact or not
versus aspects of the program that didn’t.” Mr. Samuels also said that in
moving forward there is a need to identify the relevant components of an
intervention in order to know which components are most important to
evaluate when implementing an evidence-based intervention. To that end,
a workshop attendee noted that organizations often identify manualized
interventions and then implement them without a plan to evaluate their
efforts. He noted that opportunities exist for local evaluations that seek
to marry quality research with quality program implementation. There are
“not enough people coming in [to the National Institute of Drug Abuse]
with applications for implementation and dissemination research, but they
are high priorities for us,” he said.
Another theme that arose during the workshop was the idea that in
order for interventions to be implemented well, it will be important to
establish the necessary public health infrastructure and workforce and also
to better understand the impact of program implementation on those who
are actually implementing the programs. Dr. Wyatt noted that an important
part of implementation research is studying the impact of an intervention
on the organizations that are implementing the interventions, including ef-
forts to understand the effects on the staffs of those organizations. She also
suggested that it is important for people to recognize that interventions can
create a particular burden for a community and that costs of such interven-
tions need to be more closely examined and better understood.
DISSEMINATION
The goal of developing a violence prevention workforce points directly
to the final stage in the prevention research cycle. Dissemination refers to
a set of activities intended to expand the usage of an intervention. As de-
scribed by workshop speaker Monique Widyono, dissemination is “really
about galvanizing action and momentum around work that is already hap-
pening on the ground and being able to share that [work].” Many of the
concerns that were discussed in the section on implementation were also
raised during conversations about dissemination, particularly concerns re-
lated to culturally relevant adaptations and the need to continually monitor

and evaluate an implementation. Indeed, implementation and dissemination

can share many of the same activities conceptualized in the framework
shown in Figure 4-1. Thus this section focuses primarily on the workshop’s
discussions about efforts to share information across settings and to scale
up interventions.
Workshop participants discussed a number of initiatives that focus on
dissemination activities as a part of their mission. In particular, workshop
speaker Cheryl Thomas of Advocates for Human Rights noted that UN
Women recently launched its Global Virtual Knowledge Centre to End
Violence Against Women and Girls (UN Women, 2011). This initiative
is intended to “encourage and support the efficient and effective design,
implementation, monitoring and evaluation of evidence-based program-
ming, to prevent and respond to violence against females.” Ms. Thomas
encouraged individuals to review the databases on the website in order to
contribute to the centralized knowledge base that is being developed.
The InterCambios Alliance, described by Monique Widyono on behalf of
Margarita Quintanilla��
, offers an example of efforts to engage in implementa-
tion and dissemination activities on a regional scale. Ms. Widyono noted that
the alliance’s work is not focused on the development of new materials but
rather on sharing and adapting materials that have already been developed
and have shown promise. The alliance also identifies programs that have al-
ready been evaluated in other settings, introduces them to the communities in
which the members of the InterCambios Alliance work, tests them, and asks
local organizations if the program seems like a good fit for their community.
The final step in the process, Ms. Widyono said, is to engage in efforts to
disseminate those programs widely. InterCambios’ efforts to test and adapt
programs that have already been proven to be successful in other settings il-
lustrate what many workshop participants had noted about the importance
of thoughtful dissemination. Workshop participants talked about various
efforts to create centralized repositories of information related to successful
violence prevention interventions and also spent time discussing the aspects
of dissemination that deal with scaling up interventions so that they can be
implemented on a larger scale. The importance of ensuring that interventions
brought into new communities and new settings are adapted to meet the
specific needs and values of the populations being targeted was a common
theme in discussions of scaling up. A number of participants mentioned flex-
ibility as an important characteristic of those interventions or models that
can be successfully brought to large-scale implementation. Ms. Langford said
that an important aspect of efforts to disseminate the Strengthening Families
framework was to incorporate lessons from early adopters of the model and
the adaptations that they found to be successful, while maintaining a focus
on fidelity to the core components of the model. Similarly, Dr. McCaw noted
that in scaling up the Family Domestic Violence Program among Kaiser

Permanente facilities in Northern California from 1 pilot facility to an even-

tual total of 46 facilities, she learned that it is important for the model to be
“easy to understand and easy to customize.”
Another theme that emerged from comments on how to facilitate suc-
cessful large-scale implementation was the need to provide some specific
guidance related to the implementation of a particular intervention. Dr.
McCaw said that developing a set of tools helps to facilitate implementation
in new sites and that it was important in her efforts to increase the number
of Kaiser Permanente facilities offering the Family Domestic Violence Pro-
gram. Similarly, Ms. Widyono noted that an important part of the work
done by the InterCambios Alliance is to provide a set of curricula or tools
to individuals and organizations that are seeking to adopt an intervention.
Another example of how program developers can provide tools to facilitate
large-scale implementation while also maintaining flexibility was provided
by Dr. Wolfe’s remarks about encouraging schools to adapt the Fourth R
curriculum to meet the needs and values of their communities, including
allowing parochial schools to emphasize abstinence.
Various workshop participants mentioned workforce and infrastructure
development as ways that countries can further advance violence prevention
efforts and, in particular, scale up proven interventions. Mr. Samuels said
that, from his perspective as a policy maker, it is important to create “a
supportive system that brings with it a set of generic skills that then allow
training to augment the particulars of a program.” Dr. Mercy suggested that
additional efforts should be made to develop a “cadre of people who can
understand the evidence base and can work at the ground and community
level to work with people who are going to integrate these types of effective
programs into their schools, their service programs or whatever.” To that
end, workshop participant Rosemary Chalk from the Institute of Medicine
drew a parallel between the current need to adapt and implement evidence-
based violence prevention interventions in communities and similar efforts a
century ago to implement research-based agriculture techniques through the
creation of the Agricultural Extension Service. Dr. Chalk remarked that it
might be helpful to think about how people can work in local communities
and build on local practices while at the same time not having to develop
completely new programs for each community. Rather, she suggested there
might be some benefit in creating family life extension agents and empower-
ing a “corps that is charged with getting research into the hands of people
where they are and where the local services are based.”
KEY MESSAGES
Although data from low- and middle-income countries have tradi-
tionally been lacking, these gaps are rapidly being filled. As the body of

knowledge grows, a secondary gap remains regarding how best to trans-

late and transport successful programs from one setting to another. Issues
including appropriate cultural context, infrastructure, and trained health
professional continue to provide impediments to the successful implementa-
tion of evidence-based violence prevention programs.
REFERENCES
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).
CDC (Centers for Disease Contol and Prevention). 2008. Adverse health conditions and health
risk behaviors associated with intimate partner violence. Morbidity and Mortality Weekly
Report 57(05):113-117.
Duvvury, N. K., S. Chakraborty, N. Milici, S. Ssewanyana, F. Mugisha, F; et al. 2009. Intimate
partner violence: high costs to households and communities. Washington, DC: Interna-
tional Center for Research on Women.
Switzerland: World Health Organizaiton.
IOM (Institute of Medicine). 1994. Reducing risks for mental disorders: Frontiers for preven-
tion intervention research. Washington, DC: National Academy Press.
Krug, E., L. Dahlberg, and J. Mercy. 2002. World report on violence and health. Geneva,
Reza, A., M. J. Breiding, J. Gulaid, J. A. Mercy, C. Blanton, Z. Mthethwa, S. Bamrah, L.
L. Dahlberg, and M. Anderson. 2009. Sexual violence and its health consequences for
female children in Swaziland: A cluster survey study. The Lancet 373(9679):1966-1972.
UN Women. 2011. Virtual Knowledge Centre to End Violence against Women and Girls.
http://www.endvawnow.org (accessed April 10, 2011).

Violence Prevention
Among Multiple Sectors
As the field of violence prevention has evolved over the past few de-
cades, the lack of coordination between related fields and a hesitation to
engage in multisectoral response has posed a major obstacle to the field’s
success. Traditionally, various sectors have approached violence and its
prevention from their own theoretical bases, without integration or col-
laboration, which has often resulted in duplicative work or unsustainable
planning. Many workshop speakers felt strongly that collaboration and an
integrated response are necessary for successful, long-term prevention pro-
grams. David Butler-Jones of the Public Health Agency of Canada described
Canada’s approach to public health as “the organized efforts of society to
improve health and well being and to reduce inequalities” and said that
the efforts include multiple sectors outside of health in order to offer a
comprehensive approach. He stressed the important of this perspective in
preventing missed opportunities both within and outside the health sector.
He also said this perspective is useful in identifying the various roles that
different agencies, sectors, and individuals can play.
A number of speakers observed that violence prevention, while di-
vided into silos, is often its own silo as well. Integrating violence preven-
tion interventions into broader programs aimed at improving health and
well-being would lead to greater success. Dr. Butler-Jones emphasized
the need to address violence as part of addressing health inequities: Two
things that can mean the difference between average health and excellent
health are a sense of self-determination and a sense of connectivity, and
interventions for violence prevention and for health should promote both
of these factors.
42

VIOLENCE PREVENTION AMONG MULTIPLE SECTORS 43
Mary Ellsberg cited a World Bank review that found that multisectoral
response is a key to successful intervention. “Strategies must improve co-
ordination between sector-specific approaches, civil-society initiatives, and
government institutions,” she said. “They must also take into account the
need for change at all levels of society, from national laws, policies, and in-
stitutions to community-level norms and support networks and household
and individual attitudes and behaviors.” James Lang from Partners for
Prevention listed three key components of any comprehensive strategy: an
evidence base, building the capacity of local partners, and communications
for social change.
Although the public health approach underscores the importance of
collaborating across disciplines (particularly as prevention efforts move
upstream), some speakers felt that further effort is needed to include such
sectors as education, criminal justice, and international aid. For example,
Claudia García-Moreno called for the provision of safe spaces in schools,
laws that create equitable societal structure, and public education directed
at changing norms. Kiersten Stewart said that an important objective of the
International Violence Against Women Act is to coordinate violence pre-
vention, gender equality, and international aid efforts that all seek similar
goals. Ms. Stewart also mentioned the need to include the private sector not
only as a partner in funding and programming, but also as an investor in
the public good. Mary Ellsberg spoke of the evidence basis behind success-
ful programs and said that the more successful programs have integrated
efforts, such as home visitations for teaching parental skills. Several speak-
ers commented that violence prevention and gender equality efforts need
to be coordinated because addressing gender equality alone will not affect
the prevalence of violence.
Another key element in ensuring the success of multisectoral responses
will be to build on a foundation of evidence. Claudia García-Moreno sug-
gested that prevention should move from small-scale programs to national
and multi-country interventions, but the evidence base concerning such a
translation is still weak. She also said that although awareness of the issue is
growing, allocation of resources is still lagging for both research and evalu-
ation. Dr. Ellsberg noted that political and social will are essential as well.
Ms. Widyono urged participants to remember that research in this area
drives advocacy and policy and that the interventions that work best are
ones based in evidence to show it. She also suggested that increasing the
evidence base would result in greater buy-in from implementing partners—
and that the buy-in would be even greater if the partners are included in
the research and data gathering. In such cases, as demonstrated by Partners
for Prevention, community partners are able to assist in the designing of
interventions. By developing mutually beneficial best practices, researchers,
implementers, and advocates all feel equally invested in the efforts.

Despite the will to increase coordination of efforts, however, various

barriers persist. Forum member Evelyn Tomaswieski said that identifying
relevant partners can be difficult, while forum member Arturo Cervantes
questioned whether investing in various sectors would work without a
mechanism for integration, which would includes buy-in from all partners.
Gail Wyatt said that in addition to using comprehensive approaches, in-
terventions must be built on comprehensive theories of complex traumas
and multiple types of exposures because sequelae and even interventions
can be different. Cheryl Thomas emphasized the need for agreement from
the entire group not only on the cost-effectiveness of prevention and in-
tervention, but also on the foundational theory of the violence and its risk
and protective factors. A few speakers said that mechanisms for delegat-
ing responsibility among partners are key but that they can be difficult to
implement. James Lang emphasized the lack of ideal integrated models for
social change.
Speakers also expressed frustration with the existence of silos in re-
search and in funding for research. One audience member said that there
is a need for increased data sharing and stated that some partners are not
always willing to share proprietary or confidential information. Several
speakers said that funding for a coordinated and integrated response is rare
and that researchers are often limited in these approaches by their funding
sources. Dr. Wyatt suggested that researchers should demand integrated
funding and design their interventions to facilitate collaborative funding.
Models for coordinated and sustainable programs do exist, and several
presentations provided examples. One factor in a successful program is the
integration of the intervention into pre-existing programs or activities. Judy
Langford stressed this observation in her discussion of the Strengthening
Families model, which promotes healthy behaviors in pre-existing settings,
such as daycare. Such integration makes a model more sustainable and eas-
ier to implement for those on the ground. The Fourth R program followed
a similar approach, integrating the intervention into physical education or
health classes, thereby allowing students to practice what they were learn-
ing, much as they would in other classes. Agnes Tiwari’s intervention used
obstetricians and midwives in an integral way, which increased penetration
into the community because most of the women were already using prenatal
care. International Men and Gender Equality Survey (IMAGE) took an
integrated approach by using a one-hour participatory group session into
which was integrated messaging about gender equality, violence, and HIV;
the messaging not only focused on the intersection among the three factors
but also discussed how addressing all three together leads to measurable
change. Hortensia Amaro and Roger Fallot went a step further to discuss

VIOLENCE PREVENTION AMONG MULTIPLE SECTORS 45
how integrating thinking about trauma into such existing programs would
bolster them even further, particularly by providing training to service pro-
viders on trauma sensitivity.
The trauma-informed context also requires coordination. It is, by its
nature, a model of integration as it views health care needs through the
trauma lens. Roger Fallot discussed how this approach incorporates ev-
erything known about trauma and trauma response into existing systems
of care. Such contexts facilitate healing by providing a more hospitable
environment, a major result of which is reduced re-victimization.
Brigid McCaw described Kaiser Permanente’s existing model of integra-
tion into a system of care, which makes it easy to implement system-wide
models of change and to coordinate disparate sectors into one program. In
particular, chronic care management offers a variety of lessons in this area.
Another example is the Boston Consortium Model, an integrated interven-
tion that addressed both trauma and substance abuse; when researchers
tested whether this approach was more successful than substance abuse
programs by themselves, they found that this was the case.
Partners for Prevention was able to overcome initial problems caused
by a lack of coordination by addressing internal silos. Because United Na-
tions efforts are not always coordinated, Partners for Prevention began by
bringing together sectors within that agency. In doing so, the program was
able to address external issues of lack of coordination because government
ministries were already partnered with various UN agencies that were
working together. In the same way, the InterCambios Alliance had similar
success by bringing together the organizations working on the issues and
coordinating with government agencies. Ms. Widyono stated that innova-
tive work was happening but not being shared, and InterCambios helped
develop the collaboration needed for technical capacity building. Both
speakers stressed the need for flexibility and trust in ensuring that all part-
ners’ needs are being met.
Ms. Thomas mentioned an early model in this field. “I mentioned the
Duluth Model of Coordinated Community Response,” she said. “Every-
body, I think, is just in agreement how critical it is that this multisectoral
approach occurs where people understand. A judge can’t sit up at the
bench and issue an order for protection by himself and expect this work
to keep a woman safe and hold an offender accountable. People have to
be communicating in the system. The police have to know that it exists
and how to enforce it. Shelters have to know that it exists. And if people
are communicating about that we know now that that is where laws work
when there is this coordinated community response, this holistic model, this
multisectoral approach.”

KEY MESSAGES
A holistic, integrated response requires participation from all essential
stakeholders, because the ultimate aim is not only the reduction of violence
but also the promotion of well-being. Overcoming barriers to successful
comprehensive approaches include cooperation amongst partners, a foun-
dation of evidence, and community and political will. It will also require
addressing the stovepiping of funding and research, not only between sec-
tors, but also within the health field, and violence prevention itself.

Part II
Papers and Commentary

from Workshop Speakers


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 com-
plexities 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 pub-
lication 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 presenta-
tion 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 per-
spectives 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.
49

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 ex-
posed to violence. Trauma-informed care and psychosocial empowerment
are two means by which survivors of violence can overcome potential ad-
verse outcomes and prevent the recurrence of violence.
PREVENTING INTIMATE PARTNER AND SEXUAL VIOLENCE

AGAINST WOMEN: PRIMARY PREVENTION STRATEGIES1
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 varia-
tion 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 strate-
gies for intimate partner and sexual violence is limited, with the overwhelm-
ing 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 effective-
ness. 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 mecha-
nisms to be identified and to make replication easier. Most of the evaluated
strategies aimed at preventing intimate partner and sexual violence have
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.

PAPERS ON RESEARCH 51
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 participa-
tion 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 vio-
lence 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 inti-
mate partner and sexual violence, making the evaluation of such strategies
a priority. Any comprehensive intimate partner and sexual violence preven-
tion 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 disci-
pline 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 in-
equalities 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 creat-
ing 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 commit-
ments 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 vio-
lence 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 im-
portant 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 im-
poverished areas (Fagan and Browne, 1994; Garner et al., 1995). Protec-
tive 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 cor-
roborated 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 mea-
sures 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 prevent-
ing 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 ef-
fectiveness 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 consid-
ered 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 pro-
grams 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 exclu-
sion 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 sup-
ported 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 part-
ner violence and sexual violence as follows:
• Effective: strategies that include one or more programs demon-

strated to be effective. Effective refers to being supported by mul-
tiple 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 pre-
vention of perpetration and/or experience of intimate partner and/
or sexual violence or studies showing positive changes in knowl-
edge, 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 effec-
tive, 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
Strategy Intimate Partner Violence Sexual Violence
During Infancy, Childhood,
and Early Adolescence
Interventions for children and adolescents 2 3
subjected to child maltreatment and/or
exposed to intimate partner violence
School-based training to help children 3 2
recognize and avoid potentially sexually
abusive situations
During Adolescence and Early Adulthood
School-based programs to prevent dating 1 N/A
violence
Sexual violence prevention programs for N/A 3
school and college populations

TABLE 6-1 Continued
Strategy Intimate Partner Violence Sexual Violence

Rape-awareness and knowledge programs N/A 4
for school and college populations
Education (as opposed to skills training) N/A 5
on self-defense strategies for school and
college populations
Confrontational rape prevention programs N/A 6
During Adulthood
Empowerment and participatory approaches 2 3
for addressing gender inequality:
Microfinance and gender-equality training
Empowerment and participatory approaches 2 3
for addressing gender inequality:
Communication and relationship skills
training (e.g., Stepping Stones)
Home-visitation programs with an intimate 3 3
partner violence component
All Life Stages
Reduce access to and harmful use of alcohol 2 3
Change social and cultural gender norms 3 2
through the use of social norms theory
through media awareness campaigns
through working with men and boys
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 inti-
mate 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; ineffec-
tive 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 in-
crease 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:
1. 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 inti-
mate partner or sexual violence without further research demonstrating
corresponding reductions in violent behavior.
2. Reductions in the perpetration of intimate partner or sexual violence.
3. 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, out-
come 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 methodologi-
cally 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 de-
livered. 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, ac-
quaintances, 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
STRATEGY
During Infancy, Childhood, and Early Adolescence
Home-visitation programs to prevent child maltreatment
Parent education to prevent child maltreatment
Parent education to prevent child maltreatment
Improve maternal mental health
Identify and treat conduct and emotional disorders
School-based social and emotional skills development
Bullying prevention programs
School-based multi-component violence prevention programs
During Adulthood
U.S. Air Force multi-component program to prevent suicide
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 mal-
treatment 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 pro-
grams 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 Pre-
vention of Child Abuse and Neglect, 2006) can contribute to reducing the
intergenerational transmission of violence and abuse. The most promis-
ing 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 fac-
tor 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 of-
fending. 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 mal-
treatment or exposed to parental violence are at increased risk of becom-
ing 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 in-
terventions targeted at children and adolescents who had experienced child
maltreatment (Skowron and Reinemann, 2005). Results suggested that psy-
chological 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 de-
signed 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 vio-
lence 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 pro-
vide social and emotional skills such as problem solving, anger manage-
ment, 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 chil-
dren 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 ef-
fective 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 mea-
sured 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 perpetra-
tors and victims, including social isolation and the exacerbation of antiso-
cial 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 in-
volvement 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 perpe-
tration 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).
School-Based Programs to Prevent Dating Violence

Dating violence is an early form of partner violence, occurring pri-
marily 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, includ-
ing 5 randomized trials (Foshee et al., 2008). Targeted at early sexual rela-
tionships, 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). Accord-
ingly, 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 pe-
riods. The program also significantly reduced severe physical dating abuse
perpetration over time, but only for adolescents who reported no or aver-
age prior involvement in severe physical perpetration at baseline. Program
effects on the experiencing of sexual dating violence over time were mar-
ginal. Safe Dates did not prevent or reduce the experiencing of psychologi-
cal 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 O ntario,
Canada, have also been evaluated (Wolfe et al., 2003, 2009). An out-
come evaluation of The Fourth R: Skills for Youth Relationships used a
cluster-randomized design and found that, based on self-reported perpe-
tration 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, non-
violent 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 relation-
ships 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 vio-
lence 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 pro-
grams. 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 lon-
ger 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 preven-
tion of sexual violence by strangers, acquaintances, and non-intimate dating
partners have focused on college students—though they have also increas-
ingly 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 of-
ten 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 review-
ers 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 effective-
ness 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 pro-
grams 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 re-
views, 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 confronta-
tion 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 pres-
ently 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 hitchhik-
ing, 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 ed-
ucation 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 manda-
tory 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 communi-
ties 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 ap-
proaches often utilize a combination of participatory rapid needs assess-
ment, 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 estab-
lished to increase the economic and social power of women. These initia-
tives 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 vio-
lence. 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, im-
prove 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 w omen’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 pro-
gram 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 pro-
gram, 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 ap-
proach that promotes communication and relationship skills within com-
munities. 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 preven-
tion. 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 prov-
ince 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 par-
ticipating couples over one year. It found that, compared to couples not
receiving the program, communication was improved and quarrelling re-
duced 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 vio-
lence against women, focusing in particular on the connection between
HIV/AIDS and violence against women. “Sasa” is a Kiswahili word mean-
ing “now,” and the kit includes practical resources; activities-monitoring
and assessment tools to support local activism, media, and advocacy ac-
tivities; and communication and training materials. It targets community
norms and traditional gender roles and aims to change knowledge, at-
titudes, skills, and behavior to redress the power imbalance between men
and women. It was created by Raising Voices, a Uganda-based nongovern-
mental 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 empower-
ment 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 repli-
cate 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 relation-
ships 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 preven-
tion 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 exam-
ined 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 child-
hood home visitation program—found that when compared with a control
group, the participation of mothers was associated with reduced perpetra-
tion 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, respec-
tively. 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 be-
havior 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 sug-
gesting that the following strategies aimed at reducing alcohol consumption
may be effective in preventing intimate partner violence:
• Reducing alcohol availability: In Australia, a community interven-

tion 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 ef-
fectiveness 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, treat-
ment 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 ap-
proach 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 in-
creasingly 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 drink-
ing (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 screen-
ing 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 provi-
sion 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 inef-
fective 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 alco-
hol 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 special-
ist 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 associa-
tion 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. Individu-
als 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 evalu-

ated, throughout the world to break the silence that often surrounds in-
timate 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 advo-
cacy 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 over-
estimated, 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 misper-
ceptions 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 stu-
dents, men appeared to underestimate both the importance most men and
women place on sexual consent and the willingness of most men to inter-
vene 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 materi-
als, 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 accu-
rately (Usdin et al., 2005).
As the Soul City project indicates, evidence is emerging that media cam-
paigns combined with other educational opportunities can change knowl-
edge, 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, com-

munity 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 Nica-
raguan 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 vio-
lence 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 cam-
paign 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 mas-
culinity 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 sam-
ple 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 educa-
tion 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 mascu-
linity 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 effective-
ness in actually preventing intimate partner and sexual violence. Nonethe-
less, 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 leg-
islation 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 founda-
tion for further prevention work.
• Currently, there are no strategies of demonstrated effectiveness for
preventing sexual violence outside intimate partner or dating rela-
tionships. Only one strategy has been demonstrated to be effective
in preventing intimate partner violence, namely school-based pro-
grams for adolescents to prevent violence within dating relation-
ships—and this still needs to be assessed for use in resource-poor
settings.
• Although it is too early to consider them proven, evidence is emerg-
ing of the effectiveness of several other strategies for the prevention
of intimate partner and sexual violence, particularly the use of mi-
crofinance with gender equality training and of programs that pro-
mote communication and relationship skills within communities.
• Developing the evidence base for programs for the primary preven-
tion 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 SURVEY2

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 sur-
vey 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 participat-
ing countries, and the study protocol was approved by the institu-
tional 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 them-
selves 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 ques-
tionnaire was carried out using hand-held computers, with a mix-
ture 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 question-
naire 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 re-
cent 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 ques-
tions on all the themes that make up IMAGES, the questionnaire is not
identical in all countries; thus data are not available from every coun-
try for every question. The questionnaire in Rwanda was the most ab-
breviated 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.
Topics
The questionnaire covers key topics in gender equality, including inti-
mate relationships, family dynamics, and key health and social vulnerabili-
ties for men. Based on previous research that found associations between
early childhood exposure to violence and different gendered practices re-
lated to childrearing, items on childhood antecedents to particular men’s
practices were included. Specific topics in the questionnaire include:

1. Employment. Employment experience; unemployment and under-

employment; stress and reactions associated with unemployment;
reaction by spouse/partner when unemployed; income differentials
between men and women; perceived gender dynamics in the work-
place; work–life balance; and job satisfaction.
2. Education. Educational attainment; perceived gender norms and
patterns in school.
3. Childhood experiences. Victimization by violence as children; wit-
nessing 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.
4. Relations at home (in current household). Marital/cohabitation sta-
tus; division/participation in household chores; perceived satisfac-
tion in family life; household decision making; time use in specific
domestic chores and family care, including child care.
5. Parenting and men’s relationships with their children (and with non-
related children who may live in the household). Number of chil-
dren; 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.
6. 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.
7. Health and quality of life. Lifestyle questions (substance use, exer-
cise, 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 re-
lations; mental health issues (depression, suicide ideation); social sup-
port; use of/victimization by violence in other contexts; morbidity.
8. Partner relations and spousal relations. Current relationship status/
satisfaction; use of services/help-seeking in times of violence or
relationship stress; relationship history.
9. 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.
10. 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 re-
lationship 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 attain-
ment, 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 at-
titudes 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 sta-
tistically 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 infer-
ences 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 depres-
sion, 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 mea-
sure 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 equita-
ble attitudes; unmarried men had the least equitable attitudes. H
omophobic
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 satis-
fied 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 encour-
ages 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 chil-
dren 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 hav-
ing 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 ide-
ation. 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 rang-
ing 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 ma-
jority 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.
Conclusion
Overall, IMAGES results affirm that gender equality should be pro-
moted 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
Overview
This summary describes what we know and, perhaps more impor-
tantly, 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 intergen-
erational 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 research-
ers, 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.

Child
direct and
Adult IPV indirect
exposure
Bullying /
Dating
Peer
violence
aggression
FIGURE 6-1 Cycles of violence.

SOURCE: Crooks, 2011.
It is crucial to understand Figure 2-1cycle

that the and of
6-1violence 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 approxi-
mately one-third became seriously inept, abusive, or neglectful as parents
of their own children; an additional one-third remained at risk for perpe-
trating 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) Study4 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 docu-
mented the additive detrimental effects of experiences such as exposure
to woman abuse, a parent with substance abuse or mental health prob-
lems, and incarceration of a parent. Low socioeconomic status can fur-
ther compound difficulties for children who are experiencing child abuse.
Conversely, access to protective factors (including at least one stable, non-
violent 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 ex-
periences 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 ex-
posure to violence is not something that a person can just “get over.” Three
particularly useful frameworks and theories for explaining the intergenera-
tional cycle of violence are attachment, social learning theory, and trauma.
The Role of Attachment

Attachment refers to the quality of the relationship that develops be-
tween 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 unpredict-
able 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 relation-
ships as dangerous and unpredictable.
Although attachment is most often discussed in the context of p arent–
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 expo-
sure 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.
Trauma
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 ex-
treme 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 neu-
robiological 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 alter-
native 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 dif-
ferent points.
Prevention Before
Occurrence
Prevention of Prevention of
Recurrence Impairment
Physical Abuse
Sexual Abuse
Emotional Abuse Long -Term
Neglect Consequences
Exposure to IPV
Universal Targeted
FIGURE 6-2 Intervention to prevent child maltreatment and associated impairment.

SOURCE: Macmillan et al., 2009.
Figure 6-2 revised

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 con-
trast, the review by MacMillan and colleagues looks at high-quality pro-
grams 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 indica-
tors 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’ pioneer-
ing 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 dif-
ferent families and offers five levels of intervention with increasing intensity

to match higher-needs families (Prinz et al., 2009). Mark Chaffin and col-
leagues’ work on Parent–Child Interaction Training has also been very prom-
ising 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 feed-
back 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 ba-
bies’ 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). Ad-
ditional 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 do-
mestic 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 tech-
niques) 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 re-
searched, 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 at-
titudes 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 part-
ners and children concurrently. The Fathering After Violence initiative5 for
men who have been abusive to intimate partners and the Caring Dads pro-
gram6 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 restor-
ative 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 collabora-
tion 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, particu-
larly for abuse perpetrated by the victim parent. There are philosophical
and practical reasons for these practices, but they hinder a fuller under-
standing 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 dif-
ferent 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 su-
perficial 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 promis-
ing 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 ad-
dressed 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. Dif-
ferent 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 em-
powering, trauma-specific interventions take as their primary goals ame-
liorating 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 B oston 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 vio-
lence 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 pro-
cessing 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 program-
matic, organizational, and community contexts that are necessary and valu-
able 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 in-
stitutions, 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 indi-
vidual 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 com-
mon 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 so-
cially 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 ex-

periences 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 involv-

ing 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). Con-
sumers 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 de-
veloped 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 de-
livery 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 col-
laborative 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 con-
sumers 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 em-
phases 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, implic-
itly 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 plan-
ning 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 ad-
ministrators’ thinking as well.
In putting these ideas into practice, we address six domains of organi-
zational 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:

1. Informal service procedures and settings
2. Formal service policies
3. Trauma screening, assessment, service planning, and trauma-specific
services
Systems-level changes in a culture of trauma-informed care:
1. Administrative support for developing and sustaining this culture
2. Staff training and education
3. Human resources practices
As an example, let us examine our approach to informal service pro-

cedures and settings. Here we ask agency workgroups representing all
constituencies (upper-level administrators, supervisors and middle manage-
ment, 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 con-
sumers by going through the same procedures as a new consumer would in
entering the agency. Once each physical setting, activity, contact, and rela-
tionship 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? Main-
tain 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 resi-
dential 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 cre-
ate 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 administra-
tors), 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 col-
laboration 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 col-
laborative 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 Admin-
istration’s Women, Co-Occurring Disorders, and Violence Study for related
discussions and findings.7) To the extent that secondary and tertiary pre-
vention 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 treat-
ments 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-Disorders-
and-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 care-
fully 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 sur-
vivor 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., hyper-
arousal, hypervigilance).
Recent research provides a basis for a paradigm shift from a pathol-
ogy/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, eat-
ing disorders, personality disorders, guilt, shame, complicated bereavement),
in fact what they demonstrate is the extreme degree of biological, psycho-
logical, 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 chil-
dren and adults who have experienced violence and related forms of com-
plex 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:
1. 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 phenomeno-
logical 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 iden-
tified and reinforced.
2. 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 experi-
ence 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 ac-
tive, 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 attach-
ment 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 encour-
age collaboration with and empowerment of the client; however, the
responsibilities and inherent power differences in the treatment rela-
tionship are explicitly acknowledged. The therapist seeks to use power
effectively on the individual’s behalf while simultaneously encourag-
ing the client’s development and autonomy. Importantly, the therapist
conveys an openness to the client’s questioning of authority (includ-
ing 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 survi-

vors of childhood sexual abuse found that cognitive behavior therapy was
superior to other modalities for anxiety, depression, and other internal-
izing 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 ex-
tensive 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 regu-
lation, 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 regula-
tion 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 shut-
down 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 affirm-
ing 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 stud-

ies 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 realis-
tic 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 bal-
ance 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 regula-
tors 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.
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Papers on Global
Partnerships and
Government Initiatives
Preventing violence against women and children requires a comprehen-

sive approach across all levels of society. Legal and regulatory structures
that support gender equality, family empowerment, and skills building con-
tribute to the reduction of violence at the international and national levels.
Around the world, an increasingly large number of countries have imple-
mented such laws and policies, as well as ones that address violence against
women and children specifically. In the international and regional realms
stakeholders have coordinated efforts to present systematic changes, share
evidence of effective activities, and provide support for the development
of policies and social norms to reduce violence. Speakers at the workshop
presented several case studies to this effect, from continental and regional
partnerships to initiatives at the national government level.
The first paper describes an example of a regional partnership in Latin
America called InterCambios, which was created in an attempt to harness
the collective power and success of several local groups and organizations.
The partnership also serves to provide technical collaboration and critical
analysis of both research and interventions in the region.
The second paper demonstrates the effectiveness of partnerships created
between human rights experts and local organizations working toward pol-
icy change. It describes several successful attempts by Advocates for H
uman
Rights, a nongovernmental organization (NGO) based in M innesota, to
partner with groups in Central Asia and Eastern Europe, areas that have
typically had poor records of women’s rights empowerment.
The final paper describes successful government initiatives to address
violence in New Zealand, including various laws and regulations as well
117

as coordination efforts at the national level. It pays particular attention to

efforts at addressing the needs of minority populations (in this case, the
Ma-ori populations) who are at greater risk for violence but often have
lower access to resources or recourse.
THE INTERCAMBIOS ALLIANCE

Margarita Quintanilla, M.D., M.P.H.
PATH Nicaragua
The InterCambios Alliance was created in 2003 with the aim of ad-
dressing existing gaps and facilitating greater collaboration and institu-
tional coordination in the area of gender-based violence (GBV) in Latin
America and the Caribbean.
Background
Despite compelling evidence that GBV is a serious health risk for
women and a public health issue, research indicates that, although bat-
tered women use health services more than non-abused women, only a
very small percentage of battered women are identified by health workers.
Moreover, there is a lack of local services to which providers can refer
women (Morrison et al., 2004). At a community level, there is often poor
coordination between health providers and other important actors, such as
community-based women’s groups, criminal justice authorities, and local
NGOs. Although there is increasing international recognition of the serious
impact of GBV, investment in the field is still woefully inadequate. There is
also a dearth of rigorous evaluations of promising interventions to inform
policy and programs. Recent reviews of programs working in this field note
the need for greater coherence among evidence, policy, and programs as
well as for coordinated, community-based approaches to address violence
from a public health perspective.
Worldwide evidence on the nature, prevalence, and consequences of
gender-based violence is clear and convincing—but this is not enough.
Although international attention has galvanized significant advocacy and
action (usually by women’s groups), such efforts have focused primarily on
the areas of law and services and have not been sufficient to end violence
perpetrated against women globally. Areas that need to be prioritized
include developing local research capacity, particularly in resource-poor
regions; improving monitoring and evaluation of GBV interventions to
strengthen understanding of what works and what does not, especially
in the area of prevention; supporting capacity building for entities en-
gaged in addressing violence against women, including community-based

PAPERS ON GLOBAL PARTNERSHIPS AND GOVERNMENT INITIATIVES 119
organizations, service providers, advocates, and policy makers; facilitating

collaboration and coordination of efforts across sectors and regions; and
scaling up promising local interventions.
The InterCambios Alliance

The alliance emerged from an expert meeting that PATH convened
to identify gaps and challenges in addressing GBV in the region, particu-
larly within the health sector, and to propose future collaborations to
strengthen the field. The more than 25 experts and partner organizations
at the meeting concluded that although Latin America was leading the
way in terms of innovative policies and programs to prevent GBV, too
much time and resources were spent “reinventing the wheel.” This was
largely due to the lack of opportunities to share experiences and lessons
learned and a lack of critical analysis of programs to determine which
approaches were most effective. Although several strong women’s net-
works represented women’s political interests on a regional level, partici-
pants felt there was a need for more technical collaboration and capacity
building among groups. This assessment gave rise to the creation of the
Inter-American Alliance for Health and the Prevention of Gender-Based
Violence, known as InterCambios.
The alliance’s goal is to help improve the capacities of the health sec-
tor in Latin America and the Caribbean to respond to violence against
women from an integrated public health, human rights, and gender-equality
perspective. Our strategy is based on the recognition of pioneering work
already being carried out in the region by a diverse range of individuals,
grassroots organizations, governments, NGOs, and international agencies.
InterCambios brings these groups together to share knowledge and experi-
ence, to identify lessons learned, and to develop and disseminate new ap-
proaches in four key areas of action: research, information systems, and
evaluation; public policy advocacy; strengthening care and training models;
and communication for social change.
Working with a particular focus on Honduras, Nicaragua, El Salvador,
and Guatemala, where rates of violence are known to be high, the alliance
has provided technical assistance, training, tools, and information to policy
makers, grassroots activists, and health professionals. The alliance includes
several respected regional organizations known for their work in research,
communications, service delivery, advocacy, and engaging men and youth
in addressing violence against women, especially as a health concern. In-
terCambios also works closely with strategic partners including the Pan
American Health Organization, the World Health Organization, the United
Nations Development Fund for Women (UNIFEM), and the Latin American
and Caribbean Women’s Health Network.

InterCambios’ Prevention Actions
Communication for Social Change

One of the lessons learned in the alliance’s work has been the need for
materials and methodologies that strengthen the work of those working on
gender-based violence in Latin America and the Caribbean. From the start,
InterCambios decided that the priority would not produce new materials
but rather would identify materials that had received rigorous reviews and
good feedback evaluation and then disseminate them widely in the differ-
ent sectors.
In this sense InterCambios has aimed to promote and strengthen com-
munication efforts that help to change paradigms, understanding violence
as a systemic problem and employing an ecological approach. This is based
on the identification and broad dissemination of validated educational ma-
terials, including videos, fact sheets, and brochures, on the issue of GBV
in order for them to be incorporated into the work of institutions and
organizations.
InterCambios’s website, www.alianzaintercambios.org, has become a
reference point for updated information on violence against women (VAW)
for more than 1,500 contacts. From November 2006 to September 2010
it recorded a total of 177,382 visits, with the most visited sections be-
ing Events, Documents, News, and the newsletter. The most requested
documents were Improving the Health Sector Response to Gender-based
Violence: A Resource Manual for Health Care Professionals in Developing
Countries, a guide for addressing partner violence with health personnel
and the community, and documents concerning participatory research on
teaching and learning processes. The following are some examples of the
materials that have been promoted:
• For an End to Sexual Exploitation: a manual developed by Pro-

mundo/InterCambios Alliance that aims to provide educators with
a set of educational activities to stimulate critical reflection on these
issues among groups of male adolescents between the ages of 10
and 14.
• In Her Shoes: an awareness-raising and training methodology de-
veloped by PATH InterCambios Alliance and adapted to the Latin
American context. Monitoring and evaluation results show that the
methodology allows analysis of VAW through personnel reflection,
analysis of myths and prejudices related to VAW, identification
of the role of institutions and support networks in facilitating or
limiting women’s decision making, and highlighting the link be-
tween GBV and other aspects of general and reproductive health

(e.g., sexually transmitted infections, HIV/AIDS, and unwanted

pregnancy). A total of 1,450 sets of In Her Shoes have been dis-
seminated, and 1,200 training workshops have been held in 12
countries on two continents. The document also has been adapted
to the African context.
• MenEngage: a supporting initiative on masculinities in the region
developed by Promundo/Puntos de Encuentro.
Promoting the Use of Evidence

In coordination with several stake-holders, Intercambios has helped
improve approaches to VAW through conducting research and using evi-
dence, facilitating access to both research findings and evaluation processes,
and disseminating data and lessons learned in research methodology. A
key element has been a course, based on the practical guide to research-
ing violence against women, whose evaluation stresses “the putting into
practice of the knowledge acquired to be used in everyday work, extend
research beyond academic arenas, and strengthen organizations to use
research tools to evaluate and monitor their work” (Ellsberg and Heise,
2005). Good examples of PATH’s work to strengthen the use of evidence
include strengthening the demographic and health surveys in Guatemala
and Nicaragua through coordination with the U.S. Centers for Disease
Control and Prevention, statistics institutions, and local women’s networks;
and strengthening understanding of femicide and promoting evidence-based
plans of action (Widyono, 2009; COMMCA, 2010).
Lessons Learned
Through its prevention work, InterCambios has learned several lessons,
which are:
• Because they already have communication and distribution chan-

nels, coordination with local networks and interagency commis-
sions is the best path for successful distribution of materials and
methodologies;
• Organizations and institutions have little time to dedicate to stay-
ing up to date on relevant research, so it is important to enable
them to access information and evidence through “friendly” ver-
sions, e.g., the InterCambios’ Violence and HIV CD; and
• Electronic mechanisms, such as newsletters, social networks, and
webpages, are a good alternative for maintaining a consistent pres-
ence in the community.

Strengthening Training Capacities and the

Quality of Care for Survivors of Violence
InterCambios works to strengthen the capacities and increase the qual-
ity of care available to survivors of violence. For example, it is working
with the Metropolitan Health Region of Honduras to employ a participa-
tory process to develop a model for the care and treatment of adults who
experience domestic violence. Additionally, InterCambios has developed
a toolbox to strengthen capacity-building processes related to violence
against women. The toolbox gathers different reflections and methodolo-
gies that together generate synergy and strengthen capacity-building pro-
cesses related to violence against women (training and awareness building).
It provides suggestions and practical guidance to facilitators so that each
training or awareness-building arena can provide an opportunity for reflec-
tion that helps change the attitudes and behaviors of people in contact with
women experiencing—or that have experienced—violence in their lives.
The toolbox contains the following materials: Health Sector Response
to Gender-based Violence: Resource Manual for Health Professionals in
Developing Countries (IPPF-RHO); a fact sheet on lessons learned in the
training of health personnel; the In Her Shoes methodology; the María
Luisa booklet; and interactive CDs on violence and HIV and on violence
and maternal mortality.
Challenges and Lessons Learned from Working Regionally

The following challenges and related lessons learned have emerged
since InterCambios began working regionally in Latin America and the
Caribbean.
• Compared to local initiatives, regional work is slower, which hin-

ders the organizations’ more active participation in the processes.
• The identification of strategic allies (e.g., United Nations agen-
cies or regional institutions) is vital to increasing the scope of the
actions.
• Frequent changes in NGO personnel are common, which makes it
necessary for the capacity-building processes to be ongoing.
• It is a challenge to coordinate with civil society networks and
governments individually as well as with the two sectors together,
and there are often suspicions when working with these actors;
strengthening the “technical” issues is a mechanism for mitigating
this obstacle.
• Sexual violence and its different expression on children and women
is still a pending topic.

• A changing context where new variables are appearing—migration,

organized crime, and drugs, among others—makes it necessary to
think about new strategies and approaches where regional work
plays a key role.
GLOBAL PARTNERSHIPS ON DOMESTIC

VIOLENCE LEGAL REFORM
Cheryl A. Thomas, J.D.
The Advocates for Human Rights
Introduction and Background

Since 1993 the Advocates for Human Rights’ Women’s Program has
been working with partners internationally to address domestic violence
through an improved government response, particularly, better laws and
more effective implementation of those laws. Many of these partnerships
have become long-term collaborative efforts that respond to evolving needs
and developments in a given country. We believe these partnerships have
contributed to a better legal system response to domestic violence and to a
new prioritization of victim safety and offender accountability.
Of all the forms of violence against women, domestic violence1 is one
of the most insidious and widespread throughout the world. The Council of
Europe reports that domestic violence is the major cause of death and dis-
ability for women aged 16 to 44 and accounts for more death and ill health
than cancer or traffic accidents (European Parliament Association, 2002).
Nearly one in four women in the United States reports having experienced
violence by a current or former spouse or boyfriend at some point in her life
(CDC, 2008). On average, more than three women a day are murdered by
their husbands or boyfriends in the United States (Catalano). A United Na-
tions agency for women estimates that globally at least one of every three
women will be beaten, raped, or otherwise abused during her lifetime. In
most cases the abuser is a member of her own family (Family Violence Pre-
vention Fund, 2011). A 2005 World Health Organization study found that
1 For the purposes of this paper, the following definition of domestic violence provided by
the United Nations is used: “Domestic violence is the use of force or threats of force by a
husband or boyfriend for the purpose of coercing and intimidating a woman into submission.
This violence can take the form of pushing, hitting, choking, slapping, kicking, burning, or
stabbing.” U.N. Centre for Social Development and Humanitarian Affairs. 2003. Strategies
for confronting domestic violence: A resource manual. Available at http://www.unodc.org/
pdf/youthnet/tools_strategy_english_domestic_violence.pdf (accessed April 30, 2011). This
definition reflects data indicating that women are the primary victims of domestic violence.

the percentage of women who had experienced physical or sexual intimate

partner violence in their lifetimes ranged from 15 percent in Japan to 71
percent in Ethiopia (Family Violence Prevention Fund, 2011).
Despite these alarming statistics, the United Nations reported in 2006
that 102 countries were not known to have any specific legal provisions on
domestic violence (UN, 2006).
The mission of the Advocates for Human Rights (AHR) is to implement
international human rights standards to promote civil society and reinforce
the rule of law.2 The work of AHR’s Women’s Program focuses on domestic
violence as a violation of fundamental human rights. One of the most im-
portant components of efforts to address domestic violence is policy and law
reform that promotes victim safety and offender accountability—which are
principles articulated in numerous human rights instruments. This reform
must be accompanied by reforms in all other sectors of government and civil
society, including the health sector, social services, education, and the eco-
nomic sector. This view is shared by our international partners and provides
the basis for our collaborative efforts.
Partnerships to Document the Government

Response to Domestic Violence
Global partnerships can strengthen efforts to address domestic violence.
By bringing their own unique knowledge and experience to a collaborative
effort, NGOs can empower each other, enrich the advocacy work, and
move more efficiently toward the full realization of women’s fundamental
human right to be free from violence. Partnerships allow organizations
to reach across local and international borders to share expertise, lessons
learned, and strategies.
One contribution that AHR has brought to its partnerships has been
the long-standing experience of Minnesota and the United States in ad-
dressing domestic violence.3 To illustrate, many of AHR’s partnerships have
developed in countries in Central and Eastern Europe and in the former So-
viet Union (CEE/FSU). In the early 1990s, when AHR first began working
in the region, there was little experience in addressing domestic violence.
There was minimal documentation of domestic violence in the legal system
2 AHR was founded in 1983 by a group of Minnesota lawyers who recognized the
community’s unique spirit of social justice as an opportunity to promote and protect human
rights at home and worldwide. The organization involves volunteers in research, education,
and advocacy, building broad constituencies for human rights in the United States and select
global communities. AHR holds special consultative status with the United Nations.
3 The movement to address domestic violence began more than 30 years ago in the United
States, and other countries have comparable legacies. Minnesota’s efforts began in the early
1970s.

or research on the issue of any kind. There were also few, if any, services for
victims, such as shelters, hotlines, or legal services. There were no particu-
lar laws on domestic violence, so victims were trying to access the justice
system through criminal assault laws, divorce laws, and other laws not
specific to domestic violence. Many legal system authorities were reluctant
to use these laws in domestic violence cases, explaining that it was not their
role to be involved in “family matters.” There was no training for medical
professionals, legal professionals, or civil society on effective responses to
domestic violence. Frequently, legal professionals, advocates, and others
would repeat myths or misinformation about domestic violence. A com-
mon belief, for example, was that the violence was caused by alcoholism.4
Another frequently stated view was that couples counseling could resolve
violent behavior.5 These mistaken beliefs could result in ineffective policy
making on domestic violence.
Many of our reforms in the United States were initiated in the 1970s,
and by the early 1990s a great deal of knowledge and expertise on domes-
tic violence had developed. One of the first battered women’s shelters in
the nation opened in St. Paul, Minnesota, in 1972. In this period several
states passed laws specifically addressing domestic violence and offering a
new order-for-protection remedy.6 Minnesota passed its Domestic Abuse
Act in 1979, which provided this remedy and included other reforms to
Minnesota’s laws. Beginning in the 1970s, criminal law reform resulted in
new policies and procedures for police and prosecutors aimed at ensuring
that domestic violence cases were treated more seriously than had been
done in the past. In the same decade advocates and government officials
in Duluth, Minnesota, created the Coordinated Community Response to
domestic violence, often referred to as “the Duluth Model,” which was a
groundbreaking strategy to improve the community’s response to domestic
4 Although alcoholism can exacerbate violent behavior, studies show that it is not the cause
of domestic violence. Cf. http://stopvaw.org/Other_Causes_and_Complicating_Factors.html.

5 Research has in fact shown that counseling or mediation can be dangerous for domestic
violence victims. Furthermore, counseling and mediation is often not an appropriate response
to domestic violence cases because it presupposes that both the victim and perpetrator are
equal when, in fact, we know that the offender exercises power and control over the victim.
For further discussion of these issues, see http://stopvaw.org/Domestic_Violence_Explore_
the_Issue.html.
6 Laws containing the civil order-for-protection remedy were first introduced in the United
States in the mid 1970s. The goal of these laws was to provide an immediate remedy to women
and their children that would keep them safe while allowing them to stay in their home. As is
the case today, many victims did not want to involve the criminal justice system and see their
partners go to jail; rather, their priority was stopping the violence. These laws allow a victim
to petition the court for an order directing the violent offender to leave the home. Cf. http://
stopvaw.org/Orders_for_Protection.html.

violence.7 These early reforms led to years of increasing experience by

advocates and justice system officials in implementing laws on domestic
violence. They also led to research and statistics on the nature and extent of
domestic violence, its causes and consequences, and the strength and weak-
nesses of the new laws.8 AHR has been able to share these resources with
international partners through workshops, training sessions, consultations,
and on-line technical assistance.
Another contribution AHR has been able to offer to its partners is the
ability to raise the profile of local issues. As an international human rights
organization with credentials in the United Nations, AHR’s reports and
recommendations can often reach a broader audience than the partners
would be able to do alone.
Finally, international partners have been able to use AHR’s exper-
tise in documenting domestic violence as a human rights violation and
advocating for change. Particularly in the early years of collaboration,
when women’s advocacy groups were new in CEE/FSU, AHR shared the
resources and skills needed to document domestic violence as a human
rights abuse and assisted in using that documentation to achieve changes
in laws, policies, and practices.
In a successful global partnership, the leadership of local partners is
essential to any domestic violence reform effort. The years of experience
and the profile of international human rights groups would contribute
little to real progress internationally without the vision and the hands-on
work of local partners. In the context of legal reform, the knowledge and
guidance of local partners is critical to a comprehensive understanding of
the language of relevant current laws and the workings of the legal system.
Many of AHR’s local partners are lawyers with whom AHR has worked
closely to parse through laws and legal procedures to identify weaknesses
and areas for possible improvement.
Local advocates largely define and prioritize the needs and the appropri-
ate advocacy strategy for their communities. They consider strategies that
have been used in other communities and countries, but it is their firsthand
information that provides critical guidance on any advocacy plan. That in-
formation includes the dynamics of the local legal system and other sectors,
local and national social and political situations, inherent risks to victims
with a given strategy, and other factors. Also, when the time comes for
lobbying for changes to laws and policies, it is the local advocates who do
7 The Duluth Model of Coordinated Community Response is now being replicated around
the world. See http://stopvaw.org/Coordinated_Community_Response.html.

8 Minnesota’s Domestic Abuse Act has been amended every year since it passed in 1979—
reflecting the developing knowledge about what legal system responses work to promote
victim safety and offender accountability and what responses do not work.

the daily work of garnering support for the reform. As is illustrated in the
examples below, all of AHR’s early reports on domestic violence were cre-
ated in response to an invitation of a local advocate who identified the need.
AHR’s Early Partnerships to Draft Reports on Domestic Violence

Beginning in 1993, before many of the international efforts to reform
laws on domestic violence began, AHR worked with partners to document
domestic violence as a human rights violation. Over the years AHR has
published 13 reports that include recommendations for changes to the gov-
ernments’ responses to this violence, including the legal system response.9
Many of the partnerships forged through writing these reports are ongoing
today and are focused on implementing their recommendations.
AHR’s work in CEE/FSU began in 1994 at the invitation of the Ro-
manian women’s group, the Society for Feminist Analysis (ANA), when
volunteer attorneys traveled to the region to conduct research for a report
on domestic violence. ANA’s goal was to expose domestic violence as a
widespread and devastating problem in Romania that the government was
ignoring. They believed that partnership with an international human rights
organization would garner the problem more attention among officials both
inside and outside their country, which could lead to greater improvements,
and they appreciated the longstanding Minnesota experience of addressing
domestic violence.10
The resulting report, Lifting the Last Curtain: Domestic Violence in
Romania, was published in 1995 (Minnesota Advocates for Human Rights,
1995). It offered an analysis of the government response to domestic vio-
lence, tracked what happened to a victim of violence when she sought
redress from the legal system, identified gaps and weaknesses in the sys-
tem response, and offered recommendations. Since that time Romania has
9 These reports are published at http://www.theadvocatesforhumanrights.org/Issues_
Affecting_Women880.html. They analyze information gathered through review of laws

and policies, research, and, most importantly, interviews with government officials, judges,
prosecutors, police, lawyers, advocates, medical professionals, and others about domestic
violence. In addition to the domestic violence reports, AHR has published six other reports on
other forms of violence against women: sex trafficking, employment discrimination, and sexual
assault. Most of these reports focus on other countries; however, in 2008, AHR published
the report, Sex Trafficking Needs Assessment for the State of Minnesota and worked with
advocates to lobby and pass improvements to the Minnesota criminal code on sex trafficking.
In 2004 AHR published the report, The Government Response to Domestic Violence against
Refugee and Immigrant Women in the Minneapolis/St. Paul Metropolitan Area: A Human
Rights Report and worked with advocates and government officials to make changes that
promoted victim safety and offender accountability.
10 Since 1985 the Advocates for Human Rights has documented human rights abuses around
the world and advocated for change. See www.theadvocatesforhumanrights.org.

passed a new law on domestic violence, training sessions have taken place,
and new services have been established.11
Through their partnership, ANA and AHR forged new territory in the
world of human rights advocacy. Women’s rights, including the right to
be free from violence, were not commonly viewed as human rights at that
time, and violence against women was largely not addressed as a human
rights issue.12 International dialogue on this issue was vibrant in the early
1990s as activists pushed for a new recognition of women’s rights as human
rights and were inspired by the approaching United Nations Fourth World
Conference on Women in Beijing. This aspect of the partnership between
AHR and ANA proved to be particularly powerful with an impact beyond
Romanian borders. The report highlighted domestic violence as exception-
ally insidious and widespread with devastating consequences for women,
children, families, and communities. The report clearly named domestic
violence as a violation of human rights and called on the Romanian gov-
ernment to fulfill its obligation to prevent this violence, protect victims,
and punish perpetrators. The report contributed to the growing recogni-
tion worldwide that women have a right to be free from violence in their
homes and, through commitments to international human rights treaties
and standards, governments have an obligation to prevent and punish this
violence. Advocates throughout the region, who were accustomed to hav-
ing their concerns dismissed by government officials, were empowered by
this growing recognition of domestic violence as a human rights violation.
Following the publication of Lifting the Last Curtain, advocates from
Bulgaria and Albania who had similar goals to those of the Romanians re-
quested partnerships with AHR. The resulting reports, Domestic Violence
in Bulgaria and Domestic Violence in Albania, identified weaknesses in the
laws and legal process that were jeopardizing women’s safety, preventing
domestic violence victims’ access to meaningful remedies, and undermining
offender accountability (Minnesota Advocates for Human Rights, 1996a,
1996b). Both of these reports were eventually followed by new domestic
violence laws in each country.
Soon after the publication of these two reports, AHR partnered with
Albanian and Bulgarian advocates to organize two groundbreaking confer-
ences. The goal of the first conference, organized in 1996 in collaboration
11 Romanian domestic violence advocates do remain deeply concerned about gaps and
weaknesses in the government’s response to the problem, and they continue their advocacy
efforts.
12 For a further discussion of this issue, see Charlesworth, H., C. Chinkin, and S. Wright,
1991. Feminist approaches to international law. American Journal of International Law,

85:613-635; Thomas, D., and M. Beasley. 1993. Domestic violence as a human rights issue.
Human Rights Quarterly 15:36-62; and Thomas, C. 1999. Domestic violence. Women and
International Human Rights Law 1:242.

with the women’s groups Reflexione and the Women’s Center of Albania,
was to build the capacity of new NGOs to respond to domestic violence
with shelters, hotlines, other advocacy services, and to address the problem
through public education. One of the presenters at this conference was
Sharon Rice Vaughan, who founded one of the first battered women’s shel-
ters in the United States in 1972 in St. Paul, Minnesota. This conference
included 50 participants from seven countries.
The Inter-Balkan Conference on Legal Strategies to Combat Domestic
Violence was organized with AHR’s partners from Albania and Bulgaria in
1997. This was the first conference of its kind in the region and included
participants from 12 countries. The four-day conference brought together
advocates from the Balkan region to discuss the legal systems’ responses
to domestic violence and to develop strategies for change. Advocates from
the United States presented information about long-standing legal reform
efforts in the civil and criminal systems that participants could consider
as possible new reform strategies in their own countries. A focus of these
presentations was the order-for-protection remedy, which was new to the
region and which has now become a central feature of many of the new
domestic violence laws in CEE/FSU.
After publishing the reports in Romania, Bulgaria, and Albania and
convening conferences in the region, AHR continued its partnerships with
advocates through reports, workshops, and training sessions. AHR devel-
oped a particularly long-standing partnership with the Bulgarian advocates,
which is described below.
Recent Partnerships in Drafting and

Implementing Domestic Violence Laws
Today, although though there is increasing acknowledgement inter-
nationally that domestic violence is a pervasive human rights violation
with devastating consequences, there is still an urgent need for technical
assistance in drafting and implementing new domestic violence laws and
amendments to existing laws. AHR’s more recent partnerships with local
advocates are based on this need.
Although there is a great interest internationally in creating new do-
mestic violence laws,13 advocates and government officials involved in this
process often do not have the information required to do so effectively.
They have little information about how the dynamics of domestic violence
complicate the legal system’s response to this violence, about research on
13 Although in the early 1990s there were few, if any, specific laws on domestic violence in
the 29 countries of CEE/FSU, today most of these countries have either passed a specific law
on domestic violence or are working on such laws.

strategies used throughout the world’s legal systems, or about best practices
in the legal system response to domestic violence.14 They often do not have
access to training materials or the language of longstanding laws from other
jurisdictions. This information is critical to being able to draft and imple-
ment effective laws.
One way that AHR has contributed in this area is by consulting on
the specific language of laws with the advocates and government officials
who are drafting them. At the request of international partners, AHR has
provided written commentary to draft laws from Armenia, Azerbaijan,
Bhutan, Bulgaria, Georgia, Kazakhstan, Lithuania, Montenegro, Morocco,
and Tajikistan.15 These commentaries offer specific suggestions for ways
to improve the laws to better promote victim safety and offender account-
ability. In support of these recommendations, AHR provides partners with
model policies and practices that directly address the focus of the law under
consideration.
In one example of how these commentaries have been used, draft laws
from three countries in CEE/FSU initially provided police with authority
to give one or more warnings to perpetrators before there were any conse-
quences for violent behavior. After analyzing the draft laws, AHR provided
commentary that pointed out the danger such laws present to victims and
how these warnings would undermine offender accountability—in effect,
allowing the offender one or more “free” assaults. Advocates are work-
ing to omit the warnings provisions from these laws. In another example,
the draft laws in at least two countries referred to “victim behavior” or
behavior that “provokes, results in, or creates conditions for violence.”
This language implies that the domestic violence victims may be blamed
for the violence, dissuades them from seeking protection, and undermines
offender accountability for the violence. The language referring to provoca-
tion—and, in the case of one country—the authority to cite victims for this
behavior—has been removed from these two laws.
AHR’s partners greatly appreciate and depend upon this expert com-
mentary. In January 2011, a member of the Lithuanian Human Rights
Committee wrote, “I would like to express my gratitude to your precious
and prompt work on commenting the draft law. This is a very important
legal act for us in Lithuania, done for the first time. Therefore, your com-
ments help us identity the gaps in our first draft and make improvements.”
14 There is now a significant body of research on the dynamics of domestic violence. This
research addresses batterers’ use of power and control over their victims and victims’ responses
to these tactics, including the tendency to recant their allegations against batterers when cases
go to court. For more information about the dynamics of domestic violence, see Domestic
Violence, Explore the Issue at http://stopvaw.org/Domestic_Violence_Explore_the_Issue.html.
15 Two examples of recent commentary that AHR has provided to draft laws can be found
at http://bit.ly/fJKW8b (for Kazakhstan) and http://bit.ly/fUxHWB (for Armenia).

Other ways that AHR has worked with local partners to contribute
to the drafting of laws are through roundtables, workshops, and on-line
technical assistance. Two on-line resources in particular have contributed
to the capacity of AHR’s partners to work with government officials to
develop new laws. In 2003 AHR launched the Stop Violence Against
Women (StopVAW) website, www.stopvaw.org, a forum for information,
advocacy, and change. StopVAW, which is focused on CEE/FSU, provides
current research, news about promising practices, model laws, and train-
ing modules.16 In response to the urgent need for technical assistance
on legal reform on domestic violence, AHR is working currently with
UNIFEM (recently re-named UN Women) to develop the legislation section
of the newly launched Virtual Knowledge Center to End Violence Against
Women (http://www.endvawnow.org/?legislation). This section provides
expert guidance on drafting, advocating for, implementing, and monitoring
national legislation in diverse regions around the world.17
Likewise, as partners have begun to apply new laws, they have appreciated
AHR’s training modules and model policies for police, prosecutors, and judges,
which are provided both on-line and through in-country training sessions.
AHR has worked with Minnesota police, prosecutors, and judges to develop
training programs for their counterparts internationally and to travel together
to countries to share expertise. Finally, a new focus of AHR’s partnerships
is the monitoring of the implementation of new laws to determine if they
truly are effective in promoting victim safety and offender accountability.
A central component of recent partnerships with Bulgaria, Armenia,
and Georgia has been drafting and monitoring the implementation of the
new laws. The following sections offer descriptions of AHR’s collaborative
work in these countries.
Bulgaria
Based on the findings and recommendations of the report Domestic
Violence in Bulgaria, published in 1996 and described above, Bulgarian
advocates undertook a campaign for a new domestic violence law. They
16 StopVAW has become a resource for individuals and community groups and government.
In one month of 2009, 2,308 pages of StopVAW received 25,136 unique page-views. These
visits came from 167 different countries, and 82 percent of these were new visits. Most site
visitors visited two or three pages on the StopVAW website. For several years, AHR has
worked with local advocates in the region to present their own country’s response to violence
against women in the Country Pages section of the website.
17 For another resource on drafting effective domestic violence laws and legislation, see
Good Practices in Legislation on Violence Against Women, United Nations Division for the
Advancement of Women, United Nations Office on Drugs and Crime, Report of the Expert
Group Meeting (November 2008). Available at http://bit.ly/gRqlLA.

felt that change could happen more swiftly in the civil system rather than
in the criminal system, so their goal was to provide a new civil order-for-
protection remedy for domestic violence victims. Bulgarian advocates, led
by the Bulgarian Gender Research Foundation (BGRF), engaged not only
AHR but also other partners both within and outside their country in
the process of developing a new law. Genoveva Tisheva, BGRF’s director,
described the entire process as both a local and an international effort.18
AHR provided specific language for the new Bulgarian law on the civil
order-for-protection remedy that has been used in the United States for
many years. Experts in domestic violence legal reform, including judges
and police, also traveled from Minnesota to Bulgaria numerous times to
consult with legal officials, parliamentarians, and journalists about the need
for new laws on domestic violence and about how the laws work as they
are applied at the scene of an assault, in the courtrooms, and in the daily
lives of victims. BGRF and AHR also partnered to organize several techni-
cal training sessions specifically for police, prosecutors, and judges on how
to implement domestic violence laws.
The Bulgarian Law on Protection against Domestic Violence was passed
in March 2005. It defines domestic violence for the first time in Bulgaria and
creates a new civil order-for-protection remedy for domestic violence victims.
The law allows courts to order violent offenders out of the home, and in
emergency situations, where danger is imminent, both police and judges can
direct offenders to leave the home (Advocates for Human Rights, 2008b). In
May 2005, the police removed the first batterer from his home under the new
law, and since that time, thousands of orders for protection have been issued
by Bulgarian police and courts (Advocates for Human Rights, 2008b).19
In 2008, BGRF and AHR together published the report, The Imple-
mentation of the Bulgarian Law on Protection against Domestic Violence:
A Human Rights Report. The report begins,
In the two years since the entry into force of the Law on Protection against
Domestic Violence (LPADV), its overall implementation has been positive.
While challenges remain for all sectors and legislative amendments are
needed, the response to domestic violence since the law passed in Bulgaria
is encouraging. (Advocates for Human Rights, 2008b, p. 1)
The report evaluated all aspects of the government’s implementation
of the new law and made several recommendations for change. One rec-
ommendation was that an offender’s violation of an order for protection
under the new law should be criminalized so that the law had “teeth.” The
Parliament made this change in 2006.
18 See Genoveva Tisheva, Law on Protection Against Domestic Violence: Insights and
History, available at http://stopvaw.org/31May20055.html.

19 See http://stopvaw.org/17May20053.html.

AHR’s partnership with BGRF continues. In 2008 the two groups or-
ganized the Regional Conference on Domestic Violence Legal Reform. The
conference had 100 participants from 29 countries.20 In 2010 and 2011,
AHR and BGRF have been working with partners in Croatia and Moldova
to monitor new laws on domestic violence in those countries. Together
they are also presenting workshops titled “Strategies for Monitoring the
Application of Domestic Violence Legislation Workshop for Civil Society
Organizations” for advocates from 24 countries in the region.
Georgia
After initial visits and exchanges with advocates in Georgia, which
began in 2003, AHR invited the Georgian working group of government
officials and civil society members who were in the process of drafting the
new domestic violence law to visit Minnesota. This meeting occurred in
February 2005 and forged a partnership with various advocates based
in Tbilisi, in particular, the Anti-Violence Network of Georgia (AVNG).
AHR organized a series of presentations, workshops, court observations,
visits to service providers, police ride-alongs, and meetings with prosecutors
and judges.21 The goal was to offer Georgian officials the opportunity to
observe a jurisdiction where domestic violence laws were working, with a
system that took domestic violence cases seriously, that offered civil rem-
edies to victims to promote their safety, and that arrested men and charged
them with crimes for assaulting their wives.
The two-week visit offered the Georgians information and insights
from many perspectives into the implementation of the domestic violence
law in Minnesota that they could draw from in drafting their own law. The
Law of Georgia on the Elimination of Domestic Violence, Protection, and
Support of its Victims passed in 2006.22 As with the Bulgarian law, this law
defined domestic violence for the first time and focused on providing a civil
order-for-protection remedy for victims.
The Georgian law was a huge step forward in addressing domestic
violence but had significant weaknesses. For example, it gave police the
authority to remove victims from their home—ostensibly to protect their
safety—but did not provide explicit authority to remove violent offenders
20 For more information, see http://stopvaw.org/regional_conference_on_domestic_violence_
legal_reform.html.
21 See Minnesota Advocates for Human Rights Training Program Schedule for Georgian
Working Group on Domestic Violence Legislation, Jan. 24-Feb. 4, 2005. Minneapolis,

Minnesota. For copies, contact the Advocates for Human Rights.
22 See Prevention of Domestic Violence, Protection of the Victims of Domestic Violence and
their Assistance (Legislative News of Georgia; Part 1; 2006; Art. 171).

from the home.23 Georgian advocates understood the dangers of such lan-
guage but believed that it was a compromise they must make in order for
the law to pass.24 The law was later amended to explicitly allow for the
removal of the violent offender from the home. The new amendment states
that this removal may occur despite the abuser’s ownership of the property
(Thomas, 2008). This amendment indicates the prioritization of a women’s
right to be free from violence over an abuser’s property rights.
The Georgians faced difficult challenges in implementing the law. Under
the new law the police were given greatly expanded authority to issue “re-
strictive orders” comparable to emergency orders in the United States. This
authority has proven to be a burden, one police officer stated: “The dis-
trict police are supposed to be social workers, psychologists and teachers”
(Thomas, 2008, 3).
Despite the challenges with implementing the new law, it provides
a remedy for domestic violence victims. Since the law passed, advocates
report that hundreds of orders to protect victims have been issued by the
police and judges.
Armenia
As with Bulgaria, AHR’s partnership with Armenian advocates began
with a collaboration to provide documentation of the government and
community response to domestic violence. And, as with other countries
throughout the region, in 2000 such response was negligible. AHR re-
searched and published a report in collaboration with the Women’s Rights
Center in Yerevan (WRC), and AHR’s work with WRC has continued to
the present (Minnesota Advocates for Human Rights, 2000).
After the publication of the report and other initiatives to address
domestic violence in Armenia,25 WRC worked to create a group consisting
23 Removing victims from their homes results, of course, in hardship and disruption in their
daily lives and the lives of their children, including lack of access to personal belongings, the
inability to safeguard such belongings from the violent offender, difficulties with access to
work and school, and the loss of support systems close to home including friends and families.
24 Drafters from other countries in CEE/FSU have included similar provisions in
their laws, and advocates have explained that this is the result of prioritizing a man’s
property rights over a victim’s right to be free from violence. In fact, one Polish advocate
explained that the prioritization of men’s property rights has been a major impediment
to the passage of any order-for-protection remedy in her country. Legal Reform on
Domestic Violence in Central and Eastern Europe and the Former Soviet Union, p. 3,
available at http://www.un.org/womenwatch/daw/egm/vaw_legislation_2008/expertpapers/
EGMGPLVAWpercent20Paperpercent20(Cheryl percent20Thomas).pdf. Armenia’s draft law
included a similar provision authorizing authorities to remove the victim from the home. This
amendment passed in Georgia in 2009. Cf. http://stopvaw.org/Georgia.html.
25 For example, in 2008 Amnesty International published a report on domestic violence in
Armenia titled No Pride in Silence: Countering Violence in the Family in Armenia.

of representatives of the police, government ministries, judges, and NGOs

to draft a new law on domestic violence. This group requested that AHR
provide commentary on the Armenian Draft Law on Domestic Violence
as drafts evolved. AHR provided three such commentaries (Advocates for
Human Rights, 2008a).
In response to AHR’s commentaries, critical language such as “pro-
vocative behavior” by the victim and “official warnings” to the per-
petrator was removed, and other key language was added, such as the
addition of “intimate partners” as a class of individuals to whom the
law will apply. AHR also prepared training materials on advocacy and
lobbying for the law and traveled to Armenia for meetings with the
working group and other individuals involved in drafting and advocat-
ing for the law. As of January 2011, however, the law had not passed
in Parliament.
WRC was also a valuable partner on the StopVAW website. Through
the WRC’s work, readers could follow the struggle for a domestic violence
law, including working group meetings, roundtables, training sessions on
advocacy for the draft law, study visits to other countries to witness the
implementation of their laws, and analyses of human rights reports on
domestic violence in Armenia.
Morocco
AHR’s partnership with Moroccan advocates began in 2007—much
later than the work in CEE/FSU. Moroccan women’s NGOs were commit-
ted to leading the Arab world’s reform of laws concerning violence against
women legal reform and needed technical assistance in drafting a com-
prehensive violence against women act. Aided by Global Rights, a group
based in Washington, DC, with offices in Morocco and around the world,
AHR has provided information to these advocates, primarily in the area
of domestic violence but also on sexual assault. Through training sessions,
roundtables, and on-line consultation, AHR has delivered information to
these advocates about model domestic violence laws and policies from
around the world as well as highlights of civil and criminal legal reform
efforts on domestic violence from the United States, Minnesota, and other
jurisdictions.
In one week-long meeting facilitated by Global Rights, AHR and repre-
sentatives from two countries with new and long-standing laws on violence
against women provided technical assistance to Moroccan judges, prosecu-
tors, police, health and education officials, and advocates as they prepared
the first draft of their new law. Advocates are hopeful that this new law will
be introduced in the Moroccan parliament in 2011.

Challenges to International Partnerships

Overall, while AHR’s experience partnering with NGOs from other
countries has been a very positive one, there have been notable challenges.
One significant challenge has been obtaining funding for the work. Initia-
tives to address domestic violence, including efforts to change laws and
policies and direct services to victims, are expensive. Many governments
do not support these services or efforts in any significant way, so partner
NGOs must rely on private foundations and donors. These funds are lim-
ited and often unpredictable, making it difficult to sustain the long-term
projects that are necessary to achieve lasting systems change.
Another challenge AHR and its partners have faced is the urgency of
domestic violence victims’ needs. The requests for assistance to meet these
needs can be overwhelming and can affect the spirit of the small organiza-
tions with which AHR works. Similarly, AHR encounters this challenge as
it receives many more requests for information, technical assistance, and
training sessions from around the world than it can possibly respond to.
The capacity and endurance of the NGOs are not, however, the greatest
challenge faced by AHR and its partners. The most significant obstacle to
achieving the goal of ending violence against women is convincing those
with the power to make and enforce laws and policies reflecting the fact
that women have the right to be free from violence in their homes. Despite
the many efforts described in this paper, this right is not fully accepted in
the world today.
Conclusion
AHR’s experience partnering with NGOs from other countries to im-
prove the government response to domestic violence has been a very positive
one. AHR has been privileged to work with extraordinary women and men
whose vision for ending domestic violence has propelled their countries for-
ward and resulted in better laws and policies. Although significant work re-
mains, AHR is confident that these changes will continue toward the ultimate
realization of women’s fundamental human right to be free from violence.
NEW ZEALAND’S EFFORTS TO ADDRESS

VIOLENCE AGAINST WOMEN AND CHILDREN
Denise Wilson, Ph.D., R.N.
Auckland University of Technology
New Zealand has serious and concerning problems with violence

against women and children, as is evidenced by the number of high-profile

deaths of children and women killed by partners or ex-partners. Never-

theless, a prevailing social acceptance of and willingness to turn a blind
eye to violence against women and children has made getting traction on
this problem difficult, frustrating, and at times torturous. Violence and
abuse occurring in various close interpersonal relationships is called family
violence in New Zealand and is broadly defined to include partner abuse,
child abuse and neglect, elder abuse, child-to-parent violence, and sibling
abuse. The predominant forms of family violence in New Zealand are male
partner violence against women and child abuse and neglect. Although
violence against women and children is evident across different ethnic and
social groups, indigenous women and children are clearly overrepresented
among victims and are at greater risk of being targets of family violence.
A whole-government approach has been adopted by New Zealand in an
effort to address violence against women and children at a governmental
level. This paper provides an overview of some key New Zealand govern-
ment initiatives, and it comments on how these approaches address issues
for Ma-ori (the indigenous peoples of New Zealand), given that they are
overrepresented in the statistics for violence against women and children.
Statistics confirm that generally women and children are recipients of
violence inflicted by men occurring in the home—86 percent of those ar-
rested are male, and 92 percent of protection orders are made for women
(New Zealand Family Violence Clearinghouse, 2007). More than 50 per-
cent of all homicides are family violence related. From 2000 to 2004, 45
women were killed by a male or ex-partner, and 39 children were killed (26
by men; 15 by women). One study found that 33 to 39 percent of women
experience physical or sexual abuse sometime during their lifetime, and
19 to 23 percent reported it being severe (Fanslow and Robinson, 2004).
Another study reported that 35 percent of men reported being physically
violent toward a partner sometime in a lifetime and 20 percent in the previ-
ous year (Leibrich et al., 1995). Fanslow and Robinson (2004) found that
victims of partner abuse were twice as likely as non-victims to have visited
a health care provider in the previous month.
In addition, New Zealand ranks third among Organization for Eco-
nomic Co-operation and Development countries for child maltreatment
and has 20 percent of children living in poverty (UNICEF, 2003). Among
children living in New Zealand who were hospitalized, 4 to 10 percent re-
ported having experienced physical abuse, while 11 to 20 percent reported
having experienced sexual abuse (Duncanson et al., 2009). In 2008, 47
percent of notifications to the Child, Youth, and Family Service required
further follow-up. Between 1996 and 2000, 49 children under the age of
15 died as a result of child maltreatment. For a country with a population
of less than 4.4 million, this is unacceptable. On average 8 to 10 children
die a year in New Zealand at the hands of someone who should protect

them from harm. Most at risk are those under 1 year of age and those older
than 11 years.
Addressing family violence has been difficult, especially given the en-
grained social acceptance of violence against women and children within
the context of families. The debate surrounding the repeal of Section 59 of
the Crimes Act of 1966 illustrates the deeply engrained beliefs of many liv-
ing in New Zealand. Section 59 stated, “Every parent or person in place of
a parent of a child is justified in using force by way of correction towards a
child if that force is reasonable in the circumstances.” Although the aim of
the repeal was to remove the statutory protection of parents and guardians
who used physical force when disciplining their children, a highly charged
and emotional public campaign was launched in opposition to the bill. A
chief accusation was that “loving” parents would be criminalized for dis-
ciplining their children, along with accusations that the government was
creating a “Nanny State” (by taking away the parental right to hit their
children). Despite the intention of the repeal being to improve the safety
and integrity of children, polls showed between 70 and 80 percent of New
Zealanders did not support the repeal, reflecting a resistance to addressing
child abuse when activities interfered with parental rights. The outcome
was a substitution of Section 59 defining when parental control using force
was justified to appease the public. Thus, parents or caregivers can use
force in the prevention of harm to a child or another person, in preventing
a child from committing criminal offences or engaging in offensive or dis-
ruptive behavior, and in “normal daily tasks” necessary for “good care and
parenting.” Additionally, ongoing monitoring is occurring to ensure parents
are not needlessly criminalized. Interestingly, the United Nations Report on
Children’s Rights in New Zealand (2011) criticizes the repeal for not going
far enough and banning corporal punishment for children.
Government Initiatives
Whole Government Approach

One of the 13 goals of the New Zealand Health Strategy was to reduce
interpersonal violence (King, 2000). Not only did this signal the govern-
ment’s intention to put family violence on its agenda, but also it recognized
family violence as a health issue. The 2000 Labor government required an
“integrated, multi-faceted, whole-of-government and community approach
to preventing the occurrence and reoccurrence of violence in families/
wha-nau . . .” (Ministry of Social Development, 2002, p. 6). In 2002 the Te
Rito New Zealand Family Violence Prevention Strategy was launched as
an official government response and commitment to addressing all forms
and degrees of violence, and it provided a framework for action. The

fundamental vision was for families to live free from violence. This strategy
also recognized the unique cultural and contemporary structures of Ma-ori
as tangata whenua (people of the land) and the need for Ma-ori to be pro-
vided for and fully engaged. Family violence prevention was viewed holisti-
cally and broadly and included all levels—primary prevention, secondary
early identification and immediate intervention, and tertiary prevention of
its reoccurrence. Communities were also given the right and responsibility
to be involved in preventing family violence.
The Taskforce for Action on Violence within Families was established
in June 2005 to advise the Family Violence Ministerial Team, which is
composed of ministers of parliament, on improving how family violence
is addressed and eventually eliminating it. This taskforce was composed
of chief executive officers and other decision makers from government and
nongovernment sectors, the judiciary, and various government agencies,
such as social development, women’s affairs, and health. Ma-ori and Pacific
reference groups were also established to support the task force and provide
their perspectives. In 2009 the associate minister for social development
and employment (and associate minister of health), the Honorable Tariana
Turia, was given the responsibility for the national government’s response
to addressing and reducing the impact of family violence as well as the
establishment of the Family Violence Ministerial Group (replacing the Fam-
ily Violence Ministerial Team). This ministerial group meets quarterly and
is responsible for the oversight of the whole-of-government approach and
the alignment and coordination of responses. Ministers inform and consult
with each other on developments and proposed family violence–related
work within their respective portfolios. This group includes ministers of
social development and employment, justice, health, police, education,
Ma-ori affairs, Pacific Island affairs, housing, women’s affairs, ethnic affairs,
and disability issues.
Legislation
Legislation aimed at protecting women and children includes the Do-
mestic Violence Act 1995, which changed immensely the way women and
children could be protected. This legislation removed the need for women
to lay charges of assault against a partner before the police would intervene.
Women wanting immediate protection from partners’ abuse apply for a
temporary protection order for a period of three months, and it is often
issued without notice. After this time a partner can apply to the court for
a hearing prior to making an order permanent. If the request for the order
goes undefended, the order automatically becomes permanent. At the time
a protection order is granted, orders can be made concerning occupancy or
tenancy as well as furniture in order to enable women to stay in the home

and have some or all of the furniture. A woman’s children are granted the
same protection under these orders. This legislation stipulates that, when
children live amid abuse and violence, it is considered violence against
children. Still, the research of Roberston et al. (2007) concerning protec-
tion orders for women found that systemic gaps existed and breaches of
protection orders were not always addressed.
More recently police have been allowed to issue police safety orders
(PSOs) in situations where they have reasonable grounds to believe that
family violence has occurred or may occur, with no right of appeal and
without the consent of the person(s) at risk. PSOs aim to protect those
at risk of violence, harassment, and intimidation and any children living
at the residence. Abusers are required to leave the residence for up to five
days, and they must not assault, threaten, intimidate or harass, follow, stop
or contact their partner in any place, or encourage anyone else to do this.
They must also surrender firearms and their firearms license to the police.
The Child Youth and Their Families Act of 1989 promotes the respon-
sibility of parents, families, and family groups to prevent children from
suffering harm, ill treatment, abuse, neglect, or deprivation. However, it
is commonly associated with the Child Youth and Family Service’s statu-
tory duty to protect those children who are being harmed or neglected or
who are at risk of being harmed or neglected. Despite the high demand
on its services, the efficacy of the Child Youth and Family Service is often
questioned in the media. The Care of Children Act of 2004 shifted a prior
focus on parental rights to parental responsibilities. The key focus of this
legislation is the welfare and best interests of the children where any dispute
about them exists in order to keep the children safe and free from all forms
of violence. However, where family violence exists, children still tend to be
invisible beyond custody battles.
In addition to strengthening legislation to protect women and children,
the government has initiated a number of campaigns aimed at addressing all
forms of family violence. It is valuable to examine two such government-
driven initiatives in some detail.
The It’s Not OK campaign (www.areyouok.org.nz/) is a phased nation-

wide media campaign aimed at changing societal attitudes toward family
violence and those living amidst it. Using a phased mass-media approach,
the campaign began with “It’s Not OK” (showing a range of unaccept-
able behaviors evident in society); followed by “It’s OK to Ask for Help”
(encouraging people to ask for help); and then the current campaign, “Are
You OK?” (encouraging family, friends, and colleagues to ask if people
are okay—not ignore a woman or child who may be abused, or a man
who is angry, shouting at his children and wife, who are afraid of him
including those doing the abuse or violence). Evaluation of the campaign

has demonstrated increased recall of the television advertisements with

every survey. Ninety-five percent of the people surveyed in September
2008 recalled something from at least one of the ads. Recall was high for
all groups, particularly Ma-ori males (94 percent) and Ma-ori females (98
percent). Of those surveyed, the advertisements helped 68 percent identify
unacceptable behaviors and influenced 57 percent to see change is possible.
As a result of seeing the ads, 22 percent reported taking action (McLaren,
2010). In addition, nongovernmental organizations such as Jigsaw (www.
jigsaw.org.nz/), which coordinates various agencies working with families
and children to promote their safety, have a campaign using high-profile
men to promote a positive image of fathers with their children.
The Violence Intervention Program (VIP) promotes assessment for family

violence among those using District Health Board (DHB) hospital services
as well as assessment for child abuse (work is currently under way in the
primary health care sector). VIP supports health-sector family violence
programs throughout New Zealand based on the Child and Partner Abuse
Guidelines (currently under review) and the Elder Abuse Guidelines (Minis-
try of Health, 2003, 2007). The government funds a national VIP manager
and family violence intervention program coordinator (FVIPC) positions
in all DHBs; these officials have contractual requirements to meet and re-
port indicators to the Ministry of Health. In addition DHBs are evaluated
annually to improve the quality of programs and facilitate benchmarking
between DHBs (Koziol-McLain et al., 2010). Although the Ministry of
Health supports this research and evaluation and offers technical advice
and training support to health services committed to the program, the
FVIPCs are responsible for promoting assessment and education of staff.
VIP has developed significantly to a point where there is now national
standardization in training requirements and reporting formats. The Inter
disciplinary Trauma Research Unit (ITRU) at the Auckland University
of Technology evaluates each DHB annually. Steady progress has been
made over 60 months, although some DHBs need further improvement.
Importantly, evaluations demonstrate the importance of a dedicated fam-
ily violence intervention coordinator to the program’s sustainability and
development (Koziol-McLain et al., 2010). Cultural indicators have also
been evaluated, and although improvements have been made, the more
challenging cultural indicators need further improvement.
Wha-nau Ora (Family Health and Well-Being)

The 2003 Ma-ori health strategy, He Korowai Oranga, had as its goal
wha-nau ora, or family health and well-being. Wha-nau is more than just a nu-
clear family—it is the wider extended family and may include grandparents,

aunts and uncles, and cousins. Like many indigenous peoples, Ma-ori have
a collective orientation with obligations and responsibilities to the members
of their extended family. A key to resolving inequalities in health and social
status—and in improving the family violence statistics—is to support wha-nau
to develop the capacities to achieve health and well-being (Durie et al., 2010).
Thus, the focus of wha-nau ora is on empowering wha-nau and ultimately
reducing the inequalities Ma-ori experience, and it requires service providers
to demonstrate accountability and the efficacy of initiatives. Fundamental
to this strategy is improving the health and well-being of both individual
members and the collective wha-nau through culturally based interventions
and determining their existing strengths; this involves capacity building to
identify needs and improve access to appropriate services.
In summary, although there is still a long way to go in New Zealand to
reduce the prevalence of violence against women and children, some exciting
initiatives are happening. The whole government approach is an attempt to
have a more cross-sectoral approach to addressing family violence, because
the previous silo approach adopted by government departments meant that
women and children reliant on help from services would fall through the
chasms that existed. Furthermore, interwoven into the government initiatives
are strategies to address violence against Ma-ori women and children. The
adoption of a mass media program to address societal attitudes and behaviors
is also important, so rather than a stance that ignores the plight of women
and children, they will be able to live free from violence.
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Papers on Preventive
Interventions
Interventions to prevent violence against women and children are as

varied as the settings and populations in which they operate. No matter
what the setting, however, successful interventions demonstrate measur-
able reduction in violence as well as secondary effects such as increases
in gender equality, economic empowerment, life skills development, com-
munity mobilization, resilience, and quality of life. Speakers presented
a number of case studies of such interventions and provided thoughtful
analysis of the possibility of transportation of such programs to alternate
settings.
The first paper is an overview of the Intervention with Microfinance
for AIDS and Gender Equity (IMAGE) program in South Africa. Although
economic empowerment of women is a common method of addressing
structural inequities, IMAGE also incorporated gender-based violence and
HIV prevention programming. The result was a successful multisectoral
response that resulted in reduction of a number of adverse outcomes, in-
cluding violence and HIV transmission.
The second paper describes the success of two programs to address
intimate partner violence and child maltreatment in Hong Kong. Both pro-
grams use obstetricians and nurses who regularly come into contact with
expectant parents to provide additional information and support on com-
munication and parenting skills. Special attention was paid to addressing
cultural norms.
The third paper is an analysis of The Fourth R, a school-based pro-
gram originating in Canada and now offered in a number of settings in
North America. The Fourth R integrates skills building and risk factor
144

PAPERS ON PREVENTIVE INTERVENTIONS 145
management into current school programming, reaching adolescents at a

crucial time of development.
The fourth paper summarizes the Community Advocacy Model aimed
at women experiencing intimate partner violence. It is centered around a
“family model” that assesses the strengths and needs of victims and pro-
vides them with social support to protect themselves and their children. The
approach of this intervention is based on the relationship of women with
their communities and the necessity in engaging the community to reduce
norms condoning violence.
The final paper looks at the “systems change model” of Kaiser Per-
manente, an integrated health care system that incorporates all levels and
aspects of health care delivery. Using this pre-existing structure, Kaiser
Permanente has implemented a family violence prevention program meant
to identify potential violence as victims and perpetrators access the health
care system. It also provides training to its physicians and other health care
staff, on-site resources, and linkages to community resources for violence
prevention.
THE IMAGE PROGRAM: SUMMARY

Julia Kim, M.D., M.Sc.
United Nations Development Program
The Intervention with Microfinance for AIDS and Gender Equity

(IMAGE) program1 began in 2001 in rural Limpopo, South Africa, and
is a community-based program that combines microfinance with a gen-
der and HIV curriculum. It began as a partnership between the Rural
AIDS and Development Research Program (RADAR) at the University of
Witwatersrand; the London School of Hygiene and Tropical Medicine;
and the Small Enterprise Foundation (SEF), a microfinance group based in
Limpopo. The IMAGE program has shown that it is possible to address
poverty, gender-based violence (GBV), and HIV together, underscoring
the need for future investments to support multisectoral programming to
address women’s social and economic empowerment in order to reduce
vulnerability to GBV and HIV.
The IMAGE intervention uses microfinance loans as a vehicle for em-
powering the poorest women in rural villages. The microfinance partner,
1 IMAGE has received funding from Anglo American Chairman’s Fund, Anglo Platinum,
the Ford Foundation, the UK Department for International Development, the Henry J. Kaiser
Foundation, the International Humanist Institute for Cooperation with Developing Countries,
the MAC AIDS Fund, the South African Department of Health, and the Swedish International
Development Cooperation Agency.

SEF, is based on the Grameen Bank model, whereby groups of five women
aged 18 and older served as guarantors for each other’s loans, with all five
required to repay before the group is eligible for more credit. Loans are
used to support a range of small businesses. Loan centers of approximately
40 women meet fortnightly to repay loans, apply for additional credit, and
discuss business plans.
In addition to the microfinance component, the IMAGE intervention
includes a participatory learning program called Sisters for Life (SFL), which
is integrated into routine loan center meetings. It focuses on issues such as
gender roles, cultural beliefs, domestic violence, power relations, self-esteem,
sexuality, and HIV/AIDS. The SFL sessions are aimed at strengthening com-
munication skills, critical thinking, and leadership. In the second phase,
program participants are encouraged to facilitate wider community mobili-
zation to engage both youths and men in addressing gender norms.
Evaluated as a cluster randomized trial in eight villages in rural Limpopo,
the program assessed the impacts on poverty, women’s empowerment, and
risk of intimate partner violence (IPV), and HIV/AIDS. After two years the
IMAGE study found that the risk of physical and sexual intimate partner
violence among participants was reduced by 55 percent (Kim et al., 2007).
Among young women participating in the program, several factors related to
HIV risk were also positively affected, including an increase in communica-
tion about HIV, a 64 percent increase in voluntary counseling and testing,
and a 24 percent reduction in unprotected sex (Pronyk et al., 2008). The
study also found positive impacts on household economic well-being, in-
cluding increased food security, expenditures, and household assets. In terms
of impact on women’s empowerment, the participants reported increased
self-confidence, autonomy, social capital, collective action, and an ability to
challenge gender norms (Kim et al., 2007). The program was also interested
in exploring whether additional positive changes might diffuse to young
people not directly participating in the intervention, but it did not find any
changes in sexual behavior or HIV incidence among a random sample of
young people living in the intervention villages (Pronyk et al., 2006).
In order to determine whether microfinance without the SFL training
would have been as effective, researchers conducted a cross-sectional analy-
sis comparing microfinance alone against the combined IMAGE interven-
tion. Microfinance alone and IMAGE produced similar economic impacts,
but only the IMAGE program showed benefits in terms of IPV, women’s
empowerment, and HIV risk behaviors (Kim et al., 2009). The study sug-
gests that the combination of microfinance with gender training and com-
munity mobilization is important for generating synergy and broadening
the social and health impacts of microfinance.
IMAGE has successfully been scaled up from a research pilot project to
a sustainable and fully integrated program, which has now reached 12,000

women in 160 villages. Supporting the sustainability and expansion of the

approach, the microfinance program is cost-neutral, with its operational
costs being covered by the interest charged in the loan repayment process.
In response to training requests from other microfinance and GBV orga-
nizations, the IMAGE program is currently exploring opportunities to de-
velop as a best-practice learning site to support South-South learning and
replication across different settings. Further research to inform the adapta-
tion and replication of such models will yield important lessons.
There are a number of lessons that have been learned from the IMAGE
program. The program presents encouraging evidence that it is possible to
reduce IPV and to challenge gender norms and violence even when they
appear to be “culturally entrenched” and resistant to change. Second, the
IMAGE program shows the importance of meeting women’s basic eco-
nomic needs as part of a GBV/HIV intervention. Building on a pre-existing
poverty alleviation program made it possible to maintain regular contact
with a particularly vulnerable and difficult-to-reach group (impoverished
rural women) for more than a year—an opportunity rarely afforded most
stand-alone health /HIV interventions. Although this program focused on
microfinance, other strategic entry points for women’s economic empower-
ment could be explored, such as literacy programs and job skills training.
Third, it is important to choose strong sectoral partners and to allow each
to focus on what it does well. There are risks involved in HIV programs
attempting to deliver microfinance, and in this case SEF focused on deliv-
ering the microfinance program while partnering with RADAR to develop
the gender and health aspects. Finally, IMAGE showed that programs can
work indirectly to affect the most vulnerable groups. Recognizing that
young women are particularly vulnerable to HIV and IPV, the program
worked with older women (who are often cultural gatekeepers) as well as
their younger peers to challenge existing gender norms and increase com-
munication across generations. Similarly, given the economic vulnerability
of young women, the program aimed to improve household economic
well-being through loans given to more mature women rather than putting
loans directly into the hand of adolescent girls—an approach that can raise
financial and programmatic challenges. Finally, recognizing the importance
of engaging men, the program worked directly with microfinance clients, in
order to empower them to reach out and engage men during the community
mobilization phase (Kim et al., 2007).
In order for structural-level interventions to be most effective, pro-
grams should focus simultaneously on quick wins and long-term change.
Ultimately, programmatic approaches such as IMAGE need to be supported
and complemented by policy-level interventions that create an enabling en-
vironment for sustained change (Kim et al., 2008). Mainstreaming gender
and HIV within national AIDS and development plans is one way to embed

structural interventions within this more long-term, policy-level approach.

It is encouraging that studies such as IMAGE can contribute to policy-level
change, such as the inclusion of microfinance and the empowerment of
women in the South African government’s Strategic Plan for HIV/AIDS.
Further implementation and research focusing on multisectoral approaches
to addressing intimate partner violence and HIV are needed.
INNOVATIVE PREVENTION INTERVENTIONS:

ADDRESSING IPV AND POTENTIAL CHILD
ABUSE AT PRENATAL CARE
Agnes Tiwari, Ph.D., R.N., FAAN
University of Hong Kong
Intimate partner violence (IPV) during pregnancy adversely affects the

health and well-being of pregnant women and their unborn infants. Yet,
pregnancy also offers a unique opportunity for primary prevention of IPV
as well as for interrupting the cycle of violence. In this paper two interven-
tions are presented: the Positive Fathering Program, which was designed as
a primary prevention strategy; and the Empowerment Intervention, which
aims to interrupt the cycle of violence against pregnant women and their
unborn infants.
The Positive Fathering Program

The Positive Fathering Program aims to engage expectant fathers in
prenatal education in order to prepare them for transition to fatherhood
while working in tandem with their intimate partners. Despite the name of
the program, both men and their pregnant partners are actively involved
in the program as couples. Couple involvement is essential in building a
caring, committed, and collaborative intimate relationship within which the
transition to parenthood is nurtured.
The need for engaging men in the transition to parenthood arises from
the fact that such a transition can be a challenging time for men (Cowan
and Cowan, 1995; Goodman, 2005). Specifically, men may have unreal-
istic expectations about involved fatherhood and develop role ambiguity
as fathers (Doherty et al., 1998; Goodman, 2005). Such uncertainties may
be further aggravated by the lack of role models or inadequate guidance
to ease the transition to fatherhood (Goodman, 2005). Thus, adjustment
to fatherhood may turn out to be distressing and frustrating for men and
may strain couple relationships. Furthermore, with the development of a
strong mother-infant relationship, some men may feel excluded and see
the unborn infant as an intruder in their intimate relationships (Anderson,

1996). Jealousy and the perceived need to exert control over their partners
may result in IPV during pregnancy (Campbell et al., 1993). Providing
support and guidance to expectant fathers is, therefore, essential in order
to help them develop realistic expectations of fatherhood and to improve
their confidence as new fathers. Furthermore, engaging men in prenatal
education is important so that they may jointly learn and prepare for new
parenthood with their partners, instead of feeling excluded.
Although there is an array of prenatal education programs for child-
birth, parenthood, or both, these programs focus primarily on the needs of
expectant mothers. Indeed a recent Cochrane Review suggests that there are
relatively few prenatal education programs that specifically address expect-
ant fathers’ needs (Gagnon and Sandall, 2008).
The Positive Fathering Program has been developed to address the gap
in the engagement of men in prenatal education. The program is based on
the theoretical framework of self-efficacy, which is the belief in one’s ability
to successfully perform a particular behavior (Bandura, 1982). Providing
expectant couples with knowledge and skills related to caring for the baby
and the mother as well as with opportunities to work together toward the
transition to parenthood helps them acquire confidence in their abilities to
carry out such tasks and also develops trust among the partners that each
will be supportive of the other’s efforts.
The program’s focus on developing a couple’s self-efficacy regarding
care of the baby and mother in the postnatal period is deliberate because
it provides something concrete and meaningful for engaging expectant fa-
thers, a common goal that has practical applications for the couple, and a
forum for listening and responding to one’s partner.
As the program primarily targets Chinese expectant couples, cultural
adaptation is also used to ensure that the program is culturally appropriate
for the intended participants. The key features of the cultural adaptation
are:
• discussing couple relationship issues in the context of raising chil-

dren, which is generally more emphasized than marital issues in
Asian cultures;
• adopting an experiential learning approach (which is honored in
Asian cultures) to promote motivation and understanding;
• helping participants to understand their feelings instead of sup-
pressing them and recognizing the need to understand their part-
ner’s inner world in order to make meaningful connections;
• appropriately using empirical research and theories, which are highly
valued in Asian cultures, when delivering the teaching materials;
• using metaphors when explaining abstract or complicated con-
cepts; and

• acknowledging a need to assess the extent to which participants

have been influenced by Western culture and ensuring that the
teaching is sensitive to Chinese cultural norms (Huang, 2005).
The Positive Fathering Program has four components: (1) engaging

men as expectant fathers; (2) promoting parenting self-efficacy, including
as a couple; (3) enhancing couple relationships through partnership and
experiential learning; and (4) managing traditional cultural beliefs in a
contemporary world.
To engage men in their roles as expectant fathers, the program uses
“reality boosters” to bring them closer to their unborn infant, such as
interacting with life-size dolls with the weight and texture of a newborn,
feeling fetal movement, and listening to fetal heartbeats. The program also
encourages the men to express their aspirations to be a supportive partner
and responsible father, while inviting the women to validate their partners’
expressed aspirations. Program administrators assist the expectant fathers
in exploring their needs and how such needs can be met, both by themselves
and with their partner.
In order to be more effective parents, couples learn to identify their
infant’s needs and understand appropriate infant care responses; learn and
practice the behaviors that will best meet those needs, under supervision
and with reinforcement; and explore how social support networks (includ-
ing their families, neighbors, and friends) may enhance their capacity as
new parents. The couple relationships are enhanced through partnership
and experiential learning involving active listening and responding, learning
to express their feelings, and understanding the inner world of the other
person.
In addition, the program helps expectant couples manage traditional
cultural beliefs in a contemporary world by identifying Chinese beliefs
and practices relating to postpartum care and locating them in the context
of research, theory, and reality. This allows participants to anticipate the
impact of cultural practices on the new mother and infant and to respond
constructively. Finally, couples are encouraged to talk through various
strategies they can use to accommodate the involvement of in-laws in infant
care and traditional postpartum practices.
The Positive Fathering Program was implemented, in combination
with standard prenatal education, in a large public hospital in Hong Kong
from August 2009 to February 2011. The differences between the two ap-
proaches are summarized in Table 8-1.
In practice, the Positive Fathering Program was delivered in three con-
secutive, evenly spaced sessions over a 14-week period starting at about
20 weeks of gestation. Each session took about three hours to complete,
depending on the size of the group. In order to be included in the program,

TABLE 8-1 Differences Between Standard Prenatal Education and the

Positive Fathering Program
Standard Prenatal Education Positive Fathering Program
5 sessions totaling 10 hours 3 sessions totaling 9 hours
Focus on child birth, breastfeeding, infant Focus on engaging expectant fathers, couple
care, pre- and postnatal emotions, and relationships and communication, parenting
postnatal care efficacy, in-law involvement, and cultural
postnatal practices
Conducted as large classes Conducted as small groups
(> 100/class) (6-8 couples/group)
≤ 50% of the participants are couples 100% couple attendance
Content is based on well-established Content is based on identified needs
prenatal education
Teacher-centered, didactic teaching, Couple-centered, two-way, interactive
one-way transmission of content discussion and hands-on practice
Passive learning Active learning
Minimal couple partnership in learning Couple partnership in learning is the main
theme of the program
the woman needed to be less than 20 weeks into her pregnancy at the time
of recruitment, and the couple had to agree to attend all three sessions
together. Participation was voluntary, and recruitment took place in pre-
natal clinics. The nature of the program and the process was explained to
the potential participants. Those who agreed to participate were asked to
provide a written consent because questionnaires would be administered at
different points of the program for evaluation purposes.
A small group format was adopted in order to maximize active partici-
pation and to ensure adequate hands-on practice. Each group was facili-
tated by a designated nurse or midwife, assisted by at least two members of
the research staff. The same facilitator would work with the group through
all three sessions in order to ensure continuity and to build rapport with
the participants. Meticulous training of the facilitators and research staff
was vital in order to ensure that the program was delivered as planned and
that the same standards were maintained across the groups. To this end,
a two-day training session was provided prior to the start of the program
that focused on the theoretical underpinning and intended outcomes of
the program as well as on the knowledge and skills required for delivering
the content. The facilitator’s performance in delivering the sessions was
assessed by the program leader, and re-training was provided until satisfac-
tory performance was demonstrated.
The obstetrics department of the host hospital provided the venue (a
large seminar room) and the facilities for the group sessions, including

hands-on practice in infant care and couple communication skills. Close col-
laboration between the program team and the clinicians ensured smooth re-
cruitment of participants, implementation of the group sessions as planned,
and referrals as necessary (e.g., midwives or obstetricians).
Over an 18-month period, 171 Chinese couples were recruited to the
program. Program evaluation, which was conducted using chart reviews
and self-reports elicited using instruments and telephone interviews, re-
vealed the following:
• A total of 166 couples completed the program, for a completion

rate of 97 percent.
• Five couples did not complete because they unexpectedly had to
work on the days when the intervention was held.
• No adverse events in connection with the program were reported.
• A significant improvement in couple relationship adjustment,
as measured by the Chinese version of the Dyadic Adjustment
Scale comparing the baseline scores with those taken at six weeks
post-delivery, was reported by the couples (p < 0.001) (Shek and
Cheung, 2008).
• A significant reduction in depressive symptoms, as measured by
the Chinese version of the Edinburgh Postnatal Depression Scale
comparing the baseline and six weeks post-delivery scores, was also
reported by the couples (p < 0.001) (Lee et al., 1998).
• A consumer satisfaction survey conducted at six weeks post-
delivery found that a large majority of the couples rated the pro-
gram as “extremely useful to useful.” Specifically, 86 percent of
couples reported that it was helpful in improving their intimate
relationships, 77 percent reported that it enhanced their commu-
nication skills with the partner, and 94 percent reported that the
program increased their confidence in caring for their new infant.
• Telephone interviews conducted with 10 percent of the couples also
provided anecdotal accounts of the positive outcomes of the pro-
gram in terms of couple relationships and care of the new infant.
• The cost of the program was about US$60 per couple.
To summarize, the Positive Fathering Program demonstrated acceptabil-

ity and efficacy for 166 Chinese expectant couples using public prenatal care
in Hong Kong. In the next stage of development, the program will be modi-
fied based on a hospital–community partnership model, which will combine
the use of professional and non-professional caregivers over the pre- and
postnatal period. The program’s efficacy in improving couple relationships,
enhancing parental sense of competence, and reducing postnatal depressive
symptoms will be tested using a cluster randomized controlled trial.

The Empowerment Intervention

Background
The Empowerment Intervention, a secondary prevention program for
early detection and reduction or elimination of violence against pregnant
women by their intimate partners, is based on the premise that violence
against women by an intimate partner is part of a pattern of coercive control
(Dobash et al., 1992; Parker et al., 1999). Therefore, the intervention aims
to increase abused women’s independence and control (Parker et al., 1999).
Dutton’s (1992) empowerment model, which provides the theoretical basis
for the intervention, includes: protection (with a focus on increasing abused
women’s safety) and enhanced choice making and problem solving (relating
to making decisions about relationship, relocation, and other transitional
issues). In addition, Parker and colleagues (1999) also adopt the approach
that, because relationships are complex and multi-dimensional, the woman
in the abusive relationship understands the situation best. Furthermore,
the woman knows what is best for her and her children. What she needs
is an opportunity to express her feelings to a nonjudgmental and empathic
person and to be allowed to make her own decisions.
Methods
The modified Empowerment Intervention was tested on 110 abused
Chinese pregnant women in a prenatal setting in Hong Kong in 2002 and
2003 using a randomized controlled trial (Tiwari et al., 2005). The par-
ticipants were randomly assigned to the intervention group (n = 55) or the
control group (n = 55). The intervention group received the Empowerment
Intervention as described earlier, and the control group received standard
care for abused women. Data were collected at study entry and six weeks
postnatal.
Intervention
The modified Empowerment Intervention for abused Chinese women is
based on the empowerment protocol of Parker and colleagues (1999) and
on Walker’s cycle of violence (1979), which explain how women become
victimized and why it is so difficult for them to extricate themselves from
abusive relationships (Tiwari et al., 2005). The intervention was carried
out in a private 30-minute session as part of a larger 12-week advocacy
intervention that consisted of 12 social-support telephone sessions based
on Cohen’s Social Support Theory as well as access to a 24-hour support
hotline (Cohen, 1988; Tiwari et al., 2010). The 30-minute empowerment
intervention was carried out in a one-on-one setting with an assurance of

confidentiality by a professional who had undergone training for this pur-

pose and who was fully conversant with empowerment theory and with the
modifications that had been made to ensure culture congruence.
The Empowerment Intervention includes the following three compo-
nents: information on the cycle of violence, logistical information related
to safety and legal recourse, and information for assessing the behaviors
of the abuser for danger. The original intervention was modified for use
among abused Chinese pregnant women in Hong Kong in order to en-
sure that it was consistent with the subscribed norms of Chinese women
living in a “shame-oriented” culture (Tiwari et al., 2005). In particular,
because of the fear of rejection or ridicule that many Chinese women
perceive to be associated with revealing their abusive experiences, an ad-
ditional component known as “empathic understanding” and based on
Rogers’ client-centered therapy (1951), was incorporated. Empathic un-
derstanding emphasizes the need for the helping professional to elicit the
woman’s perceptions and feelings in a nonjudgmental way. This approach
is intended to help women who are participating in the intervention to
positively value themselves and their feelings, which is an important con-
sideration, especially if previous attempts to disclose IPV were ignored
or ridiculed. The next three sections offer brief descriptions of the main
components of the modified intervention.
Cycle of Violence
Women in the intervention were taught about the cycle of violence in
order to facilitate their ability to describe their relationship and thus gain
a sense of control over the abusive situation. The cycle of violence was de-
scribed to the participants as consisting of three phases: tension building;
violence; and reconciliation, or the “honeymoon phase” (Walker, 1979).
During phase one, a woman typically works, consciously or unconsciously,
to decrease the building tension in the relationship. By the end of phase
one, she is exhausted and begins to withdraw from the relationship, fearing
that she may inadvertently set off an outburst of violence. In response to
her withdrawal, the abuser becomes violent, thus phase two begins. Dur-
ing phase two, the violent phase, the acute battering incident takes place
and may last for minutes, hours, or days. During phase three, often called
the “honeymoon stage,” the abuser attempts to reconcile the relationship,
showing love, tenderness, and remorse. The abuser’s gestures of buying
gifts, begging for forgiveness, or both may make it more difficult for the
woman to take action against her abuser. She may even believe that if she
is able to keep her abuser happy, they will live happily. Family members
may also get involved. In the case of Chinese families, which emphasize the
need to keep the family intact, the woman may be put under a great deal of

pressure to forgive or sacrifice herself for the good of the family. However,
eventually this phase ends, and once again tension begins to build up.
Level of Safety
Another component of the modified intervention is determining the
level of safety based on the indicators from the Danger Assessment in-
strument. This component is designed to assist participants in objectively
evaluating the safety of their current relationship (Campbell et al., 2000).
The women go through a process of recalling all the violent incidents
(including a ranking of severity) associated with the relationship that
had happened in the previous year by using a calendar. During this pro-
cess, information about safety issues is also discussed, including signs of
increased danger. In particular, participants are informed that the most
dangerous time occurs when a woman leaves the relationship or makes it
clear to the abuser that she is leaving for good. As social disharmony is
often a taboo subject in Chinese society, and partner violence is frequently
treated as a family affair not to be shared with outsiders, many abused
Chinese women may not recognize the signs of increased danger; hence,
time should be spent to ensure that she understands the warning signs.
Based on the participant’s assessment of the situation, a discussion of
immediate safety and formulation of an escape plan can be initiated. As
Chinese women may view the safety plan as a step closer to leaving their
partners, reassurance should be provided that having a safety plan puts
them in a better position to make decisions about their options, including
the option to stay with the abuser. In keeping with the model of empow-
erment, it is not necessary for every woman to employ all of the safety
behaviors. Rather, each woman should decide what is appropriate for her
and how many of the behaviors she wishes to take at any one time. As
a part of efforts to ensure cultural relevance of the intervention, helping
professionals must not only keep in mind the Chinese cultural context
when educating a participant about her options, but also remember that
each abused woman has her own unique characteristics and, therefore,
requires an individual safety plan, taking into account what works for her
at different stages of the relationship.
Selecting an Option
Another component of the Empowerment Intervention is selecting an
option, in which the helping professional assists the participant in objec-
tively evaluating her relationship with her partner, including its inherent
strengths and limitations. The woman may be in a state of intense confusion
or feel conflicting loyalties. As a result, this component of the intervention

includes teaching each participant problem-solving and decision-making

skills, while avoiding telling her what to do or criticizing the abuser. When
working with Chinese women it should be recognized that traditional
Chinese culture expects a woman to sacrifice herself for the greater good of
the family and also that leaving her partner may mean that she is ostracized
within the very community where she needs support. Thus, the woman may
be very reluctant to leave her abuser. The options that are available to a
Chinese woman who experiences IPV may include remaining in the home
and seeking help for herself or her partner, or both; remaining in the
home and attempting to anticipate the violence and protect herself and
her children; or leaving the relationship either temporarily or permanently.
There are a number of cultural considerations to be made in educating
women about their options. The following is a summary of some specific
issues that have been considered during the modification of this intervention
for Chinese women:
• Chinese women may be reluctant to disclose IPV to outsiders, so it

is beneficial for them to think about whom they can trust and with
whom they would share their abusive situation and their safety
plan.
• Some Chinese women may have a fear of authority figures, given
their past experience, so they may require close support of a trusted
advocate.
• For many Chinese women, protective orders may be totally alien to
them, so every care should be taken to ensure that they are properly
informed regarding protective orders before making their decisions.
Results
Following the intervention, women in the intervention group reported
significantly higher physical functioning and improved role limitation due
to physical and emotional problems compared with women in the control
group, as measured by the Chinese version of the Short Form Health Survey
(SF-36) (Lam et al., 1998). The participants also reported less psychological
abuse and less minor physical violence, as measured by the Chinese version
of the Conflict Tactics Scale (Tang, 1994). Significantly fewer women in the
intervention group reported postnatal depressive scores of 10 or more, as
measured by the Chinese version of the Edinburgh Postnatal Depression
Scale, compared with those in the control group (Lee et al., 1998).
In a recent Cochrane Review, this trial passed high evidentiary stan-
dards. The Empowerment Intervention has now been further modified for
use in a community setting and tested in a randomized controlled trial
(Ramsay et al., 2009; Tiwari et al., 2010). At present, a proposal is under

way to test the efficacy of the intervention in Hong Kong among immigrant
women from China.
THE FOURTH R: A SCHOOL-BASED STRATEGY TO

PREVENT ADOLESCENT DATING VIOLENCE
David A. Wolfe, Ph.D.
Centre for Addiction and Mental Health,
Centre for Prevention Science and University of Toronto
Best Practices in School-Based Violence Prevention

This paper focuses on the prevention of adolescent dating violence, a
significant and commonly occurring form of violence and aggression among
this age group. The more common behaviors include insults, threats, and
intimidation (i.e., mostly abusive but not violent), which are reported
among a sizable minority of youths (25 to 35 percent). The significant rates
of and consequences associated with adolescent dating violence warrant a
public health approach focusing on promotion of healthy relationships and
prevention of dating violence, rather than relying solely on identification
and intervention with youths already perpetrating or experiencing dating
violence. Accordingly, this paper discusses the rationale and evidence for
school-based strategies to prevent adolescent dating violence and describes
findings from the Fourth R program that has been evaluated and expanded
in Canadian schools over the past five years (Wolfe et al., 2009).
Programs aimed at universal school-based violence prevention with
children and youths have been expanding in numbers and sophistication
since the early 1980s. Such programs have been delivered at all grade levels,
from pre-kindergarten through high school, and generally offer knowledge
and skills to all children in their own classroom settings (rather than special
pull-out classes). A recent systematic review and meta-analysis concluded
that there is strong evidence that universal school-based programs decrease
rates of violence among all ages of children and youths. However, none
of the 249 experimental and quasi-experimental studies of school-based
programs aimed at aggressive or disruptive behavior examined by these re-
views (all conducted prior to 2005) were aimed at reducing dating violence
(Hahn et al., 2007; Wilson and Lipsey, 2007). Currently there are only two
published controlled studies of universal school-based programs aimed at
dating violence (Safe Dates and the Fourth R), both of which are described
briefly below.
An advantage of school-based prevention is that programming can
be geared to match developmental stages and demands. Because children
who are aggressive in their relationships often progress from bullying to

harassment to dating violence as they age, school-based programming

provides the opportunity to match this developmental trajectory and ad-
dress the most salient forms of interpersonal violence at the appropriate
developmental stage (Connolly et al., 2000; Chiodo et al., 2009). A further
advantage is that programs can be delivered to all students by their teach-
ers, which avoids the stigma of being selected to attend a special program
and the cost of providing other resources.
Best-practice principles based on bullying and peer violence preven-
tion have considerable significance for dating violence initiatives. Reports
suggest that successful programs are comprehensive in nature, focus on
skills, pick appropriate targets for change, use peers, include parents, and
attempt to change the larger environment (Blueprints Violence Preven-
tion Initiative, www.colorado.edu/cspv/blueprints; Office of the Surgeon
General, 2001).2 In general, effective school-based programs take a more
holistic approach that recognizes the complexity and interrelatedness of
different settings for youths and offer knowledge and assistance that is
appropriately matched.
The most common feature of effective prevention programs is the
provision of opportunities to develop interpersonal skills. Skills training
usually involves modeling and practice in conflict management and problem-
solving skills, often incorporating a role-play component to give students
opportunities to increase their ability and comfort level with their newly
developed skills. For example, students may role-play strategies to deal with
or confront instances of bullying. In some programs, students meet in small
groups to discuss and role-play positive alternatives to problem behaviors.
Skills training is most effective if it is combined with accurate information
about risks and consequences and it is action-oriented, not merely a pas-
sive discussion of behavioral options. Some promising prevention programs
aimed at relationship-based violence also provide training in help-seeking
behavior, such as learning about and navigating social service agencies in
the community (Wolfe et al., 2003).
In addition to interpersonal and problem-solving skills, effective vio-
lence prevention programs target antisocial attitudes and beliefs associated
with aggression and violence. Activities to change attitudes can include
awareness-raising activities, such as information about violence against
peers or dating partners, and empathy-building exercises. For example,
students in the Bullying Prevention Program participate in such classroom
activities as role-playing, writing, and small-group discussions geared to-
ward helping them gain a better appreciation of the harm caused by bully-
ing (Olweus and Limber, 2010).
2 See Crooks et al. (2011) for further information.

Empirically Validated Dating Violence Prevention Programs

Given the relatively short history of dating violence prevention programs
and the challenges of implementation and evaluation, it is not surprising that
very few have been carefully evaluated with an appropriate randomized con-
trolled design and sufficient measurement and follow-up. Short-term changes
in attitudes and beliefs have been documented following classroom discus-
sions or assemblies, but few have had sufficient follow-up with the partici-
pants or evaluated actual behavioral change. A critical review conducted in
2006 found only two effective programs that had been rigorously evaluated
in a cluster randomized trial (Whitaker et al., 2006). One of these, the Youth
Relationships Project, is a selected prevention program for youths considered
to be at risk of dating violence because of histories of child maltreatment or
exposure to domestic violence (Wolfe et al., 2003). The other, Safe Dates, is a
program that was developed for universal implementation in schools (Foshee
et al., 2005). Since that 2006 review, a cluster randomized trial conducted
with the Fourth R was published, as described below (Wolfe et al., 2009).
Safe Dates is a school-based program based on the premise that changes
in norms regarding partner violence and gender roles coupled with im-
provement in pro-social skills lead to primary prevention of dating violence.
The stated goals of the program are to raise awareness of what constitutes
healthy and abusive dating relationship, raise awareness of dating abuse and
its causes and consequences, equip students with the skills and resources
to help themselves or friends in abusive dating relationships, and equip
students with the skills to develop healthy dating relationships. The skills
component focuses on positive communication, anger management, and
conflict resolution. Safe Schools is structured around nine 45-minute ses-
sions in school, with additional community components. School strategies
include curriculum, theater production, and a poster contest. Community
components include services for adolescents in violent dating relationships
and training for service providers. Teachers who implement the curriculum
component receive 20 hours of training, and community service providers
receive 3 hours. In a cluster randomized trial, Safe Dates reduced psycho-
logical, moderate physical, and sexual dating violence perpetration and
moderate physical dating violence victimization at follow-up. The program
seemed most effective with adolescents who were already involved in dat-
ing violence. Program effects were mediated by changes in dating violence
norms, gender-role norms, and awareness of community services (Foshee
et al., 2005).
The Fourth R: Skills for Youth Relationships is a curriculum-based pro-
gram for youths aimed at preventing dating violence by promoting skills for
healthy, non-violent relationships. The Fourth R is based on social learning
and positive youth development theories that emphasize skills, accurate

information, and youth involvement to reduce risk behaviors and increase

positive decision making in early adolescence. Unlike single-focused pro-
grams, the Fourth R integrates topics of dating violence, bullying, sexuality,
and substance use by focusing on their underlying relationship connections
rather than problem behaviors. The program is integrated into existing cur-
riculum requirements for all students attending health and personal safety
courses (typically in grades 8 or 9) and is taught by regular classroom teach-
ers to reduce costs and increase sustainability and availability.
The Fourth R curriculum targets common elements of dating and peer
violence (7 lessons), unsafe sexual behavior (7 lessons), and substance use
(7 lessons) from a developmental and educational perspective. An underly-
ing theme of healthy, non-violent relationship skills is woven throughout
the units to increase generalization across risk situations and behaviors.
There is extensive skill development using graduated practice with peers
aimed at the development of positive strategies for dealing with pressures
and the resolution of conflict without abuse or violence. Peer and dating
examples are used interchangeably to increase relevance for youths who are
not dating. Classroom activities enhance relationship skills through active
learning and role modeling of appropriate behaviors and are accompanied
by a Youth Safe Schools Committee and newsletters for engaging parents.
The program is adaptable to meet the needs of different communities geo-
graphically and culturally.
Results from a recent cluster randomized trial of the Fourth R school-
based program (1,722 students from 20 schools) indicated that teaching
youths about healthy relationships as part of their required health curricu-
lum reduced physical dating violence and increased condom use 2.5 years
later, especially for boys, at a low $16 per-student cost. Specifically, from
grade 9 to grade 11, physical dating violence (PDV) was significantly higher
for students in the control schools than for those in the intervention schools
(9.8 percent versus 7.4 percent, respectively; adjusted OR 2.42, p = .05).
Further analyses showed that the effect of intervention differed significantly
between boys and girls (p = .002). Boys in the intervention schools were less
likely than boys in control schools to engage in PDV (2.7 percent versus 7.1
percent; adjusted OR 2.77). However, girls had similar rates of PDV in both
groups (11.9 percent versus 12.0 percent). In addition, condom use among
sexually active boys was greater in intervention schools (114 of 168, or 68
percent) than in control schools (65 of 111, or 59 percent).
How Universal Programs Prevent Violence

Against Women and Children
Effective violence prevention programs empower young people to be in-
volved in the work, which then becomes rewarding through the promotion of

cooperation and mutual support. To foster healthy adolescent development,

simultaneous efforts to reduce or prevent risk behaviors are needed. These ef-
forts need to be matched with an equal commitment to helping young people
understand life’s challenges and responsibilities and develop the necessary
skills to succeed as adults. Youths need developmentally appropriate knowl-
edge and education, delivered in a nonjudgmental and highly salient format,
which emphasizes their choices, responsibilities, and consequences. Youths,
especially at-risk youths, need education and skills to promote healthy rela-
tionships, to develop peer support, and to establish social action aimed at
ending violence in relationships. They need to feel connected not only to their
peers, but also to their schools, families, and communities. Such connections
require a commitment to building capacity in each community to be inclu-
sive of all youths and to perceiving each adolescent as a person rather than
a potential problem. The ultimate act of inclusion is to empower youths to
identify the critical issues they face and the solutions that are most meaning-
ful to the reality of their lives and circumstances.3
In addition to providing improved skills and reducing dating violence,
universal programs such as the Fourth R may serve to buffer the effects of
poor relationship models that adolescents experienced while growing up (an
important factor in reducing the cycle of violence). At post-test, youths who
had reported a history of child maltreatment at pre-test engaged in fewer
acts of violent delinquency, such as fighting or carrying a weapon, than
youths with similar maltreatment histories but no school-based intervention
(Crooks et al., 2007). Notably, this finding of reduced violent delinquency
among youths with maltreatment histories was replicated two years later at
follow-up (Crooks et al., in press). The differential impact of this program
on youths with child maltreatment histories may be due to the emphasis on
healthy relationships and positive relationship skills, and on the resulting
focus on safe and respectful behavior in the school. That is, youths who
have experienced maltreatment and been exposed to violent, coercive mod-
els of relationships in their families typically have not had opportunities to
learn healthy alternatives, and they are the youths for whom opportunities
to learn healthy, non-violent relationship skills and to attend school in an
environment where these skills are emphasized are essential.
How These Efforts Can Be Applied in Different

Settings and with Different Resources
Programs need to be designed with attention to details that increase
their likelihood of implementation and sustainability from the outset. There
3 See Wolfe et al. (2006) for discussion of theoretical and empirical support for youth
involvement in violence prevention.

are a number of areas to consider in designing a program or approaching a

school district to consider implementing a program. There are areas of po-
tential alignment that increase the acceptability and potential sustainability
of a program (e.g., aligning with curriculum expectations or state policies).
There are also potential barriers that need to be identified and addressed
prior to presenting a case for adoption of a program in a school setting
(e.g., the costs of specialized training and school policies about not allow-
ing non-teachers to present programs during school time). In some cases it
is possible to deal with these barriers, and an awareness of them and the
opportunity to identify possible solutions prior to meeting with educational
partners can go a long way. Finally, identifying possible champions within
the school system may facilitate the adoption of a program.
One significant challenge lies in examining cultural differences in the
nature of dating violence and identifying how programs may need to be
significantly revamped in addressing different populations. Beyond looking
at a deficit-based model that identifies certain racial or ethnic groups as be-
ing at higher risk for dating violence, we need to look at ways that cultural
strengths can be accessed as protective factors in interventions.
An implementation study of Canadian schools that have adopted the
Fourth R revealed that a critical factor in administrators choosing this
violence-prevention curriculum was the research base of the Fourth R and
the perception of the program’s potential to have a positive impact on stu-
dents (Crooks et al., 2008). The curriculum-based nature of the program
was also considered important. The greatest potential barrier was the time
required to implement the program. We think that this response reflects the
bias that violence prevention and health education is still seen as an add-
on to the broader health and physical education domain rather than being
viewed as an integral component worth 25 or 30 hours of instruction. The
length of the program was based on the recommended guidelines of the
Ontario Ministry of Education, and other provinces have similar guidelines.
Thus, it is not that the program itself is lengthy compared to the mandated
requirement; rather, people are still shifting their perceptions about the ap-
propriate amount of health instruction in the classroom.
Since its evaluation was completed in 2007, the Fourth R has been
implemented in more than 1,200 schools in Canada and more than 100
schools in the United States. Approximately 350 communities have imple-
mented the program, with an estimated 100,000 students each year learning
its lessons. In the 2009-2010 school year, approximately 450 new teachers
were trained in 225 different schools, and, as a result, an estimated 20,000
new students have received the Fourth R curriculum in those teachers’
classrooms. All 10 provinces and 3 territories in Canada have communities
implementing the Fourth R. In the United States it has been distributed to
various schools and agencies in Alaska, Idaho, Massachusetts, New York,

Illinois, Ohio, Texas, Missouri, Michigan, Alabama, California, Rhode

Island, Washington, and Kansas. Four U.S. evaluation sites are currently
using the program as part of the Robert Wood Johnson Start Strong teen
dating violence prevention initiative: Bronx, New York; Providence, Rhode
Island; Wichita, Kansas; and Boise, Idaho. The program also has been
adapted for Canadian Aboriginal populations (First Nations, Metis, and
Inuit), Catholic schools, and students in Alternative Education settings.
The website www.youthrelationships.org has additional information on
the program and research.
THE COMMUNITY ADVOCACY PROJECT:

AN EVIDENCE-BASED PSYCHOSOCIAL INTERVENTION
FOR WOMEN WITH ABUSIVE PARTNERS
Cris M. Sullivan, Ph.D.
Michigan State University
The Community Advocacy Project (CAP) is a 10-week psycho-social

intervention for women with abusive partners, which has been shown to
decrease women’s risk of re-abuse and to increase their psychological and
social well-being. The intervention involves providing trained advocates to
work one-on-one with women, helping them generate and access the com-
munity resources they needed to reduce their risk of future violence from
their abusive partners. Such resources include, but are not limited to, legal
assistance, employment, education, housing, social support, and medical
care. Like other interventions, CAP is grounded in a number of assump-
tions. An exhaustive review of the scholarly literature, coupled with numer-
ous conversations with survivors of intimate male violence, led the author
to the following conclusions that guide the intervention:
• Intimate male violence against women is too widespread to be at-

tributed to intrapsychic dysfunction or “relationship problems.”
• Women with abusive partners are by and large active help seekers
who go to great lengths to protect themselves and their children.
• Positive social support and access to community resources protect
women from risk of re-abuse.
• Intimate male violence against women is often tolerated, if not con-
doned, by many segments of the community, including the criminal
legal system.
• The community response to domestic violence is a critical factor
in whether a woman will be victimized (and re-victimized) by an
intimate partner or ex-partner.

Development of the Program

CAP was designed as a family-centered model, focusing on the strengths
and unmet needs of clients, as opposed to client “deficits” (Dunst et al.,
1991; Sullivan and Bybee, 1999). The family-centered model requires that
families guide the services they receive and that clients’ natural support
networks are involved in the advocacy process. The efficacy of the family-
centered model and the positive implications for consumers served by a
family-centered paradigm have been established across a number of dif-
ferent service domains (Marcenko and Smith, 1992; Scannapieco, 1994;
Markle-Reid et al., 2006). Although some family-centered interventions
employ professionals to work with families, paraprofessional volunteers
have been found to be highly successful change agents for numerous popu-
lations. The use of paraprofessionals increases the generalizability of the
intervention, as it is often easier and less costly for communities to locate,
train, and supervise them. Therefore, the decision was made to train under-
graduate female college students to serve as the paraprofessional advocates
within this intervention.
Components of the Program

Advocates work one-on-one with women in the women’s homes and
community for 4 to 6 hours per week over 10 weeks. The two primary com-
ponents of the advocacy intervention are to (1) help survivors of domestic
violence protect themselves and their children from further violence and
(2) actively advocate for women by generating and mobilizing community
resources they report needing. Safety plans are discussed and individual-
ized based on each woman’s unique circumstances. Regardless of whether
women are living with their assailants, advocates discuss what to do in case
of emergencies, and they establish plans in case they are ever surprised by
the assailants while working together.
The second component of CAP involves actively advocating for and
supporting survivors to help them address their self-identified needs and
concerns. A critical emphasis of this 10-week intervention is that the survi-
vor decides what is worked on, and she guides all aspects of the interven-
tion. The type of advocacy provided through this intervention consists of
five distinct phases: assessment, implementation, monitoring, secondary
implementation, and closure.
Assessment consists of two components: gathering important informa-
tion regarding the woman’s needs and goals and determining which com-
munity resources might appropriately meet those needs. After the unmet
need has been determined and various community resources have been
brainstormed, the advocate and woman move into the implementation
phase of generating or mobilizing the community resources.

The implementation stage involves actively working in the community

to obtain resources and to make the community more responsive to women’s
needs. If, for example, the woman is looking for new housing, the advocate’s
role is not simply to hand her information or make suggestions about next
steps. Rather, the advocate would accompany the client through the entire
process. This active participation has a number of beneficial outcomes: the
client feels emotionally supported through difficult processes, the woman is
sometimes treated more respectfully or expeditiously because she is accom-
panied by an advocate, and the advocate becomes a witness to events in case
there is a later dispute between the woman and systems. Another benefit of
this type of teamwork is that the advocate gains firsthand knowledge about
the hassles and difficulties involved in obtaining many community resources,
which often increases her respect for her client’s diligence and determination.
Monitoring the effectiveness of the implemented intervention is accom-
plished by assessing whether the resource has been successfully obtained,
and whether it is satisfactory to meeting the unmet need.
If it is not, then the advocate initiates a secondary implementation to
meet the client’s needs more effectively. For example, the advocate and
client might obtain convenient and affordable child care for her preschool
children. The advocate’s role would be to continue to ask how the child care
is working out: Do the children enjoy it? Is the mother satisfied? Is there
a backup plan in case of emergency? If the resource is not as adequate as
originally hoped, then a secondary implementation—generating or mobiliz-
ing a different community resource—is necessary.
Closure begins approximately 7 to 8 weeks into the 10-week interven-
tion. During this phase, advocates work more intensively on transferring all
of the skills they learned throughout training and supervision. Through role
playing, coaching, and discussions, the advocate ensures the woman can
effectively advocate on her own behalf with resistant or hostile community
providers after the intervention ends.
Although the five phases of advocacy intervention have been described
here as distinct stages for clarification purposes, in reality advocates en-
gage in various phases simultaneously. Multiple interventions may occur
throughout the 10 weeks, such that, for example, the advocate may be
monitoring one intervention while initiating another.
Combining Systems Advocacy and Individual-Level Advocacy

Advocacy efforts are generally classified as either individual based—
working specifically with or on behalf of individuals to ensure access to
resources and opportunities—or systems based, which entails advocating to
change and improve institutional responses. In reality, many advocacy efforts
involve working to change systems and assisting individuals simultaneously.

CAP is designed to do exactly this by providing numerous individualized

advocacy interventions and working with other community-based groups,
with the intention of ultimately creating community-level change.
Evidence for the Effectiveness of the Intervention

A number of studies have been conducted to evaluate experimentally
the effectiveness of this intervention over time. The initial feasibility study,
funded by the George Gund Foundation (1986-1988), included 41 women
(24 randomly assigned to work with advocates). Women were interviewed
pre-intervention, post-intervention, and at a 10-week follow-up. Findings
were positive, with women in the experimental condition being more suc-
cessful in obtaining desired resources than were women in the control
group. The feasibility study is described in more detail elsewhere and was
promising enough that the author received funding from the National Insti
tute of Mental Health (NIMH, 1989-1997) to continue the research on a
larger scale (Sullivan and Davidson, 1991).
The larger-scale NIMH study included a true experimental, longitu-
dinal design. Effectiveness of the advocacy intervention was examined
by randomly assigning 278 women exiting a shelter to the advocacy (ex-
perimental) or services-as-usual (National Center for Injury Prevention
and Control) condition. Participants were interviewed six times over two
years, with interviews occurring pre-intervention, post-intervention, and
at 6, 12, 18, and 24 months after intervention. An elaborate protocol was
implemented to maximize retention of the sample over time, and this pro-
tocol resulted in retention rates at any given time of 94 percent or higher.
Rates were not significantly different between the advocacy and control
conditions. The specific components of the retention plan can be found in
Sullivan et al. (1996).
The immediate impact of the advocacy intervention in helping women
access resources was assessed post-intervention by a simple between-
conditions comparison of women’s ratings of their effectiveness. Women
in the advocacy condition reported being more effective in reaching their
goals than women in the control condition. The short-term impact of the
advocacy intervention on the major outcome variables—experience of fur-
ther physical violence, psychological abuse, depression, social support,
and quality of life—was tested through multivariate analysis of covariance
(MANCOVA). Physical violence and depression were lower in the advocacy
condition, while quality of life and social support were higher.
Doubly multivariate repeated-measures MANOVA was then used to
test for the persistence of experimental–control group differences on the
major outcomes across the next two years. Women who worked with
advocates reported higher quality of life and social support over time as

well as decreased difficulty obtaining community resources. Perhaps most

importantly, women who worked with advocates also experienced less
violence over time than did the women who did not work with advocates.
Articles containing more detailed descriptions of the multivariate analyses
and findings include Sullivan et al. (1992); Sullivan (2000, 2003); Bybee
and Sullivan (2002, 2005); Goodkind et al. (2004); Beeble et al. (2009).
Adapting CAP to Other Communities

CAP can be adapted to meet a variety of a community’s needs and to
assist a wide range of domestic violence survivors. Although the p roject
originated in a mid-sized city close to a university campus, it can be
modified for larger cities as well as for more rural communities. Similarly,
although the original studies focused on women who had used domestic
violence shelter programs, CAP is equally applicable for women using
non-residential support services or who are not receiving any community
services at all (e.g., women exiting jails or prisons).
As more and more individuals consider replicating or modifying this
program, questions arise regarding implementation issues. The most com-
mon concerns are discussed in the following sections.
How Do You Keep Women from Becoming Too Dependent on the

Advocate?
For those individuals who are prone to becoming overly dependent on
others, such dependency is minimized by the short time frame (10 weeks)
of the intervention and the clearly delineated end date. It is important to
note, however, that this question typically arises from individuals who view
women with abusive partners as “not like me.” We all depend on informal
or formal advocacy-type assistance at various times in our lives (whether in
the form of family helping us gain employment, friends accompanying us
to the doctor, colleagues sharing information about opportunities or com-
modities, or something else). The more disenfranchised that individuals are
from society, the fewer networks they have to rely on for such assistance.
This advocacy model is predicated on the beliefs that we could all use more
information about resources and how to obtain them and that we can all
use a supportive person in our lives through difficult times.
We Don’t Have a University in Our Area. Would This Type of Advocacy

Project Work Using Volunteers Instead of Students?
An important next step in exploring the usefulness and generalizabil-
ity of this intervention will be to investigate whether volunteers would

advocate for women as effectively as university students. One reason col-

lege students are preferable to volunteers is that they are paying for the
experience (through tuition) and earning a grade and potential letter of
recommendation for their efforts. This maximizes the likelihood they will
work the required hours each week and make this intervention a priority
in their lives. It is only natural that when busy individuals have to prioritize
their time, it is their volunteer work that usually gets short shrift. A major
concern in using volunteers as advocates is that they may be more likely
to quit mid-way through the intervention or to put in fewer hours or less
effort than is necessary to be effective.
On the other hand, volunteers are quite capable of becoming excellent
advocates and, with appropriate training and supervision (ideally from a
paid staff member), could do as well if not better than university students.
Another advantage of using volunteers is that they may come from more
diverse backgrounds than typical university students. Domestic violence
service programs might consider aligning with church groups, community
organizations, or other volunteer programs to obtain a paraprofessional
advocacy workforce conducive to their individual needs.
Shouldn’t an Intended Goal of the Project Be to Help Women Leave the

Relationship?
It cannot be overemphasized that an integral component of this model
is to follow the woman’s lead in determining goals. Encouraging a client
to make certain choices over others is not only disrespectful but is also
likely to fail in creating lasting change. Individuals have multiple and
complex reasons for making life choices, including relationship decisions.
Ending the relationship not only does not necessarily end the violence, but
also it sometimes escalates the violence (Sev’er, 1997; Fleury et al., 2000).
The advocate’s role must be to help women do what they can to protect
themselves and their children, regardless of whether women are in or out
of the relationship. Advocates can offer information to help women make
decisions, but they should never push a woman toward one path over an-
other. Working from a strengths perspective involves viewing individuals as
naturally competent and capable, possessing valuable skills and abilities to
make decisions and create positive change in their own lives.
Had we assumed in our research that leaving the relationship should be
a desired outcome for all women, we would have analyzed whether women
who worked with advocates were more effective in leaving the relationship
than were women in the control group. This analysis would have indicated
no differences between the two groups. However, when we looked at group
differences only for women reporting they wanted to end the relationship,
a significant difference emerged. Women who worked with advocates were

more effective in ending the relationship when they wanted to than were
women in the control condition (96 percent versus 87 percent).
If a Major Goal of the Advocacy Intervention Is to Help Women Become

Safe, Why Not Just Focus on Legal Advocacy?
Interestingly, only 72 percent of the women worked on legal advocacy
issues during the NIMH-funded study, and not all of those issues pertained
to the assailant. Some women, for example, were fighting their landlords
in court or had been charged with other crimes themselves. Legal advocacy
programs are important and necessary resources for women choosing to use
the court system. However, many women choose alternatives to the crimi-
nal justice system to keep themselves and their children safe. Furthermore,
women reported having a variety of interrelated concerns needing to be
addressed, and this intervention was found to be equally effective regardless
of the types or extent of such needs (Allen et al., 2004). The more general-
ized our advocacy efforts can be, the more lives we can effectively touch.
Importance of the Program’s Underlying Philosophy

Although each advocacy intervention must be individualized to meet
the unique needs of each participant, all interventions should be guided by
three theoretical tenets that contribute to project effectiveness. First, the
participant, not the advocate, should guide the direction and activities of
the intervention. This relates to the second supposition, which is the belief
that survivors are competent adults capable of making sound decisions for
themselves. Third, the role of the advocate is to make the community more
responsive to women’s needs, and this involves active and pro-active work
in the community.
USING A SYSTEMS-MODEL APPROACH TO IMPROVING IPV

SERVICES IN A LARGE HEALTH-CARE ORGANIZATION
Brigid McCaw, M.D., M.S., M.P.H., FACP
Family Violence Prevention Program, Kaiser Permanente
Intimate partner violence (IPV) is a common and costly health problem

associated with substantial medical and mental-health issues for victims and
their children. Women, the most common victims of IPV, access the health
care system frequently over the course of their lives for preventive and rou-
tine care as well as for trauma and abuse-related conditions. Thus, health
care offers many valuable opportunities for early identification, tailored
interventions, and primary prevention.

Despite these opportunities, identification and intervention for IPV is

not a common or consistent practice in most health care settings. This is
unfortunate, but not surprising. For many years clinical practice guidelines
and recommendations from professional organizations focused primarily on
the training of clinicians. Over time, however, it became clear that clinician-
focused efforts had only limited success, producing little or no increase in
the rates of identification and referral.
In 2001 the Institute of Medicine (IOM) urged health care delivery
systems to develop and evaluate innovative programs that would go beyond
traditional clinician training methods for addressing IPV. In a report titled
Confronting Chronic Neglect: The Education and Training of Health Care
Professionals on Family Violence, the IOM called attention to a 1998 pilot
program, implemented by Kaiser Permanente Northern California, which
had been associated with a significant increase in rates of screening, identi-
fication, and referral to mental-health clinicians and had been well accepted
by clinicians. The IOM report noted that Kaiser Permanente had achieved
these results by implementing a “systems-change model” in which clini-
cian training was just one component of a larger intervention designed to
make use of the entire health care environment—not just the doctor office
visit—to address intimate partner violence.
Since its 1998 pilot Kaiser Permanente has disseminated the systems-
model approach to medical centers throughout the Northern California
region (serving 3.2 million members), and currently implementation is
under way in eight additional regions across the country. Outside of Kaiser
Permanente, the approach is being adapted for use in other clinical settings,
both in the United States and abroad.
This summary will describe Kaiser Permanente’s systems-model ap-
proach to delivering services for IPV, including how this approach has
been implemented and evaluated. We will provide an update on Kaiser
Permanente’s progress over the past 10 years on the program’s development
and dissemination, giving special attention to what has been learned that
may be of value to those who set out to implement this approach in other
health care settings.
Organizational Setting: What Kaiser Permanente

Brings to the Issue of IPV
Kaiser Permanente is one of the largest not-for-profit, integrated health
care delivery systems in the United States, serving 8.7 million members
in eight regions. The Kaiser Permanente workforce comprises more than
15,000 physicians and 164,000 employees.
Kaiser Permanente presents a unique opportunity for implementing
IPV services and prevention because it provides the entire scope of care:

outpatient, inpatient, emergency, and behavioral health services. Kaiser Per-

manente has a fully implemented electronic health record system, extensive
experience in management of chronic conditions, a team-based approach to
care, recognized research expertise, and a strong commitment to prevention
and health education—all grounded in a social mission. These elements
make it an ideal “laboratory” for developing and implementing new models
of care and addressing complex health issues.
The Kaiser Permanente Systems-Model Approach

The systems-model approach has five components: (1) a supportive
environment (Sullivan et al.), (2) clinician inquiry and referral, (3) on-site
IPV services, (4) linkages to community resources, and (5) leadership and
oversight.
Figure 8-1 below depicts how each component is a necessary and in-
terconnected piece of a coordinated health care response. It also lists the
interventions used for each component.
FIGURE 8-1 Systems model for intimate partner violence prevention.

SOURCE: McCaw, 2011.

Testing the Systems-Model Approach: The 1998-1999 Pilot

In 1998 funds were allocated to develop, implement, and test an in-
novative systems-model approach to improving IPV services in one small
medical center (serving 70,000 members) in the Kaiser Permanente North-
ern California region. The idea was to go beyond the traditional approach
of focusing primarily on didactic training of clinicians.
The systems-model approach makes use of the entire health care envi-
ronment to address IPV prevention. This approach was chosen based on
prior research showing the effectiveness of systems change for other clinical
and safety issues (Thompson et al., 1995). The effectiveness of the pilot was
evaluated based on evidence of actual change in clinician practice (increased
IPV identification and referral) rather than on the traditional knowledge-
and-attitude survey of clinicians.
The pre- and post-implementation evaluation of the pilot demonstrated
a dramatic and statistically significant increase in screening rates, identifica-
tion, and referral to a mental-health clinician, and the approach was well
accepted by clinicians. In addition, after the implementation, more members
recalled being asked about IPV, noticed IPV information available at the
facility, and reported increased satisfaction with the health plan (McCaw
et al., 2001; Kimberg, 2007).
In recognition of its success in boosting rates of IPV identification
and referral, the Kaiser Permanente program was chosen by the American
Association of Health Plans/Wyeth as the 2003 Gold Winner of its HERA
award, presented each year to an exemplary program that advances quality
in women’s and children’s health care.
Disseminating the Approach to Other Kaiser Permanente

Medical Centers in Northern California
Over the next two years, the model was transferred to six more Kaiser
Permanente medical facilities in Northern California through the guidance
of a physician champion and a multidisciplinary team in each facility. This
success led to identification of an “executive sponsor” and funding for
a part-time medical director and project manager to facilitate rapid and
efficient implementation across all 49 medical facilities in the Northern
California region.
The job of the physician director and project manager was to provide
consultation to medical facilities, identify and spread best practices, and
ensure that IPV was integrated into region-wide operations—including
scripts and protocols for use by nurses in the appointment-and-advice call
center, data systems for quality improvement, the electronic health record,
and on-line and printed resources for clinicians and members.

Tools developed to facilitate local implementation included a descrip-

tion of the roles and responsibilities of the physician champion and members
of the multi-disciplinary team and a phased work plan for implementing the
systems-model approach. Patient education materials, reviewed for read-
ability and cultural appropriateness, were designed to be easily customized
with local resource information.
Currently each Kaiser Permanente medical center in Northern Califor-
nia has a multi-disciplinary team led by a physician champion. These teams
meet regularly, implement the systems-model approach at their medical fa-
cility, provide training to clinicians and front-line staff, respond to quality-
improvement data, and ensure that IPV identification and referral is part of
everyday patient care. Twice a year members of teams from every medical
center come together for leadership development, sharing of innovative
practices, updates on research, review of quality metrics, and development
of annual goals and strategy.
Although medical facility–based teams ensure the local implementa-
tion of the systems-model approach, the role of regional leadership and
oversight is also important to make certain that activities are coordinated
among medical centers, that new research data is incorporated, and that
“lessons learned” and best practices are widely disseminated. The re-
gional medical director and program director meet regularly with other
leadership groups and the executive sponsor to evaluate the progress of
implementation, review quality-improvement metrics, and identify op-
portunities to integrate with other initiatives. Sponsorship from the top
is critical in sustaining the momentum of the work. An executive sponsor
can increase the program’s visibility, assist with goal setting, identify and
procure resources, and, when necessary, participate in problem solving
(McCaw and Kotz, 2009).
Clinician training, although it is not the primary focus of the systems-
model approach, is essential. To maximize its effectiveness, training is of-
fered in multiple ways and venues including: lectures as part of continuing
medical education, brief departmental updates, case presentations, on-line
training tools, and reports on quality-improvement data. Clinicians are of-
fered multiple options for incorporating IPV screening into their practices
in a way that is comfortable and natural for them. Cultural considerations
are incorporated into all training.4
4 For further information, see McCaw, B. 2009. Intimate partner violence. In A provider’s
handbook on culturally competent care: Women’s health. Kaiser Permanente National

Diversity Council.

Tracking Progress Using Quality-Improvement Measures

In the initial 1998 pilot project, success was measured by tracking the
number of patients identified and referred by clinicians. Later, during the
dissemination of the systems-model approach to other Northern California
medical facilities, an opportunity arose to track progress by using already
existing quality and outcome measurement systems that are based on auto-
mated diagnosis databases. In 2002 Kaiser Permanente Northern California
selected Improving IPV Prevention to demonstrate implementation of a
behavioral health prevention guideline that shows coordination between
primary care and mental health to meet an NCQA standard.5
The quality measures used to track progress toward Improving IPV
Prevention are similar to those used for other health conditions, such as
asthma, diabetes, hypertension, and depression. These measures provide
data to monitor performance over time, between medical centers and de-
partments, and to help teams focus their training and other improvement
efforts.
The quality-improvement measures include both qualitative (process
measures) and quantitative (measures based on clinical identification). The
three process measures for each medical center are: (1) a physician or nurse
practitioner champion, (2) a multi-disciplinary implementation team, and
(3) an inter-departmental referral protocol for members experiencing IPV.
The quantitative measures are designed to answer the following three
questions:
1. How many members received the IPV diagnosis?

2. How does this compare to the estimated number of Kaiser Perma-
nente members who are likely to be experiencing IPV?
3. Of the patients diagnosed, how many received appropriate referral
and follow-up?
Data collection for the quantitative measures utilizes diagnosis codes

from outpatient and emergency department medical visits, which are en-
tered into an automated database. The number of members likely to be
experiencing IPV is based on a prevalence estimate of IPV (in the previous
12 months) among women health-plan members aged 18–64 years. This es-
timate is drawn from a survey of health-plan members and from published
prevalence estimates (McCaw and Kotz, 2005).
5 For information about the NCQA standards, see http://www.innovations.ahrq.gov/content.

aspx?id=2343.

What the Data Show

The data gathered through the quality-improvement measures show
that from the program’s inception in 2000 through 2010 there was a six-
fold increase in women and men newly identified with IPV (see Figure
8-2). These results far exceed what might have been expected based on the
promising 1998 pilot test.
Figure 8-3 shows the number of women and men newly diagnosed
with IPV each year, by department. A notable trend is that identification
has steadily shifted to less acute settings, such as primary care and mental
health, suggesting that patients are being identified earlier, before more
potentially serious injury occurs.
Although not shown in Figures 8-2 and 8-3, two additional findings
from the data are notable: Of members newly diagnosed, more than 50 per-
cent received follow-up mental-health services, and the IPV identification
rate increased every year—that is, of the total number of Kaiser Permanente
women members estimated to be experiencing IPV, an increasingly greater
proportion were being identified.
Additional Lessons from Implementation

The Role of Technology
Over the 10-year implementation, “technology enablers” have proven
invaluable. For example, clinicians can draw on tools embedded in the
FIGURE 8-2 Members diagnosed with intimate partner violence, 2000-2010.


FIGURE 8-3 Number of women and men newly diagnosed with IPV.
Kaiser Permanente electronic health record to facilitate documentation of

IPV, make referrals, and learn about best practices. Clinicians can also ac-
cess point-of-care patient handouts about IPV and direct patients to Inter-
net resources in both text and video formats. On-line video training allows
clinicians to view demonstrations of how to provide caring, effective, and
efficient interventions.
IPV services have also been incorporated into Kaiser Permanente’s
appointment-and-advice call center. Use of this service has increased dra-
matically over the past 10 years. Advice nurses, trained in how to inquire
about IPV and equipped with IPV-related scripts and protocols, can respond
immediately to members who contact the health care system by phone,
directing them to the appropriate Kaiser Permanente venue of care as well
as to community resource information.
Engaging the Kaiser Permanente Workforce

The demographics of most health care workforces (made up in large
part by women of childbearing age) means that IPV is, unfortunately,
a common issue for many employees and their families. Although ini-
tial implementation of the systems-model approach focused on provid-
ing resources and information to health-plan members, it quickly became
clear that the Kaiser Permanente workforce was another key audience that
needed information about resources available in the workplace. Over time

an additional benefit of this workplace outreach emerged: Employees who

had learned about IPV became an essential aspect of the supportive environ-
ment provided for members.
One example of an innovative approach to reaching employees is the
“Silent Witness Display”—a large exhibit that presents the real-life stories
of Kaiser Permanente physicians, medical staff, and employees who have
dealt with IPV. These stories of courage, hope, and survival reflect the di-
versity of the Kaiser Permanente workforce in age, career type, and ethnic
background. The exhibit travels to every Kaiser Permanente medical facil-
ity and is regarded as a powerful tool for increasing awareness of IPV, its
impact on employees and their families, and the resources available to both
employees and members. The stories and the display are available at http://
www.kp.org/domesticviolence/silentwitness/index.html.
Research Collaborations
From the very beginning clinician–researcher partnerships have been in-
valuable. The well-designed evaluation of the pilot program yielded findings
that were both clinically meaningful and operationally useful. These findings
helped to make the case for dissemination to other medical centers, justify
the allocation of regional resources, and secure “buy-in” from front-line clini-
cians. The evaluation also generated additional information on women who
experience IPV, including demographics, perceived health status, and reasons
for accepting referral for follow-up (McCaw et al., 2002, 2007).
Over the past decade, engagement with other Kaiser Permanente re-
searchers has led to inclusion of IPV as a risk factor in studies of diabetes
and self-care, breast-cancer survivorship, incontinence, contraceptive use, and
chronic pain. IPV has also been included in studies that have implications
for improving health care delivery—such as the impact of electronic referral
on mental-health services utilization and predictive modeling using regional
call-center data (Ahmed and McCaw, 2010). A study is now under way to
compare health care utilization by IPV women who receive an intervention
in the health care setting to those who do not receive an intervention.
Challenges of Community Linkages

In contrast to other potentially life-threatening health conditions (for
example, heart attack), victims of IPV may need life-saving interventions
(such as emergency shelter and a restraining order) that are more appropri-
ately provided outside the health care setting and that require the expertise
of community advocates, law enforcement, and criminal justice. Thus, the
development of strong partnerships between health care and community
resources is a key element of the systems-model approach.

However, the development of community partnerships is often chal-

lenging because of the differing perspectives of health care providers and
the staff of community agencies. Health care providers tend to view the
medical center as a self-contained entity and may not know how—or why—
to engage community partners in their work. For them, reaching out be-
yond the walls of the facility often requires a fundamental shift in thinking.
On the other hand, staff at community agencies may not be familiar
with the “language” of health care—its quality-improvement metrics, or-
ganizational hierarchy, and clinic workflow. These contrasting perspectives
grow out of differences in training, background, expectations, pressures,
funding sources, and staff turnover. The result is that health care facilities
vary widely in how well community partners are included in the planning
and implementation of the systems-model approach.
Dissemination to Other Kaiser Permanente

Regions: Scaling-Up and Sustainability
Over the past five years, the remaining eight Kaiser Permanente re-
gions have embarked on implementing the systems-model approach. This
scaling-up of the program was inspired by its successful adoption in the
Kaiser Permanente medical facilities in Northern California and also by the
compelling data showing improvement in IPV identification and referral.
Each of the eight regions has designated a physician champion and formed
a multidisciplinary team.
Although each region exercises some degree of autonomy in its imple-
mentation, an effort has been made to maintain consistency across regions.
All regions have adopted the implementation tools developed for Northern
California—for example, the phased “work plan”—and are using them
successfully. All have adopted a single set of member-education materials
that can be customized to each region. All are offering resources to their
Kaiser Permanente workforces, including on-line manager training and the
“Silent Witness Display” described above. In addition, a set of IPV “Smart-
Tools” has been added to the program-wide electronic health information
system to facilitate identification, evaluation, documentation, referral, and
the provision of resource information and safety planning for members.
Quarterly conference calls among the regions’ leadership also help
to maintain consistency by providing an opportunity for regions to share
best practices, learn about new research, leverage resources, explore inter-
regional initiatives, and set common goals.
In the course of the dissemination throughout Kaiser Permanente, it
has become clear that to be sustainable the IPV prevention services must
be closely aligned with other Kaiser Permanente priorities: ensuring mem-
ber safety, improving coordination of care, increasing efficiency, enhancing

service, and reducing health care disparities. Most importantly, IPV pre-
vention services must be incorporated into the everyday care of members.
To the extent that IPV prevention can be aligned with these larger
goals, executive decision makers will come to see the program as an im-
perative and a positive investment. This top-level support is evident in com-
ments made at a 2007 CEO Roundtable by Robert Pearl, M.D., executive
director and chief executive officer of the Permanente Medical Group: “IPV
prevention is part of a strategic approach to quality, service, and afford-
ability. By doing the right thing, we can improve quality outcomes, member
satisfaction, and the personal lives of our patients, while also decreasing
costs to employers and individuals.”
Beyond Kaiser Permanente: Opportunities for Adoption

of the Systems-Model Approach in Other Settings
In response to inquiries from other health care delivery organizations
in the United States and abroad about how to implement the systems-
model approach, information and tools have been made available at the
Innovations Exchange operated by the Agency for Healthcare Research
and Quality and on the United Nations website, the Virtual Knowledge
Centre to End Violence Against Women and Girls (www.endvawnow.org).
To facilitate implementation at facilities outside of Kaiser Permanente, it
has been important to develop tools that are general enough to be easily
adapted to new sites.
As the systems-model approach has been adopted by other sites, the im-
plementation has been tailored to address a range of cultural issues including:
• age (messaging focused on teens),

• ethnicity (attention to differences in values and communication
style),
• language (translations of the member education materials),
• sexual preference (gender neutral), and
• religion (inclusion of faith communities in community partnerships).
It is particularly exciting to see how the systems-model approach is be-

ing adapted in other countries. In the community clinics in Bangalore, India,
where the approach is being used to improve the response to gender-based
violence, the intervention also reaches out to the mothers-in-law of women
identified as victims of violence. And, in lieu of the “on-site” services used
in the Kaiser Permanente facilities, the clinics’ community outreach workers
are trained to offer IPV information and counseling as part of their routine
home visits. Such cross-cultural adaptations of the systems-model approach
open exciting opportunities for a bilateral exchange of learning.

The Way Forward

The list below highlights key “lessons learned” that have emerged from
the 12-year evolution of the Kaiser Permanente systems-model approach to
improving services to members experiencing intimate partner violence. It is
hoped that these lessons will be of use to other health care delivery systems
as they set out to implement, disseminate, and sustain programs to improve
their response to intimate partner violence.
• Use a consistent approach based on systems-model thinking.

• Select a clear conceptual model that is comprehensive and read-
ily customized to available resources (for example, Figure 8-1).
• Implement the approach with local physician or nurse practi-
tioner champions and multi-disciplinary teams.
• Provide organizational leadership to ensure consistency of ser-
vices, alignment with other health initiatives, and dissemina-
tion of innovative practices.
• Identify qualitative and quantitative measures to ensure continuous
quality improvement.
• Take advantage of “technology enablers” to improve services.
• Engage the health care workforce as a partner.
• Establish clinician-researcher partnerships to ensure a robust design
for both the program and its evaluation, and to ensure that evalua-
tion will yield credible findings that are clinically and operationally
meaningful.
Summary
Over the next decade, health care organizations will be called upon
to assume an increasingly important role in society’s response to intimate
partner violence and other forms of family violence—through primary pre-
vention, early identification, and effective interventions. Over its 12-year
evolution, the Kaiser Permanente systems-model approach has achieved a
six-fold increase in the identification and referral of members experiencing
intimate partner violence and has been successfully replicated throughout
this large health care organization. Examples such as the Kaiser Perman-
ente approach that demonstrate measurable results and that can be easily
adapted for other settings are essential to propel the field forward.
Acknowledgments
Program implementation and dissemination: Krista Kotz, Ph.D., M.P.H.,
program director, Family Violence Prevention Program, Kaiser Permanente,

Northern California; Violeta Rabrenovich, M.H.A., CHIE, director, Medical

Group Performance Improvement, The Permanente Federation, LLC
Executive sponsorship: Donald Dyson, M.D., associate executive direc-
tor, Permanente Medical Group; Amy Compton-Phillips, M.D., associate
executive director, quality, The Permanente Federation, LLC; Jed Weissberg,
M.D., senior vice president, Kaiser Foundation Health Plan and Hospitals,
Kaiser Permanente
Research partnerships: Division of Research, Kaiser Permanente North-
ern California: Enid Hunkeler, M.A.; Ameena Ahmed, M.D., M.P.H.;
Nancy Gordon, Ph.D.; Leonard Syme, Ph.D., professor emeritus, School
of Public Health, UC Berkeley
Writing assistance: Meg Holmberg, M.S.W.
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Workshop Agenda
WORKSHOP ON PREVENTING VIOLENCE

AGAINST WOMEN AND CHILDREN
AGENDA
Approach: Using an ecologic framework that focuses on points of pri-
mary, secondary, and tertiary prevention and intervention, this workshop
will assess violence along the lifespan of women and children. Each level
will present the evidence basis of prevention, successful strategies, and
promising interventions or emerging research that can potentially be ap-
plied in global settings. An interactive panel to explore ways forward will
follow each segment.
Objective: To provide a comprehensive approach to the prevention of
violence against women and children, focusing on early interventions.
DAY 1
8:15 Registration
9:00 Introduction
Jacquelyn Campbell, Ph.D., R.N.
Chair, Forum on Global Violence Prevention
Anna D. Wolfe Chair, Johns Hopkins School of Nursing
185

9:20 Opening Remarks

Judy Salerno, M.D., M.S.
Executive Officer, Institute of Medicine
Lifetime Trajectory and an Ecological Approach:

9:30
A Global View of Violence Against Women and Children
What is the burden of violence? Where are the intersections
of violence against women and violence against children? How
can we move forward at primary, secondary, and tertiary preven-
tion levels?
Claudia García-Moreno, M.D.
Coordinator, Department of Gender, Women, and Health
World Health Organization
10:00 Q & A with Claudia García-Moreno
I. GLOBAL: CONTEXT MATTERS

On the international and national stage, efforts toward recognizing the
issues of violence against women and children have produced mixed results.
What has been successful? Where has progress been made? Where do exist-
ing challenges lie? This segment will explore legislation to reduce violence
against women and children, government initiatives, and partnerships that
transcend borders.
Moderated by: Frances Ashe-Goins, R.N., M.P.H.
Acting Director, Office of Women’s Health
U.S. Department of Health and Human Services
10:10 Policy Advocacy as a Tool for Prevention

Lessons Learned from the International Violence Against
Women Act
Kiersten Stewart, M.A.
Director of Public Policy, Family Violence Prevention Fund
10:40 Global Partnerships on Domestic Violence Legal Reform

Cheryl Thomas, J.D.
Director, Women’s Human Rights Program
Advocates for Human Rights
11:00 Partners for Prevention: Asia and the Pacific

James Lang
Programme Coordinator, Partners for Prevention
United Nations Development Programme

APPENDIX A 187
11:20 Break
11:35 U.S. Government Initiatives to Respond to Violence

Against Women
Lynn Rosenthal
White House Adviser on Violence Against Women

12:05 Canada’s Family Violence Initiative
David Butler-Jones, M.D., M.H.Sc.
Chief Public Health Officer, Public Health Agency of Canada
12:30 Inter-American Alliance for the Prevention of Gender-Based

Violence
Monique Widyono for Margarita Quintanilla, M.D., M.P.H.
Nicaragua Country Director, PATH
12:45 Q & A with Kiersten Stewart, Cheryl Thomas, James Lang,

Joanne LaCroix (for David Butler-Jones), and Monique Widyono
1:30 Lunch
II. COMMUNITIES: GENDER EQUALITY

Equal roles and rights of men and women contribute toward the reduc-
tion of violence against women and children. This segment will explore the
impact of engaging men and boys and empowering women and girls.
Moderated by: Gary Barker, Ph.D.
Director of Gender, Violence, and Rights
Keynote Address
2:15
Ending Violence Against Women and Children:
Investing in Solutions
Mary Ellsberg for Sarah Degnan Kambou, Ph.D., M.P.H.
President, International Center for Research on Women
2:45 The Science of Gender Equality

Why This Isn’t Just About Working with Women
Rachel Jewkes, M.D.
Director, Medical Research Council of South Africa

What Does an Understanding of Masculinities Bring to

3:15
the Story?
Engaging Men in Preventing Violence Against Women: Fac-
tors and Results
Gary Barker, Ph.D.
Director of Gender, Violence, and Rights
3:35 Intervention with Microfinance for AIDS and Gender Equity

Rachel Jewkes for Julia Kim, M.D., M.Sc.
Cluster Leader, Millennium Development Goals & Universal
Access, United Nations Development Programme

3:55 Break
4:15 The Way Forward

Moderated by: Gary Barker
Full panel of speakers with moderator and audience participa-
tion to discuss ways in which existing programs can be scaled up,
new approaches can be determined, or information gaps can be
addressed.
5:00 Break
DAY 2
8:00 Registration
8:30 Summary of Day 1

Jacquelyn Campbell
8:35 Government Initiatives to Reduce Violence: New Zealand

Denise Wilson, Ph.D., R.N.
Associate Professor of Ma- ori Health, Auckland University of
Technology
III. FAMILIES: INTERRUPTING/PREVENTING THE

CYCLE OF VIOLENCE—SECONDARY PREVENTION
Violence against children has strong linkages to violence against
women. As well, violence within the family both directly against and wit-
nessed by children, perpetuates a cycle. How can intervening early both

APPENDIX A 189
protect against and prevent violence? Where and when can these interven-
tions be most effective?
Moderated by: Bryan Samuels, M.P.P.
Commissioner, Administration on Children,
Youth, and Families
9:10 Intervening in the Cycle of Violence

What We Know, What We Don’t
Claire Crooks, Ph.D.
Associate Director, Centre for Prevention Science
Centre for Addiction and Mental Health
Case Studies: Innovative Prevention Interventions

9:40
Addressing Intimate Partner Violence and Potential Child Abuse
at Prenatal Care
Agnes Tiwari, Ph.D., R.N.
Associate Professor, University of Hong Kong
The Fourth R: Strategies for Healthy Youth Relationships
David Wolfe, Ph.D.
RBC Chair, Center for Addiction and Mental Health
Strengthening Families: An Integrated, Multi-Level Approach to
Preventing Child Maltreatment
Judy Langford, M.S.Ed.
Associate Director, Center for Study of Social Policy
10:45 Q & A with Claire Crooks, Agnes Tiwari, David Wolfe,

Judy Langford, Jeffrey Edleson
11:00 Break

Moderated by Jeffrey Edleson, Ph.D.
Director of Research, University of Minnesota School of Social
Work
tion to discuss ways in which existing programs can be scaled up,
addressed.

11:55 Lunch

IV. PSYCHOSOCIAL EMPOWERMENT

Interrupting the cycle of violence also requires addressing the trauma
experienced by victims of violence, and strengthening women, children,
and families. This section will focus on secondary and tertiary prevention
of violence against women and children and long-term effects of trauma.
Moderated by: Brigid McCaw, M.D.
Medical Director, Family Violence Prevention Program
Kaiser Permanente
Trauma-Informed Care: A Values-Based Context for Psychosocial

1:00
Empowerment
Roger Fallot, Ph.D.
Director of Research and Evaluation, Community Connections
Case Studies
1:30
Treatment of Trauma Among Women with Substance Abuse
Disorders
Hortensia Amaro, Ph.D.
Director, Institute on Urban Health Research
Psychosocial Trauma Interventions in Children, Families,
and Parents
Julian Ford, Ph.D.
Director, University of Connecticut Health Center Child
Trauma Clinic
Community Advocacy Project: A Psychosocial Empowerment
Intervention for Women with Abusive Partners
Cris Sullivan, Ph.D.
Director, Violence against Women Research and Outreach
Initiative Michigan State University
A Systems-Model Approach to Improve Intimate Partner Violence
Services in a Large Health Care Organization
Brigid McCaw, M.D.
Medical Director, Family Violence Prevention Program
Kaiser Permanente
3:00 Q & A with Brigid McCaw, Roger Fallot, Julian Ford, Hortensia
Amaro, and Cris Sullivan
3:10 Break

APPENDIX A 191

Moderated by Jacquelyn Campbell
tion to discuss w
ays in which existing programs can be scaled up,
addressed.

4:35 Closing Keynote
What lessons Have We Learned and How Do We Proceed?
Gail Wyatt, Ph.D.
Associate Director, University of California, Los Angeles
AIDS Institute

Speaker Biographical Sketches
Hortensia Amaro, Ph.D., is distinguished professor of health sciences and

of counseling psychology and associate dean at the Bouvé College of Health
Sciences at Northeastern University and director of the Institute on Urban
Health Research. Dr. Amaro’s research has focused on alcohol and drug
use and addiction among adolescents and adults; the development and test-
ing of behavioral interventions for HIV/AIDS prevention; substance abuse
and mental health treatment for Latina and African American women and
incarcerated men; alcohol and drug use among college populations; and
behavioral interventions for HIV medications adherence. Her 1995 article
“Love, Sex and Power” (American Psychologist) was a signal contribu-
tion to the field of HIV prevention among women and received the 1996
Scientific Publication Award from the National Association of Women in
Psychology. Dr. Amaro has served on the editorial board of the American
Journal of Public Health and other leading publications, and on several
Institute of Medicine committees. Additionally, she has served on review
and advisory committees to the National Institutes of Health, the U.S. De-
partment of Health and Human Services, the Substance Abuse and Mental
Health Services Administration, and the U.S. Centers for Disease Control
and Prevention. Bringing her research to the frontlines, Dr. Amaro has
founded five substance abuse treatment programs for women in Boston
and, for 14 years, served on the board of the Boston Public Health Com-
mission. She is a member of the Institute of Medicine.
Frances E. Ashe-Goins, R.N., M.P.H., a registered nurse and policy analyst,

is acting director of the Office of Women’s Health at the U.S. Department
192

APPENDIX B 193
of Health and Human Services. Formerly, as deputy director and director

of the Division of Policy and Program Development, she was responsible
for numerous women’s health issues, including HIV/AIDS, domestic vio-
lence, rape/sexual assault, lupus, diabetes, organ/tissue donation, minority
women’s health, international health, female genital cutting, mental health,
homelessness, and young women’s health. Mrs. Ashe-Goines also coordi-
nated the regional women’s health coordinators programs. She has written
numerous articles, appeared on radio and television programs, been fea-
tured in magazine and newspaper articles, made presentations at national
and international conferences and workshops, and received many awards
and commendations. She is a featured author of a chapter on domestic
violence in the book, Policy and Politics in Nursing and Health Care, 4th
edition.
Gary Barker, Ph.D., M.P.P., is director of gender, violence, and rights at the
International Center for Research on Women (ICRW). In this role he over-
sees ICRW’s research, policy analyses, and programmatic work to develop
solutions that address the underlying causes that lead to violence against
women, including the involvement of men and boys. Dr. Barker is a social
scientist with more than 15 years of experience researching gender equality,
men and masculinities, sexuality, and HIV/AIDS. He also is an expert in
exploring the links between men and violence in conflict and post-conflict
settings in parts of Latin America, the Caribbean, sub-Saharan Africa, and
South Asia. Prior to joining ICRW, Dr. Barker was founding executive direc-
tor of Instituto Promundo, a nongovernmental organization based in Brazil
that works to promote gender equality and reduce violence against children,
youth, and women. He also has served as a consultant to the World Bank
and many United Nations agencies. Dr. Barker was elected as an Ashoka
Fellow in 2007 and awarded an Individual Projects Fellowship from the
Open Society Institute. He is a founding co-chair of MenEngage, a global
alliance of international organizations that work to engage men and boys
to promote gender equality.
David Butler-Jones, M.D., M.H.Sc., Canada’s first chief public health of-
ficer, heads the Public Health Agency of Canada, which leads the govern-
ment’s efforts to protect and promote the health and safety of Canadians.
He has worked in many parts of Canada in both public health and clinical
medicine and has consulted in a number of other countries. In addition
to serving as chief public health officer, Dr. Butler-Jones is a professor in
the Faculty of Medicine at the University of Manitoba as well as a clinical
professor with the Department of Community Health and Epidemiology at
the University of Saskatchewan’s College of Medicine. From 1995 to 2002
he was chief medical health officer and executive director of the Population

Health and Primary Health Services Branches for the Province of Saskatch-
ewan. He has served as president of the Canadian Public Health Associa-
tion, vice president of the American Public Health Association, chair of the
Canadian Roundtable on Health and Climate Change, international regent
on the board of the American College of Preventive Medicine, member of
the governing council for the Canadian Population Health Initiative, chair
of the National Coalition on Enhancing Preventive Practices of Health
Professionals, and co-chair of the Canadian Coalition for Public Health in
the 21st Century.
Jacquelyn C. Campbell, Ph.D., R.N., is the Anna D. Wolf Chair in Nursing

at the Johns Hopkins School of Nursing. Dr. Campbell’s research addresses
the risk factors for and the evaluation of interventions to prevent domestic
violence. She has authored numerous articles on intimate partner violence,
violence against women, and adolescent exposure to violence. Dr. Campbell
has served on the National Institute of Mental Health Violence and Trau-
matic Stress Study Section and is a member of the American Academy of
Nursing and the Institute of Medicine. She has been selected as the Simon
Visiting Scholar at the University of Manchester in the United Kingdom
and, most recently, the Institute of Medicine/American Academy of Nurs-
ing/American Nursing Foundation Scholar in Residence. Dr. Campbell has
been active in the Institute of Medicine as a member of the Board on Global
Health and has served as a member of two committees of the Board on
Children, Youth, and Families.
Claire Crooks, Ph.D., is associate director of the Centre for Prevention

Science at the Centre for Addiction and Mental Health and adjunct profes-
sor at the University of Western Ontario. She is one of the lead developers
and researchers of the Fourth R, a relationship-based program aimed at
preventing violence and related risk behaviors in adolescents that has been
implemented in more than 1,000 schools in Canada and the United States.
Dr. Crooks is also a co-founder of the Caring Dads program, a parenting
intervention for men who have maltreated their children. In addition to
being an author of the program manual, she has been involved with train-
ing, consultation, and research on the Caring Dads project. Dr. Crooks has
co-authored more than 40 articles, chapters, and books on topics including
children’s exposure to domestic violence, child custody and access, child
maltreatment, adolescent dating violence and risk behavior, intervening
with fathers who maltreat their children, strength-based programming for
Aboriginal youth, and trauma. She is actively involved with training judges,
lawyers, and other court personnel through her work as a faculty member
for the U.S. National Council of Juvenile and Family Court Judges. Dr.
Crooks has testified before the Canadian Senate Committee on Human

APPENDIX B 195
Rights about the intersection between domestic violence and child custody
as a children’s rights issue.
Sarah Degnan Kambou, Ph.D., is president of the International Center for

Research on Women (ICRW), a global think tank that focuses on mak-
ing women integral to alleviating poverty worldwide. An accomplished
social scientist and development practitioner with expertise in sexual and
reproductive health, HIV/AIDS, and adolescent programming, Dr. Degnan
Kambou has worked in 26 countries and dedicated more than 25 years to
creating meaningful social change in the developing world. Prior to being
named president, she served as ICRW’s chief operating officer, and earlier, as
ICRW’s vice president of health and development, she oversaw research in
HIV/AIDS, reproductive health, and nutrition as well as in gender, violence,
and women’s rights. In 2010 Dr. Degnan Kambou was appointed by U.S.
Secretary of State Hillary Clinton to represent ICRW on the U.S. National
Commission for the United Nations Educational, Scientific and Cultural
Organization. Dr. Degnan Kambou joined ICRW after more than a decade
living in sub-Saharan Africa, where she managed signature programs for
CARE, a humanitarian relief and development organization. Prior to her
work in Africa, Dr. Degnan Kambou cofounded and for eight years served
as a director of the Center for International Health in the School of Public
Health at Boston University.
Jeffrey L. Edleson, Ph.D., is professor and director of research at the Uni-

versity of Minnesota School of Social Work and director of the Minnesota
Center Against Violence and Abuse. He is one of the world’s leading au-
thorities on children exposed to domestic violence and has published more
than 100 articles and 10 books on domestic violence, groupwork, and pro-
gram evaluation. Dr. Edleson is co-author, with the late Susan Schechter, of
Effective Intervention in Domestic Violence and Child Maltreatment Cases:
Guidelines for Policy and Practice (NCJFCJ, 1999). Better known as the
“Greenbook,” this best-practices guide has been the subject of six feder-
ally funded and numerous other demonstration sites across the country.
Dr. Edleson also has conducted intervention research and provided techni-
cal assistance to domestic violence programs and research projects across
North America as well as in several countries in other parts of the world.
Dr. Edleson’s research, policy, and practice interests have earlier focused
on research on batterer intervention programs. In recent years, his work
has focused primarily on the impact of adult domestic violence on children
and how social systems respond to these children. Dr. Edleson is an associ-
ate editor of the journal Violence Against Women and has served on the
editorial boards of numerous other journals. He is co-editor of the Oxford
University Press book series on interpersonal violence. He is a licensed

independent clinical social worker in Minnesota and has practiced in el-

ementary and secondary schools and in several domestic violence agencies.
Roger D. Fallot, Ph.D., is a clinical psychologist and director of research

and evaluation at Community Connections, a private, not-for-profit agency
providing a full range of human services in the District of Columbia. Dr.
Fallot’s professional areas of specialization include the development and
evaluation of services for trauma survivors and the role of spirituality in
recovery. The author of numerous clinical and research articles, he is a
contributing author and co-editor, with Maxine Harris, of Using Trauma
Theory to Design Service Systems (Jossey-Bass, 2001) and consults widely
on the development of trauma-informed cultures of care in human services.
A member of the federal Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Advisory Committee for Women’s Services,
Dr. Fallot was principal investigator on the District of Columbia Trauma
Collaboration Study, a SAMHSA-funded research project examining the
effectiveness of integrated services for women trauma survivors with men-
tal health and substance abuse problems. He and a group of clinicians at
Community Connections have developed a men’s version of the Trauma
Recovery and Empowerment Model, a manualized group intervention for
working with survivors of physical and sexual abuse. Dr. Fallot also is
interested in the relationships among spirituality, recovery, and well-being;
he edited and contributed chapters to Spirituality and Religion in Recovery
from Mental Illness (Jossey-Bass, 1998).
Julian D. Ford, Ph.D., is professor of psychiatry at the University of Con-

necticut School of Medicine and director of the University of Connecticut
Health Center Child Trauma Clinic and Center for Trauma Response
Recovery and Preparedness. Dr. Ford developed the TARGET (Trauma
Affect Regulation: Guide for Education and Therapy) intervention model
for adult, adolescent, and child traumatic stress disorders and co-occurring
substance use disorders. He conducts research on psychotherapy and family
therapy, health services utilization, psychometric screening and assessment,
and psychiatric epidemiology, including serving as the principal investi-
gator on several federally funded studies evaluating TARGET and other
evidence-based psychosocial interventions for families, adults, and youth.
Dr. Ford has co-edited three recent books, Treating Traumatized Children
(Routledge, 2008, with Danny Brom and Ruth Pat-Horenczyk), Encyclo-
pedia of Psychological Trauma (Wiley, 2008, with Gilbert Reyes and Jon
Elhai), and Treatment of Complex Traumatic Stress Disorders (Guilford,
2009, with Christine Courtois), and authored a textbook, Posttraumatic
Stress Disorder: Scientific and Professional Dimensions (Elsevier/Academic
Press, 2009).

APPENDIX B 197
Claudia García-Moreno, M.D., M.Sc., is a physician from Mexico with

more than 25 years of experience in public health spanning Africa, Latin
America, and parts of Asia. For the past 15 years her work has focused on
women’s health and gender in health, including contributing to gender and
women’s health initiatives at the World Health Organization (WHO). She
has led WHO’s work on women and HIV/AIDS and on violence against
women and coordinated the WHO Multi-Country Study on Women’s
Health and Domestic Violence Against Women, which includes more than
14 countries. She has been involved in setting up several initiatives such
as the Sexual Violence Research Initiative. She is on the editorial board of
Reproductive Health Matters and has published and reviewed papers on
women’s health for several international journals.
Kathy Greenlee, J.D., was appointed by President Obama as the fourth

assistant secretary for aging at the Administration on Aging (AoA) within
the U.S. Department of Health and Human Services and confirmed by the
Senate in June 2009. Ms. Greenlee brings more than 10 years of experience
advancing the health and independence of older persons and their families
and advocating for the rights of older persons. AoA is mandated by the
Older Americans Act (OAA) to be the focal point and lead advocacy agency
for older persons and their concerns at the federal level. AoA’s vision for
older people, embodied in the OAA, is based on the value that dignity is
inherent to all individuals and the belief that older people should have the
opportunity to fully participate in all aspects of society and community life;
be able to maintain their health and independence; and be free from vio-
lence, abuse, neglect, and exploitation. AoA works with its partners at the
federal, state, and community levels to help strengthen the nation’s capacity
to promote the dignity and independence of older people. AoA works to
stimulate programmatic and policy activity at the national, state, and local
levels in order to advance the work of eliminating violence against older
adults and elder abuse, neglect, and exploitation in the United States as well
as with international organizations and researchers around the world. By
doing so, AoA seeks to address the social, economic, and health impacts
of violence against older adults and elder abuse, neglect, and exploitation.
Rachel Jewkes, M.D., is director of the Medical Research Council’s Gender

and Health Research Unit in Pretoria, South Africa. A public health physi-
cian, epidemiologist, and social researcher, she has spent the past 15 years re-
searching the interface of gender inequity and gender-based violence and their
intersections with health, particularly concerning HIV. She has spent many
years developing the health sector response to rape in South Africa through
research and policy development. She is secretary of the Sexual Violence
Research Initiative of the Global Forum for Health Research and member of

the World Health Organization (WHO) Expert Advisory Panel on Injury and
Violence Prevention and Control, WHO’s Strategic and Technical Advisory
Committee for HIV–AIDS, and the PEPFAR scientific advisory board. She
has published articles on intimate partner violence and HIV in numerous
international journals, including The Lancet and the British Medical Journal.
Julia Kim, M.D., M.Sc., is the cluster leader for universal access and the
Millennium Development Goals in the HIV/AIDS group of the United Na-
tions Development Programme (UNDP). She is an internal medicine special-
ist and public health researcher by training. Prior to joining UNDP, she was
based in South Africa for 10 years, where she held joint appointments as a
senior researcher and policy advisor within the School of Public Health at
the University of the Witwatersrand and the Health Policy Unit of the Lon-
don School of Hygiene and Tropical Medicine. Her research interests have
included program and policy innovation to address gender-based violence
and HIV/AIDS at multiple levels, including in the health, education, and
criminal justice sectors. Dr. Kim’s recent work has included intervention
research on structural drivers of HIV, including the potential of strategies
such as microfinance to address the intersections between poverty, gender
inequalities, and HIV. She has served on numerous national and global
advisory groups and published across a range of issues, including gender
and development, HIV post-exposure prophylaxis, integrating reproduc-
tive health and HIV/AIDS, HIV/tuberculosis clinical services, rural health
systems development, strengthening research utilization, and addressing
social determinants of health.
James L. Lang is program coordinator of Partners for Prevention, the

regional joint program of the United Nations Development Programme
(UNDP), the United Nations Population Fund, UN Women, and UN Vol-
unteers for the primary prevention of gender-based violence in Asia and the
Pacific. Mr. Lang is a development practitioner, trainer, and author with
special interests in gender-based violence prevention and engaging boys
and men in working toward gender equality. He has worked on these is-
sues for the United Nations family and nonprofit organizations since 1997.
Previously, Mr. Lang served as the UNDP’s regional gender advisor for the
Asia-Pacific region and worked for UNDP in Laos and Sri Lanka. He has
also worked with the Family Violence Prevention Fund in San Francisco,
Oxfam Great Britain in the United Kingdom, and served as research coor-
dinator for the UN International Research and Training Institute for the
Advancement of Women and UNDP in New York. In addition to project
management and training, Mr. Lang has published numerous articles, and
edited books on the topics of poverty, men and gender, gender-based vio-
lence prevention, and other development issues.

APPENDIX B 199
Judy Langford, M.S.Ed., is senior fellow at the Center for the Study of
Social Policy in Washington, D.C., where she provides technical assistance
to foundations, governmental agencies, and private organizations on the
development and implementation of family supportive practices and poli-
cies. She is currently leading the national implementation of Strengthen-
ing Families through Early Care and Education, funded by the Doris
Duke Charitable Foundation, and serves on the Board of Directors for
the Finance Project and the Southern Institute for Children and Families.
Ms. Langford is former executive director of both the Family Resource
Coalition and the Ounce of Prevention Fund. She has served as a consul-
tant for the Pew Trusts Children’s Initiative, the Robert Wood Johnson
Foundation, the Edna McConnell Clark Foundation, the Ewing Marion
Kauffman Foundation, the Arthur M. Blank Family Foundation, and the
Casey Family Programs. She has served as chair of the Illinois Family
Policy Task Force and member of the Illinois Child Welfare Advisory
Board. Ms. Langford was previously an award-winning contributing editor
for Redbook magazine and served as honorary chair of President Carter’s
Advisory Committee for Women from 1977 to 1981. Additionally, she was
a founder of the AIDS Foundation of Chicago and a fellow of Leadership
Greater Chicago.
Brigid McCaw, M.D., M.S., M.P.H., is medical director for the Family
Violence Prevention Program at Kaiser Permanente (KP). Her teaching,
research, and publications focus on developing a health systems response
to intimate partner violence and the impact of intimate partner violence on
health status and mental health. She is a fellow of the American College
of Physicians. Kaiser Permanente, a large nonprofit integrated health care
organization serving 8.6 million members in nine states and the District
of Columbia, has implemented one of the most comprehensive health care
responses to domestic violence in the United States. The nationally rec-
ognized “systems model” approach is available across the continuum of
care, including outpatient, emergency, and inpatient care; advice and call
centers; and chronic care programs. The electronic medical record includes
clinician tools to facilitate recognition, referrals, resources, and follow-up
for patients experiencing domestic violence and provides data for quality
improvement measures. Over the past decade, identification of domestic
violence has increased fivefold, with most members identified in the ambu-
latory rather than acute-care settings. The majority of identified patients
receive follow-up mental health services. Kaiser Permanente also provides
prevention, outreach, and domestic violence resources for its workforce.
Violence prevention is an important focus for KP community benefit invest-
ments and research studies. The KP program, under the leadership of Dr.
McCaw, has received several national awards.

Margarita Quintanilla, M.P.H., is currently the country representative of

PATH in Nicaragua. Previously, she was coordinator of the Child Domes-
tic Work and Sexual Exploitation Programs of the International Program
on the Elimination of Child Labor. She has worked with the Ministry of
Health of Nicaragua and the Finnish Foreign Affairs Ministry, where she
was responsible for the project component on policies and legislation for
women’s health. Dr. Quintanilla is author of several publications on gender-
based violence in the health sector including Comprehensive Response to
Domestic Violence in the Health Services: Care Manual for Health Per-
sonnel; Medico-Legal Care in Cases of Sexual Assault in Nicaragua; and
Assessment of the Evidence Gathering, Submission, and Consideration
Procedures in Cases of Intra-Family and Sexual Violence against Women,
Children and Adolescents in Nicaragua (co-author).
Lynn Rosenthal is the first-ever White House advisor on violence against

women. She works with Vice President Joseph Biden and the White House
Council on Women and Girls to coordinate efforts across federal agencies
to address domestic violence and sexual assault. Her areas of focus since as-
suming this post include increasing resources in the federal budget, chairing
the Interagency Policy Group on Violence Against Women, and coordinating
with other White House offices to integrate these issues into other adminis-
tration priorities. Previously, Ms. Rosenthal served as executive director of
the National Network to End Domestic Violence, where she worked on the
reauthorization of the Violence Against Women Act and assisted states and
local communities with implementation of this groundbreaking federal legis-
lation. She also worked closely with corporate partners to bring funding to
local communities to respond to domestic violence. Ms. Rosenthal has been
widely recognized for her efforts to address domestic violence at the national,
state, and local levels. She has been a shelter director and leader of state
domestic violence coalitions in Florida and New Mexico. In 2006, she was
the first recipient of the Sheila Wellstone Institute National Advocacy Award.
Judith A. Salerno, M.D., M.S., was appointed executive officer of the Insti-
tute of Medicine of The National Academies in January 2008. From 2001
to 2007, Dr. Salerno served as deputy director of the National Institute on
Aging at the National Institutes of Health, U.S. Department of Health and
Human Services. In this capacity, Dr. Salerno had oversight of more than $1
billion in aging research conducted and supported annually by the institute,
including research on Alzheimer’s and other neurodegenerative diseases,
frailty and function in late life, and the social, behavioral, and demographic
aspects of aging. A geriatrician, Dr. Salerno is interested in improving the
health and well-being of older persons and has designed public–private ini-
tiatives to address aging stereotypes, novel approaches to support training

APPENDIX B 201
of new investigators in aging, and award-winning programs to commu-

nicate health and research advances to the public. Dr. Salerno also serves
on numerous boards and national committees concerned with health care
issues ranging from the quality of care in long-term care to the future of
the geriatric workforce.
Bryan Samuels, M.P.P., is commissioner of the Administration on Children,

Youth and Families and has spent his career formulating service delivery in-
novations and streamlining operations in large government organizations on
behalf of children, youth, and families. His commitment to public service is
largely motivated by his own success in overcoming great personal hardship
during his 11.5 years of growing up in a residential school for disadvantaged
children. This experience helped shape his commitment to serve children
who lived in foster care and reinforced his belief that dedicated people and
well-designed programs can make a dramatic impact on the lives of at-risk
youth. As chief of staff for Chicago Public Schools, Mr. Samuels played a
leadership role in managing the day-to-day operations of the third largest
school system in the nation. Prior to this role, he served as director of the
Illinois Department of Children and Family Services, where he moved aggres-
sively to implement comprehensive assessments of all children entering care,
redesigned transitional and independent living programs to prepare youth
for transitioning to adulthood, created a child location unit to track all run-
away youth, and introduced evidence-based services to address the impact of
trauma and exposure to violence on children in state care. Mr. Samuels has
taught at the University of Chicago’s School of Social Service Administration
and also has provided technical assistance to state and local governments to
improve human service delivery to vulnerable populations.
Kiersten Stewart is director of public policy and advocacy for the Fam-
ily Violence Prevention Fund and manages its Washington, DC, office. In
that capacity she advocates on behalf of abused women and children and
works to prevent violence in our homes and communities here and around
the world. Prior to joining the fund’s Washington, DC, office, she was the
chief of staff to U.S. Rep. Maurice Hinchey, handling his legislative work
around women’s issues, HIV/AIDS, civil rights, immigration, and poverty
and managing his successful 1998 campaign.
Cris M. Sullivan, Ph.D., is professor of ecological/community psychology

and director of the Violence Against Women Research and Outreach Ini-
tiative at Michigan State University (MSU). She also is associate chair of
the psychology department and senior fellow of MSU’s Office on Outreach
and Engagement. In addition to her MSU appointments, Dr. Sullivan is
the director of research and evaluation for the Michigan Coalition Against

Domestic and Sexual Violence and senior research advisor to the National
Resource Center on Domestic Violence. Dr. Sullivan’s areas of research
expertise include conducting longitudinal, experimental evaluations of com-
munity interventions for abused women and their children; improving the
community response to violence against women; and evaluating victim
service programs. In addition to consulting for local, state, federal, and
international organizations and initiatives, Dr. Sullivan also conducts work-
shops on effectively advocating in the community for women with abusive
partners, and their children; understanding the effects of domestic abuse on
women and children over time; improving system responses to the problem
of violence against women; and evaluating victim service agencies.
Cheryl Thomas, J.D., is director of the Women’s Human Rights Program,

a program she founded at the Advocates for Human Rights (formerly Min-
nesota Advocates for Human Rights) in 1993. Since 1994 Ms. Thomas has
traveled throughout Central and Eastern Europe, the former Soviet Union,
and Morocco to work with local partners to promote women’s human
rights. She has provided consultation and training to government officials,
legal professionals, and civil society groups in Armenia, Bosnia, Bulgaria,
Georgia, Kazakhstan, Lithuania, Morocco, and Tajikistan on best practices
in legal reform on violence against women. In 2008 she was selected to be
1 of 15 experts from around the world to participate in a United Nations
expert group meeting and publish a report on good practices in legislation
on violence against women. In 2009 she participated in a second UN Expert
Group Meeting in Ethiopia focused on harmful practices against women,
with a report published in 2010 (Good Practices in Legislation on “Harm-
ful Practices” Against Women). She has published numerous articles and
reports on violence against women as a human rights abuse, most recently
a report titled Sex Trafficking Needs Assessment for the State of Minnesota.
Previously, she was adjunct professor at the University of Minnesota Law
School, where she taught women’s international human rights, and execu-
tive director of WATCH, a court monitoring organization focused on cases
of violence against women and children. Ms. Thomas was honored as a
2005 Changemaker by Minnesota Women’s Press.
Agnes Tiwari, Ph.D., R.N., is an associate professor and assistant dean of

the School of Nursing at Li Ka Shing Faculty of Medicine of the University
of Hong Kong. More than a decade ago, Dr. Tiwari set up the first nurse-
led health clinic providing health screening and interventions in a shelter
for abused women in Hong Kong. To date, not only has the service been
extended to more than half of the shelters, but also the health data gathered
have provided much-needed information about the needs of Chinese women
survivors of intimate partner violence in general and the mental health impact
of psychological abuse on Chinese women in particular. Her decade-long

APPENDIX B 203
efforts to advocate for abused women, supported by her research program,

have influenced the Hong Kong government to set up a territory-wide initia-
tive providing crisis support services to families across Hong Kong, and she
has been appointed as an advisor to the initiative. Dr. Tiwari has developed
several models of intervention for abused women and evaluated their efficacy
to promote resilience and prevent violence using randomized controlled tri-
als. She also has designed and implemented different approaches of service
delivery for primary prevention of violence against women and children
in prenatal and community settings. Empowerment is a key feature of the
models and approaches, which can be adapted to different settings, including
those with resource constraints. The results of a recent randomized control
trial that Dr. Tiwari led, focusing on advocacy intervention to improve the
mental health of community-dwelling abused women, were published in the
Journal of the American Medical Association (2010).
Monique Widyono, M.P.A., M.S.W., is a program officer for gender, vio-

lence, and rights at the Program for Appropriate Technology in Health
(PATH). At PATH, she has focused on gender-based violence and develop-
ing a framework for understanding femicide. Previously Ms. Widyono was
co-executive director of Equality Now, a New York-based women’s rights
organization, and has been on the staff of the U.N. Division for the Ad-
vancement of Women.
Denise Wilson, Ph.D., R.N., is associate professor at Ma-ori Health AUT

University and editor-in-chief of Nursing Praxis in New Zealand. Addi-
tionally, she is a member of the Ministry of Health Family Violence Advi-
sory Committee, Korowai Atawhai Advisory Group, Wharangi Ruamano
(Ma-ori Nurse Educators), and the Nursing Network for Violence Against
Women International. She is fellow of the College of Nurses Aotearoa (New
Zealand) and Te Mata o te Tau (Academy of Maori Research & Scholar-
ship). Dr. Wilson has served as a member of the 1998 Ministerial Taskforce
on Nursing, the Nursing Council of New Zealand’s Education Advisor, and
a board member of Te Rau Puawai. Prior to commencing employment at
AUT, Dr. Wilson was senior lecturer in Nursing (Maori Health) at Massey
University. Before her academic career, Dr. Wilson was a registered nurse
in various acute-care and community settings. She has an extensive back-
ground in undergraduate and postgraduate nursing education, teaching in
the areas of Ma-ori/indigenous health, nursing practice, research design and
methods, cultural safety, and family violence. Dr. Wilson is of Ngati Tah-
inga Tainui Awhiro and Ngati Porou ki Harataunga descent.
David A. Wolfe, Ph.D., is a psychologist and author specializing in issues af-

fecting children and youth. He holds the inaugural RBC Chair in Children’s
Mental Health at the Centre for Addiction and Mental Health (CAMH),

where he is head of the Centre for Prevention Science located in London. He

also is professor of psychiatry and psychology at the University of Toronto
and editor-in-chief of Child Abuse & Neglect: The International Journal.
His recent book is entitled Adolescent Risk Behaviors: Why Teens Experi-
ment and Strategies to Keep Them Safe (Yale University Press, 2006, with
Peter Jaffe & Claire Crooks). Dr. Wolfe has broad research and clinical
interests in abnormal child and adolescent psychology with a special focus
on child abuse, domestic violence, and developmental psychopathology. He
has authored numerous articles on these topics, especially in relationship
to the impact of early childhood trauma on later development in child-
hood, adolescence, and early adulthood. Dr. Wolfe has been pioneering
new approaches to preventing many societal youth problems such as bul-
lying, relationship violence, and substance abuse. He recently received the
Donald O. Hebb Award for Distinguished Contributions to Psychology as
a Science from the Canadian Psychological Association, and the Blanche L.
Ittleson Award for Outstanding Achievement in the Delivery of Children’s
Services and the Promotion of Children’s Mental Health from the American
Orthopsychiatric Association.
Gail Elizabeth Wyatt, Ph.D., a licensed clinical psychologist and a board-

certified sex therapist, is professor of psychiatry and biomedical sciences
at the Semel Institute for Neuroscience and Behavior at the University of
California, Los Angeles (UCLA). For the first 17 years of her career, Dr.
Wyatt was the first ethnic minority to receive training as a sexologist.
She received a prestigious K award from the National Institute of Mental
Health to develop the expertise to develop culturally congruent measures,
conceptual frameworks, and interventions to capture sexual decision mak-
ing among ethnic minority men and women within a socio-cultural frame-
work. She was the first African-American woman in California to receive a
license to practice psychology and the first African-American woman Ph.D.
in a school of medicine to reach full professor. Dr. Wyatt directs the Sexual
Health Program, the National Institutes of Health–funded Phodiso Training
Project in South Africa, and the HIV/AIDS Translational Training Program
and is associate director of the UCLA CFAR/AIDS Institute. She has been
internationally recognized for her work in Jamaica, Africa, India, and, most
recently, South Africa where she conducts a longitudinal study of the after-
math of rape among South African women. She has published numerous
books and journal articles, including the best-selling book Stolen Women:
Reclaiming our Sexuality Taking Back Our Lives (John Wiley and Sons,
1997). Dr. Wyatt was instrumental in the Call for a State of Emergency
by numerous state, community, and religious organizations to address the
AIDS epidemic in black communities and subsequent health and mental
health disparities that continue to fuel the virus.

Planning Committee
Biographical Sketches
Jacquelyn C. Campbell, Ph.D., R.N. (Chair), is the Anna D. Wolf Chair in

Nursing at the Johns Hopkins School of Nursing. Dr. Campbell’s research
addresses the risk factors for and the evaluation of interventions to prevent
domestic violence. She has authored numerous articles on intimate partner
violence, violence against women, and adolescent exposure to violence. Dr.
Campbell has served on the National Institute of Mental Health Violence
and Traumatic Stress Study Section and is a member of the American Acad-
emy of Nursing and the Institute of Medicine. She has been selected as the
Simon Visiting Scholar at the University of Manchester in the United King-
dom and, most recently, the Institute of Medicine/American Academy of
Nursing/American Nursing Foundation Scholar in Residence. Dr. Campbell
has been active in the Institute of Medicine as a member of the Board on
Global Health and has served as a member of two committees of the Board
on Children, Youth, and Families.
Clare Anderson, M.S.W., LICSW, is the deputy commissioner at the Ad-

ministration on Children, Youth and Families (ACYF). Prior to joining
ACYF, she was senior associate at the Center for the Study of Social Policy,
where she promoted better outcomes for children, youth, and families
through community engagement and child welfare system transformation.
Ms. Anderson provided technical assistance through a federally funded
child welfare implementation center and to sites implementing community
partnerships for protecting children and the Annie E. Casey Foundation’s
Family to Family Initiative. She also conducted monitoring of and provided
support to jurisdictions under court order to improve child welfare systems.
205

Ms. Anderson previously worked as a direct practice social worker as a

member of the Freddie Mac Foundation Child and Adolescent Protection
Center at Children’s National Medical Center in Washington, DC. She was
a consultant to and clinical director at the Baptist Home for Children and
Families (now the National Center for Children and Families) in Bethesda,
MD, and a member of the clinical faculty at the Georgetown University
Medical Center, Department of Psychiatry’s Child and Adolescent Services.
Gary Barker, Ph.D., M.P.P., is director of gender, violence, and rights at the
International Center for Research on Women (ICRW). In this role, he over-
sees ICRW’s research, policy analyses, and programmatic work to develop
solutions that address the underlying causes that lead to violence against
women, including the involvement of men and boys. Dr. Barker is a social
scientist with more than 15 years of experience researching gender equality,
men and masculinities, sexuality, and HIV/AIDS. He also is an expert in
exploring the links between men and violence in conflict and post-conflict
settings in parts of Latin America, the Caribbean, sub-Saharan Africa, and
South Asia. Prior to joining ICRW, Dr. Barker was founding executive direc-
tor of Instituto Promundo, a nongovernmental organization based in Brazil
that works to promote gender equality and reduce violence against children,
youth, and women. He also has served as a consultant to the World Bank
and many United Nations agencies. Dr. Barker was elected as an Ashoka
Fellow in 2007 and awarded an Individual Projects Fellowship from the
Open Society Institute. He is a founding co-chair of MenEngage, a global
alliance of international organizations that work to engage men and boys
to promote gender equality.
Jeffrey Edleson, Ph.D., is professor and director of research at the Univer-

sity of Minnesota School of Social Work and director of the Minnesota
Center Against Violence and Abuse. He is one of the world’s leading au-
thorities on children exposed to domestic violence and has published more
than 100 articles and 10 books on domestic violence, groupwork, and pro-
gram evaluation. Dr. Edleson is co-author, with the late Susan Schechter, of
Effective Intervention in Domestic Violence and Child Maltreatment Cases:
Guidelines for Policy and Practice (NCJFCJ, 1999). Better known as the
“Greenbook,” this best-practices guide has been the subject of six feder-
ally funded and numerous other demonstration sites across the country.
Dr. Edleson also has conducted intervention research and provided techni-
cal assistance to domestic violence programs and research projects across
North America as well as in several countries in other parts of the world.
Dr. Edleson’s research, policy, and practice interests have earlier focused
on research on batterer intervention programs. In recent years his work
has focused primarily on the impact of adult domestic violence on children

APPENDIX C 207
and how social systems respond to these children. Dr. Edleson is an associ-
ate editor of the journal Violence Against Women and has served on the
editorial boards of numerous other journals. He is co-editor of the Oxford
University Press book series on interpersonal violence. He is a licensed inde-
pendent clinical social worker in Minnesota and has practiced in elementary
and secondary schools and in several domestic violence agencies.
Claudia García-Moreno, M.D., M.Sc., is a physician from Mexico with

more than 25 years of experience in public health spanning Africa, Latin
America, and parts of Asia. For the past 15 years her work has focused on
women’s health and gender in health, including contributing to gender and
women’s health initiatives at the World Health Organization (WHO). She
has led WHO’s work on women and HIV/AIDS and on violence against
women and coordinated the WHO Multi-Country Study on Women’s
Health and Domestic Violence Against Women, which includes over 14
countries. She has been involved in setting up several initiatives such as the
Sexual Violence Research Initiative. She is on the editorial board of Repro-
ductive Health Matters and has published and reviewed papers on women’s
health for several international journals.
Joanne LaCroix, M.B.A., B.S.W., is manager of the Family Violence Pre-

vention Unit of the Public Health Agency of Canada. Ms. LaCroix’s back-
ground is in child welfare and family violence. She began her career as a
front-line social worker and gradually held a number of supervisory and
managerial positions in two of Canada’s provinces, Quebec and Ontario.
Much of her work as a manager at the provincial level involved building
relationships that would foster concerted, coordinated responses to child
abuse and family violence. In her current position in the federal govern-
ment, she builds on the experience she has developed in the field to create
and sustain connections among policy makers, researchers, and service
providers and to continue to support and move forward the violence pre-
vention agenda. The Public Health Agency of Canada leads and coordinates
the federal Family Violence Initiative, a collaboration of 15 departments,
agencies, and crown corporations. The initiative promotes public awareness
of the risk factors of family violence and the need for public involvement in
responding to it; strengthens the capacity of the criminal justice, housing,
and health systems to respond; and supports data collection, research, and
evaluation efforts to identify effective interventions.
Susan E. Salasin is director of the Trauma and Trauma-Informed Care Pro-

gram at the Substance Abuse and Mental Health Services Administration
(SAMHSA). For the past three decades Ms. Salasin served in federal govern-
ment positions at the National Institute of Mental Health and at the Center

for Mental Health Services (CMHS) at SAMHSA. Through the SAMHSA

Mental Health Transformation Program, she currently chairs the Federal
Intergovernmental Committee on Women and Girls and Trauma, which
includes more than 30 agencies and sub-agencies. Through CMHS in 2005
she created the National Center for Trauma Informed Care. Previously,
she served as founding chair of the World Federation for Mental Health
(WFMH) Scientific Committee on the Mental Health Needs of Victims of
Violence. For this work she received an award from WFMH. She was co-
editor of the book The Mental Health of Women (Academic Press, 1980)
and editor of Evaluating Victim Services (Sage, 1981).

Forum Member
Biographical Sketches
Jacquelyn C. Campbell, Ph.D., R.N. (Co-chair), is the Anna D. Wolf Chair

in Nursing at the Johns Hopkins School of Nursing. Dr. Campbell’s re-
search addresses the risk factors for and the evaluation of interventions
to prevent domestic violence. She has authored numerous articles on inti-
mate partner violence, violence against women, and adolescent exposure
to violence. Dr. Campbell has served on the National Institute of Mental
Health Violence and Traumatic Stress Study Section and is a member of the
American Academy of Nursing and the Institute of Medicine. She has been
selected as the Simon Visiting Scholar at the University of Manchester in
the United Kingdom and, most recently, the Institute of Medicine/American
Academy of Nursing/American Nursing Foundation Scholar in Residence.
Dr. Campbell has been active in the Institute of Medicine as a member of
the Board on Global Health and has served as a member of two committees
of the Board on Children, Youth, and Families.
Mark L. Rosenberg, M.D., M.P.P. (Co-chair), is executive director of the

Task Force for Global Health. Previously, for 20 years, Dr. Rosenberg
was at the Centers for Disease Control and Prevention, where he led its
work in violence prevention and later became the first permanent director
of the National Center for Injury Prevention and Control. He also held
the position of the special assistant for behavioral science in the Office of
the Deputy Director (HIV/AIDS). Dr. Rosenberg is board certified in both
psychiatry and internal medicine with training in public policy. He is on
the faculty at Morehouse Medical School, Emory Medical School, and
the Rollins School of Public Health at Emory University. Dr. Rosenberg’s
209

research and programmatic interests are concentrated on injury control and

violence prevention, HIV/AIDS, and child well-being, with special attention
to behavioral sciences, evaluation, and health communications. He has au-
thored more than 120 publications and recently co-authored the book Real
Collaboration: What It Takes for Global Health to Succeed (University
of California Press, 2010). Dr. Rosenberg has received numerous awards
including the Surgeon General’s Exemplary Service Medal. He is a member
of the Institute of Medicine. Dr. Rosenberg’s organization, the Task Force
for Global Health, participated in the IOM-sponsored workshop Violence
Prevention in Low- and Middle Income Countries: Finding a Place on
the Global Agenda, and the Task Force remains interested in helping to
continue the momentum of the workshop through the Forum on Global
Violence Prevention. The Task Force is heavily involved in the delivery of a
number of global health programs and sees many ways that interpersonal
violence and conflict exacerbate serious health problems and inequities.
Clare Anderson, M.S.W., LICSW, is the deputy commissioner at the Ad-

ministration on Children, Youth and Families (ACYF). Prior to joining
ACYF, she was senior associate at the Center for the Study of Social Policy,
where she promoted better outcomes for children, youth, and families
through community engagement and child welfare system transformation.
Ms. Anderson provided technical assistance through a federally funded
child welfare implementation center and to sites implementing community
partnerships for protecting children and the Annie E. Casey Foundation’s
Family to Family Initiative. She also conducted monitoring of and provided
support to jurisdictions under court order to improve child welfare systems.
Ms. Anderson previously worked as a direct practice social worker as a
member of the Freddie Mac Foundation Child and Adolescent Protection
Center at Children’s National Medical Center in Washington, DC. She was
a consultant to and clinical director at the Baptist Home for Children and
Families (now the National Center for Children and Families) in Bethesda,
MD, and a member of the clinical faculty at the Georgetown University
Medical Center, Department of Psychiatry’s Child and Adolescent Services.
Frances E. Ashe-Goins, R.N., M.P.H., a registered nurse and policy analyst,

is acting director of the Office of Women’s Health at the U.S. Department
of Health and Human Services. Formerly, as deputy director and director
of the Division of Policy and Program Development, she was responsible
for numerous women’s health issues, including HIV/AIDS, domestic vio-
lence, rape/sexual assault, lupus, diabetes, organ/tissue donation, minority
women’s health, international health, female genital cutting, mental health,
homelessness, and young women’s health. Mrs. Ashe-Goines also coordi-
nated the regional women’s health coordinators programs. She has written

APPENDIX D 211
numerous articles, appeared on radio and television programs, been fea-

tured in magazine and newspaper articles, made presentations at national
and international conferences and workshops, and received many awards
and commendations. She is a featured author of a chapter on domestic
violence in the book, Policy and Politics in Nursing and Health Care, 4th
edition.
Katrina Baum, Ph.D., is division director of the Violence and Victimiza-

tion Research Division at the National Institute of Justice. Dr. Baum most
recently was senior statistician at the Bureau of Justice Statistics, where
she worked on the National Crime Victimization Survey. Her tenure there
included research on juvenile victims, college students, school crime, and
groundbreaking studies on identity theft and stalking. Her reports have
been cited in the New York Times and other major newspapers, and she has
appeared on a local television affiliate. Prior to joining the U.S. Department
of Justice, Dr. Baum managed a variety of research projects in criminal jus-
tice. While working at the Cartographic Modeling Lab in Philadelphia, she
developed the Firearms Analysis System, which is a geographic information
system used to track firearm-related injuries using data from the Philadel-
phia Police Department and the National Tracing Center of the Bureau of
Alcohol, Tobacco, Firearms and Explosives. She also served as the local
evaluator for Weed & Seed and Safe Schools/Healthy Students grants.
Susan Bissell, Ph.D., serves as chief of child protection of the Programme

Division at UNICEF. She previously worked on issues concerning educa-
tion and children in especially difficult circumstances with UNICEF Sri
Lanka and UNICEF in Bangladesh, where she also focused on child labor.
Dr. Bissell has managed a number of reports, including a 62-country study
on the implementation of the general measures of the UN Convention on
the Rights of the Child and global research on the Palermo Protocol and
child trafficking. As member of the editorial board of the report of the
UN Secretary General’s Study on Violence Against Children, which was
released in 2006, she has also been involved in follow-up activities that will
advance the implementation of the recommendations of the study. She has
contributed to several articles on children’s rights, including “Promotion
of Children’s Rights and Prevention of Child Maltreatment” (2009) and
“Overview and Implementation of the UN Convention on the Rights of the
Child” (2006), both of which were published in The Lancet.
Arturo Cervantes Trejo, M.D., M.P.H., Dr.P.H., serves as technical secre-

tary of the National Council for Injury Prevention and general director of
the National Center for Injury Prevention with the Mexican Ministry of
Health. He also holds the Carlos Peralta Quintero Chair of Public Health

at the Faculty of Medicine of Anahuac University in Mexico. He is board

certified by the National Council of Public Health in Mexico and is a mem-
ber of the charter class of the National Board of Public Health Examiners in
the United States. As head of the National Center for Injury Prevention, Dr.
Cervantes has co-authored the National Specific Action Program for Road
Safety and the National Specific Action Program for Violence Prevention as
well as numerous analyses of morbidity and mortality from external causes
of injury. Currently, he participates in the presidential task force Todos
Somos Juárez, which is developing a strategy for violence prevention and
social development for the city of Ciudad Juárez Chihuahua. Todos Somos
Juárez is led by the federal government with the participation of the govern-
ment of the state of Chihuahua, the municipal government of Juárez, and
the city’s civil society. The strategy includes 160 policy actions in health, la-
bor, education, culture, economic, and security areas undertaken to address
the underlying social and economic issues that fuel crime and insecurity in
Ciudad Juárez, Mexico’s eighth largest city and the most populous city on
the Mexico–United States border.
XinQi Dong, M.D., M.P.H., is associate professor of medicine, behavioral

sciences, and nursing at the Rush University Medical Center. Dr. Dong’s
research is focused on the epidemiological studies of elder abuse and ne-
glect, both in the United States and China, with particular emphasis on its
adverse health outcomes across different racial/ethnic groups. Dr. Dong is
a recipient of the Paul B. Beeson Scholar in Aging Award, and his work has
been recognized by the American Geriatric Society, American Public Health
Association, and the Institute of Medicine of Chicago. He was awarded the
Nobuo Maeda International Aging and Public Health Research Award and
the Central Society for Clinical Research Award. He was the first geriatri-
cian to be the recipient of the national Physician Advocacy Merit Award by
the Institute of Medicine as a Profession (IMAP). Through culturally and
linguistically appropriate ways, Dr. Dong actively works with the Chinese
communities to promote understanding and civic engagement on the issues
of elder abuse and neglect. He currently serves on the board of directors for
the Chinese American Service League, the largest social services organiza-
tion in the Midwest serving the needs of Chinese population.
Amie Gianino, M.S., is the representative of Anheuser-Busch InBev (ABI)

to the Global Violence Prevention Forum. Ms. Gianino, the senior global
director for the company’s Better World efforts, began her career with the
company in 1989. Evidence suggests that cultural factors play a strong
role in determining whether and how violence manifests in a country’s
population. Individual factors, such as personality type, are also important
predictors of violent behavior. Still, some posit that alcohol may be a cause

APPENDIX D 213
of violent behavior. As the world’s largest brewer— and as the beer industry
leader in social responsibility—ABI is especially interested in the dialogue
surrounding the intersection of alcohol and violence. The company believes
that measures to change negative cultural norms relating to violence and
other risky behaviors are important goals. To this end, ABI has been sup-
porting social norms initiatives for more than 10 years in the United States
and Europe, with plans for further work in China and Latin America. ABI
has also supported the Alcohol Medical Scholars Program (AMSP) since
1997. The AMSP helps train physicians to teach others in the medical
community how to better diagnose and treat alcohol dependency issues. In
addition, ABI has supported domestic violence prevention initiatives.
Kathy Greenlee, J.D., was appointed by President Obama as the fourth

assistant secretary for aging at the Administration on Aging (AoA) within
the U.S. Department of Health and Human Services and confirmed by the
Senate in June 2009. Ms. Greenlee brings more than 10 years of experience
advancing the health and independence of older persons and their families
and advocating for the rights of older persons. AoA is mandated by the
Older Americans Act (OAA) to be the focal point and lead advocacy agency
for older persons and their concerns at the federal level. AoA’s vision for
older people, embodied in the OAA, is based on the value that dignity is
inherent to all individuals and the belief that older people should have the
opportunity to fully participate in all aspects of society and community life;
be able to maintain their health and independence; and be free from vio-
lence, abuse, neglect, and exploitation. AoA works with its partners at the
federal, state, and community levels to help strengthen the nation’s capacity
to promote the dignity and independence of older people. AoA works to
stimulate programmatic and policy activity at the national, state, and local
levels in order to advance the work of eliminating violence against older
adults and elder abuse, neglect, and exploitation in the United States as well
as with international organizations and researchers around the world. By
doing so, AoA seeks to address the social, economic, and health impacts
of violence against older adults and elder abuse, neglect, and exploitation.
Rodrigo V. Guerrero, M.D., Dr.P.H., serves as city counselor of Cali, Co-

lombia. Previously, he has held the posts of professor, department head,
dean of health sciences, and president at Universidad del Valle in Colombia,
and he was mayor of Cali, Colombia. As mayor, Dr. Guerrero developed
an epidemiological approach to urban violence prevention through the
Program DESEPAZ, which has been successfully applied in several cities
of Colombia and in other countries. After leaving the mayoral post, he
joined the Pan American Health Organization in Washington, DC, where
he started the Violence Prevention Program. Dr. Guerrero has written

numerous articles on youth violence and violence as a health issue. In ad-

dtion to his current post as city counselor, Dr. Guerrero dedicates his time
to Vallenpaz, a nonprofit organization devoted to helping rural communi-
ties in conflict-ridden areas of Colombia. He is a member of CISALVA,
the Violence Research Center of Universidad del Valle, and the Institute of
Medicine.
John R. Hayes, M.D., is the global strategy leader for neuroscience medical
affairs at Eli Lilly and Company. Before assuming his current position, Dr.
Hayes served as vice president for Lilly Research Laboratories. Lilly has
done extensive research into areas of suicidality and harmful behavior in
the context of mental disorders and has provided significant support for
independent research as well as professional and public education about
these important and often controversial public health issues. Previously Dr.
Hayes has held faculty positions at Texas A&M University and the Indiana
University School of Medicine and was president of St. Vincent Hospitals
and Health Systems and chief executive officer of Seton Health of Indiana.
Dr. Hayes was chairman of the board of the Indiana Health Industry Forum
and has served on the boards of 5 for-profit and 12 not-for-profit institu-
tions. He has been president of the Academy of Psychosomatic Medicine
and a director on the American Board of Family Medicine and of the Amer-
ican Psychiatric Foundation, and he is a Distinguished Life Fellow of the
American Psychiatric Association. He has won national teaching awards,
authored scientific publications, and served as visiting faculty at numerous
medical institutions globally over the course of his career.
David Hemenway, Ph.D., is an economist and professor at Harvard School

of Public Health (HSPH) and a James Marsh Visiting Professor-at-Large
at the University of Vermont. Additionally, he is director of the Harvard
Injury Control Research Center and the Youth Violence Prevention Center.
He was president of the Society for the Advancement of Violence and Injury
Research and in 2007 received the Excellence in Science award from the
injury section of the American Public Health Association. He has received
fellowships from the Pew, Soros, and Robert Wood Johnson foundations.
Dr. Hemenway has written more than 150 journal articles and is sole
author of five books. Recent books include Private Guns Public Health
(University of Michigan Press, 2006) and While We Were Sleeping: Success
Stories in Injury and Violence Prevention (University of California Press,
2009). Dr. Hemenway has received 10 HSPH teaching awards.
Frances Henry, M.B.A., serves as advisor to the F Felix Foundation. Previ-

ously, from 2005 to 2009, she created and directed Global Violence Preven-
tion, a project that advanced the science-based prevention of violence in

APPENDIX D 215
low- and middle-income countries through a coalition of U.S. researchers

and practitioners. Based on her experiences of childhood sexual abuse, she
founded and for 13 years directed Stop It Now!, an organization dedicated
to preventing the sexual abuse of children. She is author of Vaccines for
Violence, a set of five essays exploring how she learned to counter violence
by dealing with fear, by balancing accountability and compassion, and by
increasing her capacity to connect to others. Ms. Henry’s previous work
includes owning a management consulting company and directing presiden-
tial and gubernatorial commissions for women. She served as staff for the
U.S. Commission on International Women’s Year.
Mercedes S. Hinton, Ph.D., is a program officer for the Initiative on Con-

fronting Violent Crime at the Open Society Foundations (OSF), where she
directs the program’s Central America work. Previously, she worked as
a consultant for the World Bank’s conflict, crime, and violence team and
served for seven years on the faculty of the London School of Economics in
the United Kingdom. Dr. Hinton is a prize-winning author of a number of
books and publications in the area of policing and democratization in the
developing world. She is fluent in English, French, Portuguese, and Span-
ish. Her books include Policing Developing Democracies (Routledge, 2009;
co-edited with Tim Newburn) and The State on the Streets: Police and Poli-
tics in Argentina and Brazil (Lynne Rienner Publishers, 2006), which was
awarded the British Society for Criminology’s prize for best book of 2006.
Larke Nahme Huang, Ph.D., a licensed clinical–community psychologist,

is senior advisor to the administrator of the Substance Abuse and Men-
tal Health Services Administration (SAMHSA) at the U.S. Department of
Health and Human Services. In this position she provides leadership on
national policy for mental health and substance use issues for children,
adolescents, and families. She is also the agency lead on issues of behav-
ioral health equity and eliminating disparities and for the administrator’s
Strategic Initiative on Trauma and Justice. In 2009 she did a six-month
leadership exchange at the Centers for Disease Control and Prevention,
where she was a senior advisor on mental health. For the past 25 years Dr.
Huang has worked at the interface of practice, research, and policy. She has
assumed multiple leadership roles dedicated to improving the lives of chil-
dren, families, and communities. She has been a community mental health
practitioner; a faculty member at the University of California, Berkeley and
Georgetown University; and a research director at the American Institutes
for Research. She has worked with states and communities to build sys-
tems of care for children with serious emotional and behavioral disorders.
She has developed programs for underserved, culturally and linguistically
diverse youth; evaluated community-based programs; and authored books

and articles on children’s behavioral health and transforming systems and

services. Her publications include “Advancing Efforts to Improve Chil-
dren’s Mental Health in America” (Administration and Policy in Mental
Health, 2010) and Children of Color: Psychological Interventions with
Culturally Diverse Youth (Jossey-Bass, 2003). In 2003 Dr. Huang served as
an appointed commissioner on the President’s New Freedom Commission
on Mental Health.
L. Rowell Huesmann, Ph.D., M.S., is the Amos N. Tversky Collegiate Pro-

fessor of Psychology and Communication Studies and director of the Re-
search Center for Group Dynamics at the University of Michigan’s Institute
for Social Research. He is also editor of the journal Aggressive Behavior
and past president of the International Society for Research on Aggres-
sion. His research over the past 40 years has focused on the psychological
foundations of aggressive and violent behavior and on how predisposing
personal factors interact with precipitating situational factors to engender
violent behavior. This research has included several life span longitudinal
studies showing how the roots of aggressive behavior are often established
in childhood. One particular interest has been investigating how children
learn through imitation and how children’s exposure to violence in the
family, schools, community, and mass media stimulates the development
of their own aggressive and violent behavior over time. He has conducted
longitudinal studies on the effects of exposure to violence at multiple sites in
the United States as well as in Finland, Poland, Israel, and Palestine. These
studies have shown that simply seeing a lot of violence (political violence,
family violence, community violence, media violence) in childhood changes
children’s thinking and perceptions and increases the risk of interpersonal
aggressive behavior later in life. He has also conducted research showing
that interventions that change children’s beliefs about the appropriateness
of conflict and aggression can be effective in preventing aggression. In 2005
Dr. Huesmann was the recipient of the American Psychological Associa-
tion’s award for distinguished lifetime contributions to media psychology.
Kevin Jennings, M.A., M.B.A., is assistant deputy secretary for the Office
of Safe and Drug-Free Schools at the U.S. Department of Education. Previ-
ously he was a high school history teacher, first at Moses Brown School
in Providence, RI, and then at Concord Academy in Concord, MA, where
he was chair of the history department. In 1995 Mr. Jennings left teach-
ing to be the founding executive director of the Gay, Lesbian, and Straight
Education Network (GLSEN), a national education organization working
to make schools safe for lesbian, gay, bisexual, and transgender students,
staff, and families. He held the position of executive director at GLSEN
until 2008. Among his awards are the Distinguished Service Award of the

APPENDIX D 217
National Association of Secondary School Principals and the Human and

Civil Rights Award of the National Education Association. He is the author
of six books, the most recent of which—Mama’s Boy, Preacher’s Son—was
named a book of honor by the American Library Association in 2007.
Carol M. Kurzig is president of the Avon Foundation for Women. Previ-

ously, she was president of the National Multiple Sclerosis Society’s New
York City chapter and director of public services and assistant to the
president at the Foundation Center. She was a director and served as board
chairman of the Support Center for Nonprofit Management and currently
serves as a vice chairman of the Nonprofit Coordinating Committee Board
of Directors. The Avon Foundation for Women was created in 1955 to
“improve the lives of women” and is now the leading corporate-affiliated
global philanthropy dedicated to women. Through 2009 Avon global
philanthropy raised and awarded more than $725 million, all of which
focused on women and their families (primarily for breast cancer, domes-
tic violence, and emergency and disaster relief). Avon currently supports
breast cancer and domestic violence programs in more than 50 countries.
The foundation’s grant-making programs include the Avon Breast Can-
cer Crusade, with goals to accelerate research and ensure access to care;
women’s empowerment programs, with an emphasis on domestic violence
through its Speak Out Against Domestic Violence program; and special
programs in response to national and international emergencies. Its ex-
tensive fundraising programs include the nine-city Avon Walk for Breast
Cancer series and special events to raise awareness and funds for gender
violence programs.
Joanne LaCroix, M.B.A., B.S.W., is manager of the Family Violence Pre-

vention Unit of the Public Health Agency of Canada. Ms. LaCroix’s back-
ground is in child welfare and family violence. She began her career as a
front-line social worker and gradually held a number of supervisory and
managerial positions in two of Canada’s provinces, Quebec and Ontario.
Much of her work as a manager at the provincial level involved building
relationships that would foster concerted, coordinated responses to child
abuse and family violence. In her current position in the federal govern-
ment, she builds on the experience she has developed in the field to create
and sustain connections among policy makers, researchers, and service
providers and to continue to support and move forward the violence pre-
vention agenda. The Public Health Agency of Canada leads and coordinates
the federal Family Violence Initiative, a collaboration of 15 departments,
agencies, and crown corporations. The initiative promotes public awareness
of the risk factors of family violence and the need for public involvement in
responding to it; strengthens the capacity of the criminal justice, housing,

and health systems to respond; and supports data collection, research, and
evaluation efforts to identify effective interventions.
Jacqueline Lloyd, Ph.D., M.S.W., is a health scientist administrator in the

Prevention Research Branch in the Division of Epidemiology, Services,
and Prevention Research at the National Institute on Drug Abuse (NIDA)
within the National Institutes of Health. Her program areas at NIDA
include screening and brief interventions, youth at risk for HIV/AIDS, en-
vironmental interventions, peer interventions, women and gender research,
and health communications research. Prior to joining the staff at NIDA,
Dr. Lloyd held faculty positions at Temple University in the School of So-
cial Administration and at the University of Maryland at Baltimore in the
School of Social Work. She has taught courses in research methods, health,
and mental health human behavior theory. Her own research activities
have included evaluation of a community-based youth prevention program;
investigation of HIV risk behaviors and substance use among youth; and
investigation of the role of family, peer, and social network contextual fac-
tors on risk behaviors and treatment outcomes among youth and injecting
drug users. Her many publications include “HIV Risk Behaviors: Risky
Sexual Activities and Needle Use Among Adolescents in Substance Abuse
Treatment” (AIDS and Behavior, 2010) and “The Relationship between
Lifetime Abuse and Suicidal Ideation in a Sample of Injection Drug Users”
(Journal of Psychoactive Drugs, 2007).
Brigid McCaw, M.D., M.S., M.P.H., FACP, is medical director for the Fam-
ily Violence Prevention Program at Kaiser Permanente (KP). Her teaching,
research, and publications focus on developing a health systems response
to intimate partner violence and the impact of intimate partner violence on
health status and mental health. She is a fellow of the American College
of Physicians. Kaiser Permanente, a large nonprofit integrated health care
organization serving 8.6 million members in nine states and the District
of Columbia, has implemented one of the most comprehensive health care
responses to domestic violence in the United States. The nationally rec-
ognized “systems model” approach is available across the continuum of
care, including outpatient, emergency, and inpatient care; advice and call
centers; and chronic care programs. The electronic medical record includes
clinician tools to facilitate recognition, referrals, resources, and follow-up
for patients experiencing domestic violence and provides data for quality
improvement measures. Over the past decade, identification of domestic
violence has increased fivefold, with most members identified in the ambu-
latory rather than acute-care settings. The majority of identified patients
receive follow-up mental health services. Kaiser Permanente also provides
prevention, outreach, and domestic violence resources for its workforce.

APPENDIX D 219
Violence prevention is an important focus for KP community benefit invest-

ments and research studies. The KP program, under the leadership of Dr.
McCaw, has received several national awards.
James A. Mercy, Ph.D., is special advisor for strategic directions at the Divi-
sion of Violence Prevention in the National Center for Injury Prevention and
Control of the Centers for Disease Control and Prevention (CDC). He began
working at CDC in a newly formed activity to examine violence as a public
health problem and, over the past two decades, has helped to develop the
public health approach to violence and has conducted and overseen numer-
ous studies of the epidemiology of youth suicide, family violence, homicide,
and firearm injuries. Dr. Mercy also served as a co-editor of the World Report
on Violence and Health prepared by the World Health Organization and
served on the editorial board of the United Nation’s Secretary General’s Study
of Violence Against Children. Most recently he’s been working on a global
partnership with UNICEF, the President’s Emergency Plan for AIDS Relief,
World Health Organization, and o thers to end sexual violence against girls.
His recent publications include “Attention-Deficit/Hyperactivity Disorder,
Conduct Disorder, and Young Adult Intimate Partner Violence” (Archives of
General Psychiatry, 2010) and “Sexual Violence and Its Health Consequences
for Female Children in Swaziland: A Cluster Survey Study” (Lancet, 2009).
Peggy Murray, Ph.D., M.S.W., is senior advisor for the Institute on Alcohol
Abuse and Alcoholism (IAAA) at the National Institutes of Health and is
responsible for the institute’s research translation initiatives in health pro-
fessions education. She also serves as an adjunct professor at the Catholic
University School of Social Work. She is co-author of A Medical Educa-
tion Model for the Prevention and Treatment of Alcohol-Use Disorders, a
20-module curriculum and faculty development course for medical school
faculty in the primary-care specialties. The model has been translated into
five languages and implemented in eight countries to date. The relationship
of alcohol misuse to aggressive behavior and violence is a complex one, and
research has shown that this relationship is more than associative. In addition
to alcohol misuse promoting aggressive behavior, victimization as a result
of violence can lead to excessive alcohol consumption. Strategies to prevent
violence must take this into account and, to be effective, must deal with the
alcohol use of both the perpetrators and victims of violence. Alcohol affects
the brain and behavior at many levels from the cell to the brain to the in-
dividual as a whole, to particular neighborhoods and micro cultures, to the
global society. For more than 20 years, Dr. Murray has worked at the IAAA
in positions that have led to collaboration with scientists across all of its divi-
sions and offices. She hopes to bring a broad perspective on alcohol misuse
to the identification of effective approaches to global violence prevention.

Michael Phillips, M.D., M.P.H., is currently director of the Suicide Research

and Prevention Center of the Shanghai Mental Health Center, executive
director of the World Health Organization (WHO) Collaborating Center
for Research and Training in Suicide Prevention at Beijing Hui Long Guan
Hospital, professor of psychiatry and global health at Emory University,
professor of clinical psychiatry and clinical epidemiology at Columbia
University, vice chairperson of the Chinese Society for Injury Prevention
and Control, and treasurer of the International Association for Suicide
Prevention. He is currently the principal investigator on a number of multi-
center collaborative projects on suicide, depression, and schizophrenia. His
recent publications include “Repetition of Suicide Attempts: Data from
Emergency Care Settings in Five Culturally Different Low- and Middle-
Income Countries Participating in the WHO SUPRE-MISS Study” (Crisis,
2010) and “Nonfatal Suicidal Behavior among Chinese Women Who Have
Been Physically Abused by their Male Intimate Partners” (Suicide and
Life-Threatening Behavior, 2009). Dr. Phillips is a Canadian citizen who
has been a permanent resident of China for more than 25 years. He runs
a number of research training courses each year; supervises Chinese and
foreign graduate students; helps coordinate WHO mental health activities
in China; promotes increased awareness of the importance of addressing
China’s huge suicide problem; and advocates improving the quality, com-
prehensiveness, and access to mental health services around the country.
Colleen Scanlon, R.N., J.D., has been senior vice president of advocacy
at Catholic Health Initiatives in Denver, CO, since 1997. In this role Ms.
Scanlon directs the development and integration of a comprehensive advo-
cacy program within one of the largest Catholic health care systems in the
country. Previously she was director of the American Nurses Association
Center for Ethics and Human Rights in Washington, DC, and a clinical
scholar in the Center for Clinical Bioethics at Georgetown University Medi-
cal Center. Ms. Scanlon’s background includes a variety of clinical positions
in palliative care, oncology, psychiatric care, and home health care nursing.
She has been involved in the development of educational monographs and
videos and co-authored a book entitled Managing Genetic Information:
Implications for Nursing Practice (American Nurses Association, 1995).
She is currently chair of the Catholic Health Association Board of Trustees
and serves on the Board of Visitors of Georgetown University School of
Nursing and Health Studies and the Catholic Medical Mission Board. She
has received several awards, including an Honorary Doctorate and Distin-
guished Alumna Award from Georgetown University, the Mara Mogensen
Flaherty Award from the Oncology Nursing Society, and the American
Cancer Society Lane Adams Award.

APPENDIX D 221
Kristin Schubert, M.P.H., is a program officer for the Vulnerable Popula-

tions Portfolio at the Robert Wood Johnson Foundation. This Portfolio
invests in ideas that have the potential to represent fundamental break-
throughs in the circumstances that affect vulnerable people. As a program
officer, Ms. Schubert’s chief responsibility is to create and manage scal-
able initiatives that recognize the critical relationship between health and
where a person lives, works, learns, and plays. Her portfolio focuses on
improving the health and well-being of vulnerable children, particularly
adolescents, across a multitude of issues and systems, such as violence and
juvenile justice. Ms. Schubert came to the Foundation in 2000 from Yale
University, where she was a policy analyst for a Centers for Disease Control
and Prevention–funded prevention research center. Her work focused on
eliminating barriers to health among racial and ethnic groups and improv-
ing the health of adolescents. Earlier in her career she worked at Memorial
Sloan-Kettering Cancer Center in New York City as a molecular biologist.
Ms. Schubert holds an M.P.H. in health policy and administration from
Yale University and a B.S. in molecular biology from Lehigh University.
Evelyn Tomaszewski, M.S.W., is a senior policy advisor within the H uman

Rights and International Affairs Division of the National Association of
Social Workers (NASW), where she is responsible for implementation of
the NASW HIV/AIDS Spectrum Project. This project addresses a range
of health and behavioral health issues with a focus on HIV/AIDS and co-
occurring chronic illnesses. Ms. Tomaszewski promotes the NASW Global
HIV/AIDS Initiative through collaboration with domestic and international
groups and agencies, most recently, completing a capacity and training
needs assessment addressing the social work workforce, volunteers, and
psycho-social care providers in collaboration with FHI—Ethiopia and Phy-
sicians for Peace. She staffs the National Committee on Lesbian, Gay,
Bisexual, and Transgender Issues and the International Committee, and
she previously staffed the Women’s Issues Committee. She has expertise
in policy analysis and implementation addressing gender equity, violence
prevention, and early intervention; the connection of gender, equity, and
risk for HIV/AIDS and other sexually transmitted infections; and public
health approaches to interpersonal violence and community health. Ms.
Tomaszewski has more than two decades of social work experience as a
counselor, community organizer, educator/trainer, and administrator.
Elizabeth Ward, M.B.B.S., M.Sc., is a medical epidemiologist with years

of public health experience in the Jamaican government health system. Dr.
Ward is a consultant at the Institute of Public Safety and Justice at the Uni-
versity of the West Indies and chair of the board of directors of the Violence

Prevention Alliance Jamaica. She was formerly the director of disease pre-
vention and control of the Health Promotion and Protection Division in the
Ministry of Health. She has coordinated program development, research,
and data analysis and has been responsible for disease prevention and con-
trol. She spearheaded the development of the Jamaica Injury Surveillance
System, which tracks hospital-based injuries island-wide. Additionally, Dr.
Ward has contributed to the development of Jamician government policies
as a task force member for the National Security Strategy for Safe Schools
and as a member of the working groups for the security component of the
National Development Plan, the National Strategic Plan for Children and
Violence, and the Strategic Plan for Health Lifestyles.

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THE NATIONAL ACADEMIES PRESS

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Institute of Medicine 2011. Preventing Violence Against Women and Children:

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Deepali M. Patel, Rapporteur

Forum on Global Violence Prevention

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“Knowing is not enough; we must apply.

Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society

The Institute of Medicine was established in 1970 by the National Academy of

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PLANNING COMMITTEE ON PREVENTING VIOLENCE

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FORUM ON GLOBAL VIOLENCE PREVENTION

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PEGGY MURRAY, Senior Advisor for International Research, Office of the

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This report has been reviewed in draft form by individuals chosen

NAEEMAH ABRAHAMS, Senior Researcher, Gender & Health Research

Although the reviewers listed above have provided many constructive

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2 The Co-Occurrence of Child Maltreatment and Intimate

3 Paradigm Shifts and Changing Social Norms

4 The State of Prevention Research in Low- and

5 Violence Prevention Among Multiple Sectors 42

6 Papers on Research in Preventing Violence Against

Preventing Intimate Partner and Sexual Violence Against Women:

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International Men and Gender Equality Survey 79

Enhancing Emotion Regulation: A Framework for

7 Papers on Global Partnerships and Government Initiatives 117

The InterCambios Alliance 118

Global Partnerships on Domestic Violence Legal Reform 123

New Zealand’s Efforts to Address Violence Against

8 Papers on Preventive Interventions 144

The IMAGE Program: Summary 145

Innovative Prevention Interventions: Addressing IPV

The Fourth R: A School-Based Strategy to Prevent

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The Community Advocacy Project: An Evidence-Based

Using a Systems-Model Approach to Improving IPV Services

A Workshop Agenda 185

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Violence against women and children is a serious public health con-

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Preventing Intimate Partner and Sexual Violence Against Women:

partner violence and child maltreatment. Workshop speaker Denise W ilson

FIGURE 2-1 The cycle of violence.