Thursday, December 18, 2014

Primary Violence Prevention And Asking The Right Questions: Why School-based Interventions Fail To Change Behaviors – Sylvie Hundley

1.0 Introduction

On an average day in the United States, sixty-five people die and more than 6,000 people are physically injured from interpersonal/intimate partner violence (9). In recent years this violence seems to be occurring with greater frequency and severity in our society (2-3,9,15-17). Intimate partner violence (IPV), generally termed to encompass physical, sexual, or psychological harm by a current or former partner or spouse, (14) is a growing public health concern that affects billions globally (2-3,9,15-17).

1.1 Public Health, Psychopathology and Intimate Partner Violence

Integrating the public health model for IPV prevention has caused a shift in the way we respond to violence from a reactive approach to a preventative approach (2-3,6,9-10,12-13,15-17). Additionally, research on developmental psychopathology, supported by the National Institute of Health, has expanded our understanding of violence. Psychopathology studies have shown that adolescent and adult violent behavior almost always can be traced back to origins in early life. They have demonstrated with statistical accuracy that adolescent violence can be predicted from indicators demonstrated as early as five years of age (3). Public health and psychopathology studies indicate that the development of violent behavior is an interaction between cultural forces and failures in development. These studies support the popular belief that youth violence prevention is the most effective way to end IPV (3,9).

1.2 Forming Prevention Programs: Focus On Youth Prevention

In the past two decades youth violence rates have stabilized suggesting that the problem is no longer an epidemic but instead has become endemic to our society (3). In response, scores of IPV intervention programs have been haphazardly assembled to squelch violent behavior. Many prevention programs focus on interrupting the development of violent behavioral in youth before violence begins. (3,9). To capitalize on the adolescent “window of opportunity” for learning and early intervention efforts, most primary prevention programs are conducted in middle school to high-school settings. While there is no universal model for IPV prevention, given the social and (usually) gendered nature of the problem most youth programs appear to be loosely based on social learning theory and feminist theory (3,6,11,15-17).

1.3 Program Evaluation

In an attempt to find the cure-all program that can be implemented to end IPV, violence interventions have been rigorously analyzed for efficacy. Unfortunately Meta analysis of IPV prevention programs report that the overwhelming majority cannot demonstrate measurable outcomes (11,15-17). The few programs that do manage to document statistical significance report slight changes in in knowledge and attitudes among the intervention group. However, knowledge and attitudes are easier to change than behaviors (3) and there remain few effective adolescent IPV preventions available (11). Additionally, among some interventions the change in attitude was documented in the undesired direction (16,17).

1.4 Asking “Why?”

This lack of efficacy is not surprising, given that IPV is not only pervasive in many communities, but also vastly underreported and often construed as a normal part of immature relationships (2-3,6,9-10,12-13,15-17). Despite the fact that our approach to eliminating IPV from society is broadening in scope under the public health lens, our response is still too reactionary and too focused on the violent outcome.  This is demonstrated by the overwhelming attention placed on measuring program effectiveness instead of measuring the mediators of behavior change. It is crucial that programs measure the skills that intervention strategies intend to change in order to determine which changes in specific skills ultimately lead to changes in behavior. The goal should not only be determining which programs work, but to understand why (17).  Public health has provided a bridge between conceptualization of how chronic violence develops and application of how prevention programs can interrupt that development. But in order to accurately implement prevention programs that work in the real world, their needs to be another bridge connecting the sciences, social theories and preventions to the public at large (3).

2.0 Criticisms
            There are three main elements of consideration that have not been properly evaluated in IPV primary prevention programs that inhibit substantial measures of behavior change.    

2.1 Missing The Critical Components Of Social Learning And Cognitive-behavioral Theories

Almost all youth IPV prevention programs employ feminist and social learning theories as a basis for intervention. However, the extent to which interventions use critical components of these theories is unclear, especially social learning theory. Social learning and cognitive-behavioral theories emphasize the importance of identifying potential factors that influence the development of new skills in the adoption of new behaviors. However, few interventions examine the acquisition of previously absent behaviors as part of their intervention (11).

2.1.1 Limited Setting and Social Learning Theory
It is clear that violence is a learned behavior any exposure to violence in early age is highly predictive of entering a violent relationship later in life (2-3,6,9-10,12-13,15-17). Social learning theory acknowledging that learning does not happen in isolation of ones environment; stressing the importance of external influences on various internal processes. The theory postulates that a large contribution to behavioral development is the product of observing and then emulating the actions of others within an individual’s community (1). This is known as modeling. Modeling behavior is common among adolescents given the overwhelming need to attain peer acceptance and “fit in” with a group (1-3,6-7,11,14-17). School programs that focus on changing the nature of violence among peer-group interactions and peer-group norms can be extremely influential in behavior modification but programs of this nature are less common than individual approaches (2). Furthermore, just as peers and schools exert their own influence on behavior, so too do the other environments children inhabit and confront on a daily basis (2,11). For this reason, school-based IPV intervention programs that apply social learning theory in a “microenvironment” are inherently flaw. School-based programs for IPV interventions are isolating the school environment from the home environment and so create unrealistic circumstances that fail to address real-world situations, and fail to produce real-world results. Without connecting school-life and home-life school-based interventions are putting youth in opposition with their origin and limiting potential to influence behavior. It is important that school interventions do not come at the expense of parent-teen communication, mistrust, or conflict.

2.1.2 Social Ecological Model and Excluded Populations
As youth might observe violence in their home, they may also look to the larger community to teach them about healthy relationships (8). To account for the multiple ways the environment influences youth behavior, the CDC utilizes the social ecological model as a basis for IPV prevention initiatives. Similar to social learning theory, the social ecological model identifies the interactions between external and internal processes in the development of behaviors. The social ecological model conceives of relationships as operating on different levels: interpersonal, community, and society level (13). School interventions largely ignore community or population level interactions by focusing instead on individual choices (3,11,15-17). The social ecological model proposes that there are multiple levels at which behaviors can be influenced. School-based interventions focusing on only one level of the model may be overlooking whole segments of the population.
Additionally, some students, especially those most at risk may not be accessible by schools (17) Many students may lack school engagement and/or have difficulty getting involved in school-related activities. Many school-based interventions systems use a messy, one-classroom-at-a-time educational approach to IPV prevention. They usually bring in a speaker from outside of the community who addresses a class with an isolated, presentation about IPV (17). This approach can evoke strong psychological reactants. This has been demonstrated in some programs that reported a “backlash” among the male population who developed attitudes in opposition to program messages (16,17).

2.1.3 Family Environment
Social learning theory suggests that through teaching and shaping their children’s behavior, parents dramatically affect acceptance or rejection of acceptable behaviors (1) yet family venues have received relatively little attention in IPV prevention programs (17). This is surprising given the mounting evidence for the intergenerational predictors of violence. The popular notion of a cycle of violence suggests that witnessing partner violence or experiencing family violence at a young age is strongly associated with increased risk for children to develop attitudes, beliefs, and behaviors that lead to their own involvement in violent relationships (1-4,6-9,11-13,15-17).

2.2 Universal Interventions and Limited Theoretical Approach.

School-based interventions appear to be advantageous for many reasons. They can easily reach large numbers of students in a short time, create safe environments, promote learning, and affect social interactions and peer modeling behavior. Most IPV interventions are universal, that is, they are directed towards one or only a few targeted skills, contexts, or persons without regard for risk or personal factors (3,11,15-17). Although universal interventions are an excellent way to provide basic information to a large population, different people experience IPV in different ways (3,8-9,11,15-17).
Studies show that IPV is a multidimensional problem that spans across a constellation of risks factors (2-4,6-9,11-13,15-17). Risks do not exist in isolation from one another; each uniquely contributes to the development of violent behavior and outcomes (3,17). The complexity of IPV require interventions to either focus simultaneously on multiple risk factors or target specific prevention efforts to specific children (3). Selective interventions allow for targeting of specific at-risk populations or environments, and thus the content of those interventions can directly address whatever risk factors are believed to lead to partner violence.  Ultimately, the development of selective interventions requires a solid theoretical framework in order to identify the vulnerable population to target interventions (16,17).

2.2.1 Narrow Focus On Theories
The majority of IPV programs represent a fairly limited range of theoretical approaches (15,17).  The background-situation model of courtship aggression developed by Riggs & Oleary, attachment theory, social expectations theory, and the social ecological model are all important behavioral theories that are largely underutilized by school intervention programs (3,11,15-17).
2.2.1a Background-Situational model
The background-situation model of courtship aggression takes into account the interaction background factors that may affect an individual’s tendency to be generally aggressive, and situational factors that result in the expression of partner violence. Background factors include modeling of antagonism by parents, parent–child aggression, prior use of violence, arousability, and certain personality factors. Situational factors include relationships conflict, stress, alcohol use, and partner aggression. In essence, background factors explain who might be involved with partner violence and situational factors explain when partner violence might occur (17). The background-situational model may be important for identifying specific variables as predictors of IPV.
2.2.1b Attachment Theory
Attachment theory focuses on cognitive formations of relationship processes. Attachment theory proposes that children conceptualize relationships based on their history with significant caregivers. The theory suggests that this cognitive-affective understanding of relationship elements, (the relationship, the self, and the other) functions both as a prototype and template for developing future relationships. Although cognition develops and changes over time, internal working models, which operate outside of awareness, are thought to remain generally consistent (16). Studies suggest that power, reciprocity, and intimacy are developmentally important for adolescents, their development of intimate relationships and violence within those relationships ( 2-4,6-9,11-13,15-17). Thus focusing on the role of coercive interactional processes in the development of IPV using Attachment theory may be beneficial.

2.3 Multiple Risk Factors And The Lack Of Generalizability

Studies show that dating violence begins in middle school and disproportionately affects minority groups yet there are minimal interventions that target this demographic (11,17). Two school-interventions such as Safe Dates and fourth R: Skills for youth Relationship (fourth R) programs have been shown to produce significant behavioral effects: both reduced dating violence perpetration or victimization. However, these programs may not be as effective in ethnic-minority middle school youths because they were developed for and evaluated in older, predominantly White youths (11).
There are a number of factors that contribute to keeping the interpersonal pattern of violence and aggressive behavior consistent over time. The emerging conceptualization is that chronic violent behavior results from life-course developmental experiences (3). The life-course perspective (18) helps to understand how the combination of early programing experiences at critical/sensitive life stages and the cumulative effect of lifetime exposure to IPV impacts individual’s risk and protective factors. Studies suggest that the source of violent behavior resides at the intersection of the individual and the culture interacting over time.

2.3.1. Intergenerational cycles of IPV
The social learning model would predict that those who witness violence in their upbringing would be more likely to repeat behavior in their own relationships (1). Supporting the concept of modeling, several studies have documented a relationship between witnessing violence in the home and increased risk of being both a victim and a perpetrator of violence. Family risk factors, particularly those associated with parental behavior and the home environment are highly associated with IPV risk (1-4,6-9,11-13,15-17). Youth who experience IPV report witnessing their parents exhibiting acceptance of abuse or engaging in violent relationships and perceive the abuse to be normal because they, “grew up in an environment where that’s what they see people do.”(7, p.568). 

2.3.2 Cultural Competence
Studies suggest that abuse is as a learned behavior in which cultural norms played an important role. Often parental acceptance or downplay of adolescent IPV was attributed to cultural beliefs that supported traditional gender roles and permissive attitudes toward violence. Supporting feminist theory, studies find that adherence to traditional sex roles is among the most powerful predictor of attitudes supporting tolerance of IPV (7,17). The importance of underlying attitudes about sex roles, power, and control are strongly influenced by culture (2,4,7,8). Studies show that across many Latino communities “gender roles not only serve as a justification for abuse, but they also increase women’s vulnerability to abuse by keeping them isolated, subservient to male partners, and self-sacrificing to community and family” (7, p.568). Additionally, In some cultures abuse is not viewed as an issue. If the child is brought up in an environment where abuse is normal and the community says the abuse is within what they consider normal, then it becomes difficult, and possibly insulting to label their relationships as “undesirable.”

2.3.3 Adolescence
The adolescent life stage is a period of heightened risk for IPV given the developmentally distinct ways they experience violence (4,7). Adolescents are highly susceptible to modeling behavior and tend to conform to rigid gender stereotypes and social norms. Adolescence is a period of value and identity formation as well as a time when youth are creating their ideas of love and attachment (2-4,6-9,11-13,15-17). Additionally, pubertal development and social influences aid in the formation of romantic interests and sexual motivations increasing sensation seeking, risk taking and reckless behavior. Taken together, the reorganization of regulatory systems that occurs in adolescents’ development and social influences shape the adolescent life stage as a critical period, tangled with both risks and opportunities (14).
            It may also be important to consider whether partner violence is merely one component of the characteristic risk-seeking behaviors that occur in adolescence. It may be that adolescent are “hard wired” to take risks of this nature because their brain is not fully developed (16,17). In this instance it is important for interventions to work on building an environments that are as safe as possible for adolescents to take risks.

3.0 Conclusion: Bridging The Gaps

IPV prevention programs are still in early development, but are likely to be an important component of prevention strategies (2,3,6,9,11-13,15-17).  Current primary prevention efforts for partner violence consist almost exclusively of universal, school-based, dating violence prevention programs that target individual-level factors. These programs show little variability with regard to theoretical foundations, intervention strategies, or targeted populations. Additionally, prevention programs fail to incorporate key components of the few models they do use by limiting interventions to school venues (3,11,15-17). School-based interventions need to find a community outlet (8) and incorporate a more accurate use of social learning theory (11) that acknowledges the differences between the home and school environments. More work is needed regarding program development to expand the theoretical basis for interventions, and to develop targeted and culturally sensitive interventions that understand the complex interactions of youth development and environmental influences. Interventions that utilize these theories must be culturally competent and address the different ways that people may experience or be predisposed to violence.

4.0 Proposed Intervention: Making IPV Prevention Programs “Sexy”

            Given the nature of IPV, it is essential the intervention happen early. School-based interventions accomplish this goal, but they must have a structured curriculum that is supported by behavioral theories/models along with community-based activities. In order to yield the best overall outcomes for families impacted by IPV prevention programs must utilize a combination of outreach and collaborative strategies that are rooted in the community and connect to personal values. This can be accomplished with effective use of social marketing theory and advertising theory.

4.1 Social Marketing And Advertising

Social marketing and advertising theory have been growing in popularity within the public health arena (5). Social marketing theory is a way to create and package intervention programs so that it fulfills the needs of a target population’s wants. There are certain basic cultural values that are held in common and have a strong impact within community networks (5,7,17). Social marketing and advertising theory are able to create mass universal appeal for a product by offering desirable benefits that grab the attention of communities of interest. Programs that properly utilize these theories have been proven to facilitate the acceptance, rejection, modification, abandonment, or maintenance of particular behaviors by groups of individuals (5). Once a target population has been identified a combination of advertising theory, social expectations theory, and social networking theory can be used to effectively seed a campaign.

4.1.1 Using Social Networks To Insert Desirable Behaviors
Social expectations theory states that people will follow societal norms. Adolescents are especially susceptible to following cultural norms and so can be more easily persuaded using advertising theory. Social Expectations theory evaluates behavior on a population level, targeting social norms, as a predictor of how whole groups might behave. Social networking theory works as a means to focus interventions by mapping out out networks within groups. Understanding the social norms within one cluster of a social network and targeting that population with an effective use of advertising theory can effectively seed behavior changes that increase positive peer modeling, community endorsement of acceptable dating behavior, and social support for IPV prevention.
In order to effectively package and sell anti-violence, IPV programs must conduct extensive marketing research with youth, their parents, and other influencers inside and outside school compounds (5). The social-ecological model can be used to better understand violence and the effect of potential prevention strategies. In considering the complex interplay between individual, relationship, community, and societal factors the social ecological model helps to address the dynamics that put people at risk for experiencing or perpetrating violence (13).

4.2 The Notion Of Exchange

IPV intervention programs need to address deep desires, inspirations and aspirations of their young audience. Most programs assume that freedom from violence is a big enough promise to catch interests however, as adolescents is a time when many youth are still forming their ideas of love violence may not be a deterring factor for them. In fact, many service providers report that they found it difficult to get some youth to see that they were being abused in a relationship (7). Some adolescents may be so focused on “being in love” and belonging to someone that jealousy and possessive behaviors are often misinterpreted as signs of affection (2-4,7,11,15-17). Programs to target youth and their communities need to utilize advertising theory to create mass universal appeal for IPV prevention initiatives. This may involve celebrity endorsement or social media, which highlights the attractiveness of strong women and caring men.

4.3 Researched Based Preventions, Targeting Interventions To Appeal To Core Values

It is important that vulnerable populations receive IPV prevention services specific to the unique way they perceive violence (2-9,11,15-17). This means evaluating core values specific to cultural identities to convey messages that will be well received by the target population (5). School-based universal interventions are missing their mark by assuming that education leads to prevention (5,17). The educational model believes that creating awareness is the best way to create behavior change. However, knowledge is not as strong of a core value as love and acceptance. The educational model works best works when the benefits of the behavior change are inherently attractive, immediate, and obvious and costs are low (i.e. SIDS campaign, educating parents to put baby to sleep on it’s back to prevent sudden infant death syndrome). In contrast, marketing is the most effective strategy when program goals are not directly consistent with self-internalized beliefs because it offers alternative choices that invite voluntary behavior exchange. Programs need to have a greater focus on selective interventions that allow for targeting of specific at-risk populations or environments. The content of those interventions can then directly address whatever risk factors are believed to lead to partner violence.

4.3.1 Enforcing Freedom
It is important not to over generalize and apply labels. Message should reinforce freedom not take it away. In these way, IPV intervention programs need to give out positive stereotypes, avoid psychological reactants, and construct messages in a way that reinforces freedom not box people into categories. Using marketing gives IPV programs a brand, reinforces core values, and ensures sustained intervention (5). Marketing and advertising theory would ensure that messages are applicable to real-world environments and are delivered effectively.

4.4 Taking Control
Studies on IPV prevention have found that the community must take responsibility for ongoing program activities, and advertising theory is a way to get the communities interested in a campaign (5). Furthermore, the community must assume ownership of their campaign (8). This involves giving youth the ability to develop their own campaigns, create advertisements for their campaign, develop social networks, and ultimately enhance executive functioning and subconsciously change behaviors.

5.0 Conclusion: A Call to Action

            For an IPV prevention campaign to be successful, it must consist of a promise that provides a solution to issues that the target population considers important and offer a benefit they truly value. Promotional strategies must carefully design a specific message using appropriate communication techniques that resonate within communities. Community-based preventions that utilize marketing theory have the potential to harness community strengths by facilitating mobilization, empowerment, and participation, balances power differentials which ultimately benefit social changes (5).

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