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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