Thursday, May 20, 2010

A Critique of Domestic Violence Awareness and Outreach: What Message the Faces of Battered Women Really Conveys – Vina Chhaya

With one in four women in the United States experiencing violence at some point in her life (1), an average of 500 rapes per day reported in 2007 (2), and more than $8.3 billion spent on associated medical and mental health care services (3), domestic violence is an issue that needs to be addressed. Many organizations have made it their aim to increase awareness around domestic violence, particularly in health clinics and patient waiting rooms, where outreach materials are able to have the most impact and translate most immediately into action. While these venues present the perfect setting to increase awareness around domestic violence, the outreach material currently being used has not been demonstrated to reduce the prevalence of domestic violence or increase treatment seeking behavior among patients. These images of solemn women, often alone, or having bruises, are ineffective at increasing the number of women disclosing violence to their provider and also fail to empower women with the sense of security and control they need to perhaps make progress towards seeking treatment. Additionally, the statistics presented shown in posters, brochures, and stealthy tear-away cards fail to appropriately engage women who are experiencing abuse in their relationships and are in denial that this is happening to them. Finally, the overall approach to increasing screening is currently provider-initiated, which does not facilitate long-term behavior and norm change among victims of domestic violence to feel a sense of control, empowerment, or comfort with providers enough to talk with them about such a pressing issue.

Using the transtheoretical, or stages of change, model as a basis to explain the thought process of women experiencing domestic violence, we see that even while attempting to take action, there is a lot of cyclical transition between stages (4). The stages of change model identifies five distinct phases of the thought process and helps define a person’s readiness to perform a concrete action or make a decision (5). By understanding the stages of precontemplation, contemplation, preparation, action, and maintenance, and determining which stage a patient is in, the provider can better understand the dynamics of domestic violence in the patient’s thought process to provide referral to more appropriate resources (6). Women in precontemplation and contemplation are the intended target audience for domestic violence outreach materials, as these are the women who need to confirm the existence of abuse in their relationship and be nudged to take action. Those victims in the preparation stage have already been empowered to take action and have a plan, needing to be reminded that resources exist (5). For the purposes of increasing self-disclosure of domestic violence and empowering women to engage in treatment seeking behavior, outreach material should target women in precontemplation and contemplation.

During precontemplation, people experiencing domestic violence have no intention to take action in the foreseeable future. There is no desire to understand more about domestic violence and these women are not informed of the consequences. As a result, there is a great need to confirm to these women that domestic violence is affecting them and show them that a network of support exists (5). Contemplation, on the other hand, is where the woman self-identifies with being in an abusive relationship and is thinking about the available resources and consequences of her actions. These women exhibit ‘behavioral procrastination’ as they continue to weigh options and think about the presence of domestic violence in their relationship (5). Women in contemplation need to be shown the availability of resources and encouraged to take action, preferably in a manner that empowers them and leads to changing behavioral norms surrounding treatment seeking.

Thus, women in precontemplation are trying to understand that their relationship is abusive, while women in contemplation are evaluating how to manage their relationship (4). Outreach material should be made with the intent of targeting women in both these stages, taking into account the different thought processes involved in each stage. With regard to these two preceding stages preparing women for action, whether it is disclosure or searching for specific resources to manage their relationship, there should be outreach materials with images focusing on empowering these victims, use of statistics according to stage, and an overall approach geared towards patient-initiated action and empowerment.

Argument 1: Images and Overall Tone of Material

Current domestic violence outreach material includes the solemn faces of women, sometimes battered (7), and often always alone (8). While these images are powerful, they highlight only the negative realities of being a victim of domestic violence; namely that one suffers and is alone.

During the precontemplation stage, the victim may express an optimism bias, meaning that she understands the realities facing victims of domestic violence and knows her own situation, but is unable to logically connect her current situation with possible future events. Evidence has shown this bias to result in underestimation of risks and in some cases the victim may return to the abuser failing to realize the likelihood of abuse happening again (9). Outreach material images also fail to make women reading these materials in examination or waiting rooms connect to the faces of women, most often, being abused, portrayed in posters and brochures. While the term ‘you’ is used, it can still be interpreted as referring to the generic population and does nothing to help self-recognition, connecting the realities of abuse in a relationship to abuse in my relationship (10). This demonstrates confirmation bias as well, when the woman fails to identify with abuse in her own life, but can appreciate the effect it has in the lives of others. Overall, there is no strong message showing the realities of domestic violence, in the form of isolation and injuries, and allowing a person viewing the image to have the space to make the connection between the image and themselves.

Additionally, victims of domestic violence, when moving between stages of change, are connected to existing support networks and consult family, friends, or community organizations to address the realities they are facing in an abusive relationship (4). Even with the presence of friends, family, or other resources, women have indicated that they are comfortable being asked by their provider, often lingering at the end of appointments in the hopes of the provider asking (11). With current outreach material showing women in isolation, it fails to reinforce the existing support system many victims do have and use. Regardless of the stage a victim is in, existing outreach material fails to remind them of available networks, further preventing realization of the abuse for women in precontemplation or transition toward action for those women in contemplation.

Finally, certain campaigns have chosen to employ a fear tactic approach to raising awareness about domestic violence. While research has demonstrated that there is a linear effect between fear and the effect it has on behavior change (12), there have also been instances where this method has produced the opposite effect intended in the target population, specifically a domestic violence campaign in Scotland (12).
Fear campaigns also make many assumptions about the target population and are designed to be most effective among those who are better equipped psychologically and socially to understand the message (12). This ostracizes women experiencing violence, who are already vulnerable and feeling isolate and who the campaign was originally intended to reach, and makes them feel more vulnerable to the abuse. Another school of thought is that fear tactics, if used often enough, tend to desensitize the public from the severity of the issue (12). This, again, results in wasted resources and an ineffective approach to identifying with abuse and then taking action towards disclosing or seeking other resources. Use of fear has been shown to be effective in commercial campaigns, where a clear brand, image, and message already exist (12). However, with only a few images in posters and on brochure covers available to get a clear message across, perhaps donning the bruised faces of women to give an existing message direction is not the best approach. This is especially true when this message showing the consequences of abuse is not appropriate to target women who have yet to self-identify with the abuse or are in a state of contemplation about the abuse and remain cycling between stages of change.

Argument 2: Statistics and Information
Public health is a discipline that has evolved around facts and statistics, with a strong evidence base informing programming and policy decisions. While informative and convincing to those who understand what the numbers actually indicate, they fail to do much to affect behavior change in victims of domestic violence who are in the precontemplation stage.

A main issue with statistics is confirmation bias for women in the precontemplation stage. For these women, who have yet to identify with the harmful health effects of their abusive relationship, this information in pamphlets fails to help with recognition of their abuse and consequently with any movement towards action. While having these materials available for all women in waiting rooms and bathrooms appears to be beneficial in capturing women in the contemplation stage, passing out this material during a visit may be fruitless for women in precontemplation. The valuable information presented is lost on these women because they know the facts, but are unable to apply this to what they are experiencing, not having come to terms with their own abusive relationship yet.

Women do appreciate educational materials, particularly if in the contemplation stage when they have already recognized that the abuse is affecting them. In fact, women indicated that having outreach materials in the exam rooms and bathrooms were helpful (4). Simple language to assist in self-recognition was also found to be beneficial to women in the precontemplation stage (9). However, any additional information beyond a few statistics and screening question was found to be unproductive (4).

In general, there is limited evidence demonstrating the effect of existing interventions on women, specifically posters, brochures, and other domestic violence outreach material (13). More research focuses on the impact of provider training, tools or surveys used to assess the presence of domestic violence, and systemic approaches to increase provider-initiated screening in primary care settings (13). However, one can extrapolate from existing research that the impact of outreach material must be minimal since immediately following an intervention that used posters, there was only a small increase in domestic violence cases reported, and this rise fells to near its original level over a few years (13).

Nevertheless, without research focusing on the impact of outreach material alone, specifically to women in different stages of change, better posters and pamphlets to achieve desired increases in self-disclosure or resource-seeking behavior will not be achieved. In fact, without proper assessment, including too many facts, words, or the wrong images could have a deleterious effect in the intended target population (13). This could result in more apathy towards domestic violence screening and resistance to any attempts linking victims to resources.

Argument 3: General Outreach Approach
The current domestic violence awareness and outreach approach focuses on provider-initiated screening to capture victims of domestic violence and provider training to deal with referrals to appropriate resources in primary care settings. While provider-initiated screening has actually been beneficial and is preferred by women (10), it focuses on alleviating provider’s fears of appropriate methods of handling disclosure. Strengthening domestic violence screening programs by increasing provider self-efficacy surrounding disclosure of violence by victims during visits has been shown to increase screening rates (10) and result in better linkages to resources and referrals. It is estimated that 7% to 25% of domestic violence cases presenting in health care settings are actually identified, being the impetus to focus on system-level interventions targeting providers (14). By enhancing the clinic setting to support screening and referral, reminding providers to screen, and giving providers confidence in their ability to deal with disclosure, Thompson et al. showed that 3.9 times as many women were screened and 1.3 times as many cases presented (14).
Even though the benefits of training health center staff to be more aware of domestic violence is clear, the effects of the training seems to wane over time (13). While they did demonstrate high levels of screening and case finding nearly 2 years after the intervention, there was no measure of how effective provider-initiated screening and referral was for women self-identifying and then moving towards action. Furthermore, there is no indication that as the facility sees staff turnover and other changes over time that screening rates and case identification will remain at post-intervention levels.

During time spent between patients and providers, the burden of raising the topic is on the provider. Given the limited patient-provider time during visits, among other barriers to screening, the complexity of assessing the stage of the woman, and the fact that the woman may not identify with the abuse herself, it is difficult to completely put the burden of identifying cases of domestic violence on the provider. With examinations in place to address other patient complaints, which may suggest domestic violence, providers can only do so much during the limited time they are given. While increased screening by providers has shown to increase patient satisfaction, which increases self-disclosure rates over time (9), there is not much done with this intervention to empower the victim to feel comfortable enough with the issue and her provider to disclose at that moment. Crafting appropriate materials to shift some of the burden onto the victims by encouraging them to disclose may increase self-disclosure rates both immediately after the intervention and long-term as well.
Thus, while the focus on provider-initiated training helps alleviate fear of offending the victim and how to deal with disclosure and educates providers on the prevalence of domestic violence in their patient population (15), there are other interventions to increase self-disclosure and assist in a victim’s progression towards action, including creating a supporting environment and empowering victims to feel comfortable enough to disclose. There is evidence indicating that women prefer to be screened alone and by a health history form compared to being questioned by a social worker or relying on handouts (15). Of the 133 women participating in this study, only 11 (7.9%) said they would be offended if a provider asked about domestic violence (15). However, reliance entirely on provider-initiated screening could result in disparity of care, just as reliance on selective screening and self-disclosure would (16). These missed opportunities to intervene and prevent additional health consequences of domestic violence are also seen more among victims who have not identified with the abuse, those in the precontemplation stage (16, 17). Even if 80 to 85% of women would disclose if asked by a provider, designing outreach materials for the purpose of empowering women to seek existing support networks, encouraging women to disclose, and initiating the conversation with their provider may tip these women on the verge of contemplation into discussing the issue (or even into preparation).

Proposal 1: Images and Overall Tone
Given the use of solemn and sometimes fearful images in domestic violence outreach material (7,8), I propose to create outreach materials depicting a victim of domestic violence surrounded by family, friends, or another existing support network. This positive framing, in addition to affirming the reality of the abuse, will reinforce the fact that there are resources and people who can help. Additional images could focus on the patient-provider relationship and patient-initiation of disclosure. In both cases, the environment depicted would convey a comfortable, nurturing setting where victims of domestic violence, specifically those who have acknowledged the abuse and begun to evaluate the pros and cons of actions, would be encouraged to disclose or connect with resources.

Another message that needs to be clear is for women in precontemplation, who have experienced the abuse but fail to connect information on the abuse and its damaging effects on her health with her own health (10). For these women, there should be materials showing a victim, still surrounded by a group of people, with the words, “I’m just like you,” then followed by thoughts common to women who are still trying to identify with the abuse. This opening statement would cause any woman waiting for her appointment to continue reading and then perhaps upon seeing the similarity between this woman’s relationship and her own, may slowly move towards contemplation.

Finally, use of the fear tactic to move victims along towards action should be avoided (11,12). During these complex stage transitions, victims of domestic violence are extremely vulnerable and harsh images could provoke the opposite response. Although the campaign would increase awareness surrounding the issue for the general public, it could reduce self-disclosure and impede progression towards action, further isolating the intended target audience (12). Overall, the images and tone of domestic violence outreach material should be nurturing and provide a sense of control for victims. There should be a push to regain control for those women who have self-identified and are making progress towards decisive action and planning by transitioning to the preparation stage. Consequently, those women in precontemplation should be made to realize that by succumbing to abuse they are giving up an element of control in their lives. Framed positively and tailored for women in two stages of domestic violence primed for intervention, precontemplation and contemplation, outreach material could impact self-disclosure, empowerment, and the public’s attitude about domestic violence.

Proposal 2: Statistics and Information
When creating material specific for women in both precontemplation and contemplation, it is important to understand the value of statistics and educational information around domestic violence issues for each group. These statistics stating that one in every four women has experienced abuse at some point during her life (1) and facts to indicate the effect of abuse on health and well-being over time are valuable as general outreach material. However, for women who have yet to recognize the existence of abuse in their own relationship, the importance of this information is lost. Optimism bias is emphasized as they recognize the harmful effects of abuse in general, but fail to apply it to themselves. For women in contemplation, however, who have already self-identified, this information could help them understand specific health outcomes and consequences of not taking action and allowing the abuse to continue. Thus, as part of provider training, providers will learn to do a stage assessment when screening patients to give them material appropriate for their specific stage.

For posters, the language should be kept simple (9), avoiding the heavy use of statistics and information on health outcomes, to focus on creating a clear message to women in all stages to self-identify, to reach out to existing support networks, and to take control of the decision to disclose. The purpose should focus on helping women in precontemplation self-identify or encouraging women in contemplation to disclose and/or seek resources. Detailed information on health outcomes of abuse should be restricted to brochures, pamphlets, or other material that can be dispensed on an individual level and stage-matched to patients to provide optimum impact of the information. Information provided in the form of a questionnaire or checklist that someone can pick up as they wait for their appointment may also help increase access to services (18). Thus, perhaps creating material with simple language and minimal use of educational information specifically for women in precontemplation along with providing stage-matched material during visits may help preventing women from feeling overwhelmed when they haven’t even identified with the abuse yet.

Finally, in order to truly craft appropriate materials that are having the intended outcomes of increasing self-identification with abuse and encouraging women to seek resources and value their health, research needs to be conducted to formally evaluate the impact of specific outreach materials. Content, images and information, in addition to the placement should be evaluated. At present, it appears that there are standard locations for posters, small information cards, and brochures (18), but understanding where women value their presence most may help use resources effectively. In a similar manner to testing commercials for appeal, images and content to be used for domestic violence outreach materials should be tested on groups of patients, victims and non-victims, to assess for effectiveness and whether or not any material could be considered offensive.

Proposal 3: General Outreach Approach
Concerning the overall approach to domestic violence screening and referral, which currently emphasizes increasing provider education and sensitivity around the topic, I recommend developing materials that empowers women to self-disclose. While there is no evidence to demonstrate that creating an environment for women to regain control over their abusive relationships does not already exist, there is limited evidence to show the effect of outreach materials on disclosure (13) and specifically that providing this empowerment results in increased self-disclosure. Thus, before scaling up this intervention, a pilot test to determine the effect on self-disclosure and possibly shift to contemplation, through increased confidence, should be measured. At present, provider-initiated screening and training to alleviate fear resulting from possible patient disclosure does result in higher screening rates and case findings, but does nothing to affect behavior change in the target population of victims of domestic violence.

Provider training and connecting primary care settings to domestic violence resources, by providing materials or having advocates on-site could also increase access to services and lead to increased disclosure rates. Thus, I recommend keeping these measures in place as evidence has shown increased case finding in the short-term (10). However, more research should be undertaken to determine the impact of provider training on screening and disclosure rates in the long-term. While it may be the case that improving the infrastructure of a health care facility is the only way to strengthen a domestic violence program, combinations of other interventions should be evaluated and any process shown to maintain the initial impact over time should be documented for replication at other sites.

Posters and brochures should encourage women to disclose abuse to providers, reminding them that providers have other things on their mind. Clever thought bubbles and the image of a patient and physician in an examination room could persuade people to talk to their physician about not only their relationship, but also other issues concerning their health. Shifting at least a portion of the burden of talking about domestic violence on victims may help victims develop confidence, leading them towards action, and result in stronger patient-provider relationships overall. Finally, these outreach materials should also include media which reduce optimism bias (9). Making images on posters familiar and having items in a checklist that a victim could identify with could help women in precontemplation realize that she is, in fact, a victim of domestic violence.

With recent research shedding light on the increasing costs of health care associated with domestic violence and 25% of women in the US affected by some form of violence or abuse, domestic violence is a public health issue in need of attention. While many outreach organizations exist, the link to primary care settings is often poorly defined and women are lost once they are identified by providers and referred to the proper resources. Outreach materials, though, in the form of brochures, pamphlets, and posters, have the capacity to affect behavior change in victims of domestic violence. Current materials show women in isolation, often with bruises or other injuries, and provide a very negative frame for domestic violence. While it is a tragic behavior, the reaction to abuse in a relationship doesn’t have to be associated with pain. In addition, outreach materials fail to provide appropriate stage-matched images and information for those women in precontemplation and contemplation, which could help increase self-disclosure. Finally, the overall approach taken in domestic violence awareness and outreach to sensitize and train providers fails to focus on victim empowerment and self-efficacy. Thus, I propose critically evaluating the impact of outreach material, both images and information, to understand how to best assist women in precontemplation identify with the abuse and women in contemplation move towards disclosure. Positively framing outreach materials, keeping language simple, and showing effective images to promote using existing networks of friends, family, providers, or other resources, could empower a vulnerable population of victims and reshape the way the public understands domestic violence.


1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence. Atlanta, GA: Centers for Disease Control and Prevention.
2. Bureau of Justice Statistics. National Crime Victimization Survey: Criminal Victimization, 2007. 2008. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics.
3. Max W, Rice DP, Finkelstein E, Bardwell R and S Leadbetter. The Economic Toll of Intimate Partner Violence Against Women in the United States. Violence and Victims. 2004; 19(3): 259-272.
4. Zink T, Elder N, Jacobson J and B Klostermann. Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation. The Annals of Family Medicine. 2004; 2: 231-239.
5. Velicer WF, Prochaska JO, Fava JL et al. Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis. 1998; 38: 216-233.
6. Fraiser PY, Slatt L, Kowlowitz V and Glowa PT. Using the stages of change model to counsel victims of intimate partner violence. Patient Education and Counseling. 2001; 43: 211-217.
7. Family Violence Prevention Fund. Health Care and Domestic Violence Posters. Are you tired of making excuses for him? San Francisco, CA: Family Violence Prevention Fund.
8. Family Violence Prevention Fund. Health Care and Domestic Violence Posters. Reproductive Health Posters. San Francisco, CA: Family Violence Prevention Fund.
9. Martin AJ, Berenson KR, Griffing S et al. The Process of Leaving an Abusive Relationship: The Role of Risk Assessments and Decision-Certainty. The Journal of Family Violence. 2000; 15(2): 109-122.
10. McCaw B, Berman WH, Syme L, and EF Hunkeler. Beyond Screening for Domestic Violence: A Systems Model Approach in a Managed Care Setting. American Journal of Preventive Medicine. 2001; 21(3): 170-176.
11. Ramsay J, Richardson J, Carter Y et al. Should health professionals screen women for domestic violence? Systematic review. British Medical Journal. 2002; 325: 314.
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13. Soames Job, RF. Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health. 1988; 78(2): 163-167.
14. Garcia-Moreno, C. Dilemmas and opportunities for an appropriate health-service response to violence against women. The Lancet. 2002; 359: 1509-1514.
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16. Thackeray J, Stelzner S, Downs SM and C Miller. Screening for Intimate Partner Violence: The Impact of Screener and Screening Environment on Victim Comfort. Journal of Interpersonal Violence. 2007; 22(6): 659-670.
17. Phelan, Mary Beth. Screening for Intimate Partner Violence in Medical Settings. Trauma, Violence, & Abuse. 2007; 8(2): 199-213.
18. McNutt LA, Carlson BE, Rose IM and DA Robinson. Partner Violence Intervention in the Busy Primary Care Environment. American Journal of Preventive Medicine. 2002; 22(2): 84-91.


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