research paper about family violence

Antecedents, Characteristics, and Dynamics of IPV in the Israeli Jewish Ultra-Orthodox Community: A Cultural Exploration

• Aiala Szyfer Lipinsky
• Limor Goldner

Understanding Australian Massage Therapists’ Attitudes and Confidence to Respond to Domestic and Family Violence in Clinical Practice: Findings From a Community Survey

• Sarah Fogarty
• Phillipa Hay
• Kathleen Baird

Post Cluster-Randomized Controlled Trial: Longer-Term Efficacy of a Bystander Program to Reduce Violence Perpetration and Victimization in a Prospective Cohort

• Ann L. Coker
• Zhengyan Huang
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Reaching a Fuller Picture of the Perceived “Need” of Police and Contexts Surrounding Women’s Formal Reporting for Intimate Partner Violence

• Luisa Prout
• Briana Barocas

Establishing a Cutoff Score for the Healing after Gender-based Violence Scale (GBV-Heal): A Brief Report

• Laura Sinko
• Sachiko Kita
• Denise Saint Arnault

Intergenerational Childhood Exposure to Intimate Partner Violence, Maternal Psychological Distress, and Physical Injury Victimization in Emerging Adults

• Carley Marshall
• Sara Abou Chabake
• Rachel Langevin

From Abuse to Resilience in Romantic Relationships of Women: A Model Testing Study

• Elvan Yıldız-Akyol
• Kemal Öztemel

Intent vs Impact: A Qualitative Investigation of Domestic Violence and Extreme Risk Protective Order Gun Prohibitions in Two States

• Kellie R. Lynch
• Michael K. Gusmano
• Jeff R. Temple

A Chance to have a Voice : The Motivations and Experiences of Female Victim-Survivors of Domestic, Family and Sexual Violence who Joined a Lived Experience Research Group

• Renee Fiolet
• Kelsey Hegarty

Domestic Violence in Pregnant Trauma Patients: A Multicenter Analysis

• Claudia Alvarez
• Jeffry Nahmias
• Areg Grigorian

Effect of Sexual Violence Bystander Training in High Schools on Adolescent Pregnancy Rates

• Emily R. Clear
• Hartley C. Feld

Applying a Socio-Ecological Model to Understanding the Needs of Children and Young People Bereaved by Intimate Partner Homicide across their Life Course

• John Devaney

Lessons Learned in Developing Online Violence Prevention Trainings

• Jessica Willard
• Annelise Mennicke

Developing a Research Agenda with Victim-Survivors to Improve Health Sector Responses to Domestic, Family and Sexual Violence in Australia

• Heather McKay

Characteristics of Child Fatalities that Occur in the Context of Current or Past Intimate Partner Violence: a Scoping Review

• Laurie M. Graham
• Hyun-Jin Jun

The Role of Mothering in Portuguese Women’s Decision-Making within Abusive Relationships

• Joana Ferreira

Revamping Advocacy for the Digital Age: Approaches for Nurturing Survivor-Centered Digital Resiliency

• Heather L. Storer
• Lindsay B. Gezinski
• Sherry Hamby

Intimate Partner Violence and Relational Maintenance During Incarceration

• Katherine A. Durante
• Amber L. Morczek

“So Just with every Facet, Every Side of this Journey, They Have Somebody Walking alongside with Them”: Practitioners’ Perspectives of the Lethality Assessment Program as a Collaborative Model

• Amanda Goodson
• Sarah Jane Brubaker

Evaluating a National Academic Mentorship Program to Grow the Next Generation of Gender-based Violence Intervention and Prevention (VIP) Researchers

• Danielle M. Davidov

“Some Handle It in Ways Others See as Insane:” College Individuals’ Meaning-Making about their Motivations for Severe Unwanted Pursuit Behaviors

• Nicholas A. Pierorazio
• Christina M. Dardis

Understanding Social Workers and Health Professionals’ Public Stigma against Women who Experience Intimate Partner Violence in Spain

• Lara Murvartian
• Francisco Javier Saavedra-Macías
• Allison Crowe

“A Blessing and a Curse”: The Impact of Sociopolitical Events and National Discourse Surrounding Sexual Violence on College Campuses

• Caterina DeFazio

“I Need to Talk to Someone…What Do I Do?“: Peer-to-Peer Disclosures of Child Maltreatment on Social Media

• Anneliese H. Williams
• Amelia W. Williams
• Laura M. Schwab-Reese

Short-Term Transactional Relation Between Parenting Behavior and Preschoolers’ Aggression: Disentangling the Between-Person and Within-Person Effects

• Eva Yi Hung Lau

Keeping Safe Together: A Brief Report on Children’s Experiences of One ‘All of Family’ Domestic Violence Intervention Program in Melbourne, Australia

• Kristin Diemer
• Kate Hammond
• Cathy Humphreys

A Brief Report on Empowering Children and Young People through Participation: Giving Space and Voice to Childhood Experiences of Domestic Violence and Abuse

• Áine Costello
• Stephanie Holt

The Association Between Depression, Suicidal Thoughts and Intimate Partner Violence Perpetration Among Young Men in Mwanza, Tanzania

• Diana Aloyce
• Heidi Stöckl
• Gerry Mshana

Intimate Partner Violence Polyvictimization and Female Survivors’ Help-Seeking: Variations by Race/Ethnicity

• Hyunkag Cho
• Woojong Kim

Professional Support for Children Bereaved by Domestic Homicide in the UK

• Alice Gomersall
• Emma Howarth

“Something’s got to give”: A Qualitative Exploration of Policies and Practices by Child Welfare Services in Cases of Children Exposed to Intimate Partner Violence in Ontario, Canada

• Carolyn O’Connor
• Ramona Alaggia
• Kendra L. Nixon

‘Nowadays, Girls Have Exceeded Their Limits’: A Qualitative Analysis of Dating Violence in Young Adults from Bengaluru, India

• Ritika Chokhani
• Abhilasha Das
• Veena A. Satyanarayana

Exploring the Link Between Relationship Cycling and Aggression in Challenging Romantic Relationships

• René M. Dailey
• Abigail Dalgleish Hazlett
• Chelsea Brass-Rosenfield

Actor-Partner Associations of Emotion Regulation, Relationship Quality, and Cyber Dating Abuse among Heterosexual Emerging Adult Couples

• Matthew E. Jaurequi
• Morgan L. Strickland
• Sarah Taylor

Examining Relationships Among Alcohol Use Disorder, Child Caretaking, and Intimate Partner Violence in High-Risk Couples

• Sarah T. Giff
• Shannon R. Forkus
• Julianne C. Flanagan

Queering Family Violence: Introduction to Queer Family Violence Studies

• Marianna Muravyeva
• Alexander Sasha Kondakov

How to Prevent Domestic Homicides: A Qualitative Study of Recommendations from a Canadian Domestic Homicide Review Committee

• Michael Saxton
• Shaz Bukhari

Racial and Ethnic Disparities in the Effects of Group Prenatal Care On Identification of Intimate Partner Violence: Findings from a Randomized Controlled Trial of CenteringPregnancy

• Heather Hensman Kettrey
• Alyssa J. Davis
• Amy H. Crockett

Correction: On the Structural Conditions Shaping Implementation of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ)-Inclusive Practices within Intimate Partner Services in Australia

• Stephanie Lusby
• Adam Bourne

Differential Intervention Outcomes Among Fathers Who Commit Domestic and Family Violence: The Influence of Parental Relationship Status

• Emma Gatfield
• Patrick O’Leary

Stressor, Coping, Resources and Potentially Harmful Behaviors by Family Caregivers of Cognitively Impaired Older Adults in China: The Mediation Role of Caregiver Burden

• Yaofeng Chen

Sociocultural Contexts Affecting Trauma Recovery and Posttraumatic Growth for Women Survivors of Intimate Partner Violence

• Jyotsana Sharma
• Gerard Lawson
• Kimberly Osborn

Young Mothers and Dating Violence: An Examination of Depressive Symptomatology and Interpersonal Competency

• Lauren C. Wallace
• Meredith C. Jones
• Dustin Fife

The Child Protection Response to Domestic Violence and Abuse: a Scoping Review of Interagency Interventions, Models and Collaboration

• Hannah Hale
• Kelly Bracewell
• Jane E. M. Callaghan

“Are We Making an Impact?“: Perspectives on Providing Interpersonal Violence Prevention Education during the COVID-19 Pandemic in the U.S.

• Julia O’Connor
• Ana Carrazana Yero
• Emilie Mitchell

‘It’s so Beneficial to be Able to Stop the Cycle’ : Perceptions of Intergenerational Transmission of Violence and Parenting Practices Among Pregnant Women and their Abusive Partners

• Federica Taccini
• Jill Domoney
• Kylee Trevillion

Coresident Households and IPV Risk: An Analysis of Prevalence and Correlates

• Ellen M. Whitehead
• Taryn N. Jonet
• Mellisa Holtzman

On the Structural Conditions Shaping Implementation of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ)-Inclusive Practices Within Intimate Partner Services in Australia

Experiences of transnational abandonment in the lives of abused south asian women in the united states.

• Shreya Bhandari

Using National Incident-Based Reporting System Data to Explore Animal Cruelty Incidents that Occur with Intimate Partner and Family Violence: A Brief Report

• Lynn A. Addington
• Mary Lou Randour
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Domestic Violence Facts and Statistics    *  Domestic Violence Video Presentations   *   Online CEU Courses

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PASK FINDINGS

61-Page Author Overview

Domestic Violence Facts and Statistics at-a-Glance

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PASK Video Summary by John Hamel, LCSW

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17 Full PASK Manuscripts and tables of Summarized Studies

INTERNATIONAL RESEARCH

THE PARTNER ABUSE STATE OF KNOWLEDGE PROJECT

The world's largest domestic violence research data base, 2,657 pages, with summaries of 1700 peer-reviewed studies.

Courtesy of the scholarly journal, Partner Abuse www.springerpub.com/pa and the Association of Domestic Violence Intervention Providers www.domesticviolenceintervention.net

MAJOR UPDATE COMING, JANUARY, 2025!

Over the years, research on partner abuse has become unnecessarily fragmented and politicized. The purpose of The Partner Abuse State of Knowledge Project (PASK) is to bring together in a rigorously evidence-based, transparent and methodical manner existing knowledge about partner abuse with reliable, up-to-date research that can easily be accessed both by researchers and the general public.

Family violence scholars from the United States, Canada and the U.K. were invited to conduct an extensive and thorough review of the empirical literature, in 17 broad topic areas. They were asked to conduct a formal search for published, peer-reviewed studies through standard, widely used search programs, and then catalogue and summarize all known research studies relevant to each major topic and its sub-topics. In the interest of thoroughness and transparency, the researchers agreed to summarize all quantitative studies published in peer-reviewed journals after 1990, as well as any major studies published prior to that time, and to clearly specify exclusion criteria. Included studies are organized in extended tables, each table containing summaries of studies relevant to its particular sub-topic.

In this unprecedented undertaking, a total of 42 scholars and 70 research assistants at 20 universities and research institutions spent two years or more researching their topics and writing the results. Approximately 12,000 studies were considered and more than 1,700 were summarized and organized into tables. The 17 manuscripts, which provide a review of findings on each of the topics, for a total of 2,657 pages, appear in 5 consecutive special issues of the peer-reviewed journal Partner Abuse . All conclusions, including the extent to which the research evidence supports or undermines current theories, are based strictly on the data collected.

Contact: [email protected]

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PREVALENCE RATES

Arthur Cantos, Ph.D. University of Texas

Denise Hines, Ph.D. Clark University

Zeev Winstok, Ph.D. University of Haifa (Israel)

CONTEXT OF ABUSE

Don Dutton, Ph.D University of British Columbia (Canada)

K. Daniel O'Leary State University of New York at Stony Brook

Jennifer Langhinrichsen-Rohling, Ph.D. University of South Alabama

ABUSE WORLDWIDE ETHNIC/LGBT GROUPS

Fred Buttell, Ph.D. Tulane University

Clare Cannon, Ph.D. University of California, Davis

Vallerie Coleman, Ph.D. Private Practice, Santa Monica, CA

Chiara Sabina, Ph.D. Penn State Harrisburg

Esteban Eugenio Santovena, Ph.D. Universidad Autonoma de Ciudad Juarez, Mexico

Christauria Welland, Ph.D. Private Practice, San Diego, CA

RISK FACTORS

Louise Dixon, Ph.D. University of Birmingham (U.K.)

Sandra Stith, Ph.D. Kansas State University

Gregory Stuart, Ph.D. University of Tennessee Knoxville

IMPACT ON VICTIMS AND FAMILIES

Deborah Capaldi, Ph.D. Oregon Social Learning Center

Patrick Davies, Ph.D. University of Rochester

Miriam Ehrensaft, Ph.D. Columbia University Medical Ctr.

Amy Slep, Ph.D. State University of New York at Stony Brook

VICTIM ISSUES

Carol Crabsen, MSW Valley Oasis, Lancaster, CA

Emily Douglas, Ph.D. Bridgewater State University

Leila Dutton, Ph.D. University of New Haven

Margaux Helm WEAVE, Sacramento, CA

Linda Mills, Ph.D. New York University

Brenda Russell, Ph.D. Penn State Berks

CRIMINAL JUSTICE RESPONSES

Ken Corvo, Ph.D. Syracuse University

Jeffrey Fagan, Ph.D. Columbia University

Brenda Russell, Ph.D, Penn State Berks

Stan Shernock, Ph.D. Norwich University

PREVENTION AND TREATMENT

Julia Babcock, Ph.D. University of Houston

Fred Buttell, Ph.D.Tulane University

Michelle Carney, Ph.D. University of Georgia

Christopher Eckhardt, Ph.D. Purdue Univerity

Kimberly Flemke, Ph.D. Drexel University

Nicola Graham-Kevan, Ph.D. Univ. Central Lancashire (U.K.)

Peter Lehmann, Ph.D. University of Texas at Arlingon

Penny Leisring, Ph.D. Quinnipiac University

Christopher Murphy, Ph.D. University of Maryland

Ronald Potter-Efron, Ph.D. Private Practice, Eleva, WI

Daniel Sonkin, Ph.D. Private Practice, Sausalito, CA.

Lynn Stewart, Ph.D. Correctional Service, Canada

Casey Taft, Ph.D Boston University School of Medicine

Jeff Temple, Ph.D. University of Texas Medical Branch

• Open access
• Published: 20 June 2023

A qualitative quantitative mixed methods study of domestic violence against women

• Mina Shayestefar 1 ,
• Mohadese Saffari 1 ,
• Razieh Gholamhosseinzadeh 2 ,
• Monir Nobahar 3 , 4 ,
• Majid Mirmohammadkhani 4 ,
• Seyed Hossein Shahcheragh 5 &
• Zahra Khosravi 6  

BMC Women's Health volume  23 , Article number:  322 ( 2023 ) Cite this article

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Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi’s 7-step method.

In qualitative study, seven themes were found including “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems”. In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions

Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Peer Review reports

Violence against women by husbands (physical, sexual and psychological violence) is one of the basic problems of public health and violation of women’s human rights. It is estimated that 35% of women and almost one out of every three women aged 15–49 experience physical or sexual violence by their spouse or non-spouse sexual violence in their lifetime [ 1 ]. This is a nationwide public health issue, and nearly every healthcare worker will encounter a patient who has suffered from some type of domestic or family violence. Unfortunately, different forms of family violence are often interconnected. The “cycle of abuse” frequently persists from children who witness it to their adult relationships, and ultimately to the care of the elderly [ 2 ]. This violence includes a range of physical, sexual and psychological actions, control, threats, aggression, abuse, and rape [ 3 ].

Violence against women is one of the most widespread, persistent, and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication [ 3 ]. In the United States of America, more than one in three women (35.6%) experience rape, physical violence, and intimate partner violence (IPV) during their lifetime. Compared to men, women are nearly twice as likely (13.8% vs. 24.3%) to experience severe physical violence such as choking, burns, and threats with knives or guns [ 4 ]. The higher prevalence of violence against women can be due to the situational deprivation of women in patriarchal societies [ 5 ]. The prevalence of domestic violence in Iran reported 22.9%. The maximum of prevalence estimated in Tehran and Zahedan, respectively [ 6 ]. Currently, Iran has high levels of violence against women, and the provinces with the highest rates of unemployment and poverty also have the highest levels of violence against women [ 7 ].

Domestic violence against women harms individuals, families, and society [ 8 ]. Violence against women leads to physical, sexual, psychological harm or suffering, including threats, coercion and arbitrary deprivation of their freedom in public and private life. Also, such violence is associated with harmful effects on women’s sexual reproductive health, including sexually transmitted infection such as Human Immunodeficiency Virus (HIV), abortion, unsafe childbirth, and risky sexual behaviors [ 9 ]. There are high levels of psychological, sexual and physical domestic abuse among pregnant women [ 10 ]. Also, women with postpartum depression are significantly more likely to experience domestic violence during pregnancy [ 11 ].

Prompt attention to women’s health and rights at all levels is necessary, which reduces this problem and its risk factors [ 12 ]. Because women prefer to remain silent about domestic violence and there is a need to introduce immediate prevention programs to end domestic violence [ 13 ]. violence against women, which is an important public health problem, and concerns about human rights require careful study and the application of appropriate policies [ 14 ]. Also, the efforts to change the circumstances in which women face domestic violence remain significantly insufficient [ 15 ]. Given that few clear studies on violence against women and at the same time interviews with these people regarding their life experiences are available, the authors attempted to planning this research aims to investigate the prevalence and experiences of domestic violence against women in Semnan with the research question of “What is the prevalence of domestic violence against women in Semnan, and what are their experiences of such violence?”, so that their results can be used in part of the future planning in the health system of the society.

This study is a combination of cross-sectional and phenomenology studies in order to investigate the amount of domestic violence against women and some related factors (quantitative) and their experience of this violence (qualitative) simultaneously in the Semnan city. This study has been approved by the ethics committee of Semnan University of Medical Sciences with ethic code of IR.SEMUMS.REC.1397.182. The researcher introduced herself to the research participants, explained the purpose of the study, and then obtained informed written consent. It was assured to the research units that the collected information will be anonymous and kept confidential. The participants were informed that participation in the study was entirely voluntary, so they can withdraw from the study at any time with confidence. The participants were notified that more than one interview session may be necessary. To increase the trustworthiness of the study, Guba and Lincoln’s criteria for rigor, including credibility, transferability, dependability, and confirmability [ 16 ], were applied throughout the research process. The COREQ checklist was used to assess the present study quality. The researchers used observational notes for reflexivity and it preserved in all phases of this qualitative research process.

Qualitative method

Based on the phenomenological approach and with the purposeful sampling method, nine women who had referred to the counseling units of healthcare centers in Semnan city due to domestic violence in February 2021 to March 2022 were participated in the present study. The inclusion criteria for the study included marriage, a history of visiting a health center consultant due to domestic violence, and consent to participate in the study and unwillingness to participate in the study was the exclusion criteria. Each participant invited to the study by a telephone conversation about study aims and researcher information. The interviews place selected through agreement of the participant and the researcher and a place with the least environmental disturbance. Before starting each interview, the informed consent and all of the ethical considerations, including the purpose of the research, voluntary participation, confidentiality of the information were completely explained and they were asked to sign the written consent form. The participants were interviewed by depth, semi-structured and face-to-face interviews based on the main research question. Interviews were conducted by a female health services researcher with a background in nursing (M.Sh.). Data collection was continued until the data saturation and no new data appeared. Only the participants and the researcher were present during the interviews. All interviews were recorded by a MP3 Player by permission of the participants before starting. Interviews were not repeated. No additional field notes were taken during or after the interview.

The age range of the participants was from 38 to 55 years and their average age was 40 years. The sociodemographic characteristics of the participants are summarized in table below (Table  1 ).

Five interviews in the courtyards of healthcare centers, 2 interviews in the park, and 2 interviews at the participants’ homes were conducted. The duration of the interviews varied from 45 min to one hour. The main research question was “What is your experience about domestic violence?“. According to the research progress some other questions were asked in line with the main question of the research.

The conducted interviews were analyzed by using the 7 steps Colizzi’s method [ 17 ]. In order to empathize with the participants, each interview was read several times and transcribed. Then two researchers (M.Sh. and M.N.) extracted the phrases that were directly related to the phenomenon of domestic violence against women independently and distinguished from other sentences by underlining them. Then these codes were organized into thematic clusters and the formulated concepts were sorted into specific thematic categories.

In the final stage, in order to make the data reliable, the researcher again referred to 2 participants and checked their agreement with their perceptions of the content. Also, possible important contents were discussed and clarified, and in this way, agreement and approval of the samples was obtained.

Quantitative method

The cross-sectional study was implemented from February 2021 to March 2022 with cluster sampling of married women in areas of 3 healthcare centers in Semnan city. Those participants who were married and agreed with the written and verbal informed consent about the ethical considerations were included to the study. The questionnaire was completed by the participants in paper and online form.

The instrument was the standard questionnaire of domestic violence against women by Mohseni Tabrizi et al. [ 18 ]. In the questionnaire, questions 1–10, 11–36, 37–65 and 66–71 related to sociodemographic information, types of spousal abuse (psychological, economical, physical and sexual violence), patriarchal beliefs and traditions and family upbringing and learning violence, respectively. In total, this questionnaire has 71 items.

The scoring of the questionnaire has two parts and the answers to them are based on the Likert scale. Questions 11–36 and 66–71 are answered with always [ 4 ] to never (0) and questions 37–65 with completely agree [ 4 ] to completely disagree (0). The minimum and maximum score is 0 and 300, respectively. The total score of 0–60, 61–120 and higher than 121 demonstrates low, moderate and severe domestic violence against women, respectively [ 18 ].

In the study by Tabrizi et al., to evaluate the validity and reliability of this questionnaire, researchers tried to measure the face validity of the scale by the previous research. Those items and questions which their accuracies were confirmed by social science professors and experts used in the research, finally. The total Cronbach’s alpha coefficient was 0.183, which confirmed that the reliability of the questions and items of the questionnaire is sufficient [ 18 ].

Descriptive data were reported using mean, standard deviation, frequency and percentage. Then, to measure the relationship between the variables, χ2 and Pearson tests also variance and regression analysis were performed. All analysis were performed by using SPSS version 26 and the significance level was considered as p < 0.05.

Qualitative results

According to the third step of Colaizzi’s 7-step method, the researcher attempted to conceptualize and formulate the extracted meanings. In this step, the primary codes were extracted from the important sentences related to the phenomenon of violence against women, which were marked by underlining, which are shown below as examples of this stage and coding.

The primary code of indifference to the father’s role was extracted from the following sentences. This is indifference in the role of the father in front of the children.

“Some time ago, I told him that our daughter is single-sided deaf. She has a doctor’s appointment; I have to take her to the doctor. He said that I don’t have money to give you. He doesn’t force himself to make money anyway” (p 2, 33 yrs).

“He didn’t value his own children. He didn’t think about his older children” (p 4, 54 yrs).

The primary code extracted here included lack of commitment in the role of head of the household. This is irresponsibility towards the family and meeting their needs.

“My husband was fired from work after 10 years due to disorder and laziness. Since then, he has not found a suitable job. Every time he went to work, he was fired after a month because of laziness” (p 7, 55 yrs).

“In the evening, he used to get dressed and go out, and he didn’t come back until late. Some nights, I was so afraid of being alone that I put a knife under my pillow when I slept” (p 2, 33 yrs).

A total of 246 primary codes were extracted from the interviews in the third step. In the fourth step, the researchers put the formulated concepts (primary codes) into 85 specific sub-categories.

Twenty-three categories were extracted from 85 sub-categories. In the sixth step, the concepts of the fifth step were integrated and formed seven themes (Table  2 ).

These themes included “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems” (Fig.  1 ).

Themes of domestic violence against women

Some of the statements of the participants on the theme of “ Facilitators” are listed below:

Husband’s criminal record

“He got his death sentence for drugs. But, at last it was ended for 10 years” (p 4, 54 yrs).

Inappropriate age for marriage

“At the age of thirteen, I married a boy who was 25 years old” (p 8, 25 yrs).

“My first husband obeyed her parents. I was 12–13 years old” (p 3, 32 yrs).

“I couldn’t do anything. I was humiliated” (p 1, 38 yrs).

“A bridegroom came. The mother was against. She said, I am young. My older sister is not married yet, but I was eager to get married. I don’t know, maybe my father’s house was boring for me” (p 2, 33 yrs).

“My parents used to argue badly. They blamed each other and I always wanted to run away from these arguments. I didn’t have the patience to talk to mom or dad and calm them down” (p 5, 39 yrs).

Overdependence

“My husband’s parents don’t stop interfering, but my husband doesn’t say anything because he is a student of his father. My husband is self-employed and works with his father on a truck” (p 8, 25 yrs).

“Every time I argue with my husband because of lack of money, my mother-in-law supported her son and brought him up very spoiled and lazy” (p 7, 55 yrs).

Bitter memories

“After three years, my mother married her friend with my uncle’s insistence and went to Shiraz. But, his condition was that she did not have the right to bring his daughter with her. In fact, my mother also got married out of necessity” (p 8, 25 yrs).

Some of their other statements related to “ Role failure” are mentioned below:

Lack of commitment to different roles

“I got angry several times and went to my father’s house because of my husband’s bad financial status and the fact that he doesn’t feel responsible to work and always says that he cannot find a job” (p 6, 48 yrs).

“I saw that he does not want to change in any way” (p 4, 54 yrs).

“No matter how kind I am, it does not work” (p 1, 38 yrs).

Some of their other statements regarding “ Repressors” are listed below:

Fear and silence

“My mother always forced me to continue living with my husband. Finally, my father had been poor. She all said that you didn’t listen to me when you wanted to get married, so you don’t have the right to get angry and come to me, I’m miserable enough” (p 2, 33 yrs).

“Because I suffered a lot in my first marital life. I was very humiliated. I said I would be fine with that. To be kind” (p1, 38 yrs).

“Well, I tell myself that he gets angry sometimes” (p 3, 32 yrs).

Shame from society

“I don’t want my daughter-in-law to know. She is not a relative” (p 4, 54 yrs).

Some of the statements of the participants regarding the theme of “ Efforts to preserve the family” are listed below:

Hope and trust

“I always hope in God and I am patient” (p 2, 33 yrs).

Efforts for children

“My divorce took a month. We got a divorce. I forgave my dowry and took my children instead” (p 2, 33 yrs).

Some of their other statements regarding the “ Inappropriate solving of family conflicts” are listed below:

Child-bearing thoughts

“My husband wanted to take me to a doctor to treat me. But my father-in-law refused and said that instead of doing this and spending money, marry again. Marriage in the clans was much easier than any other work” (p 8, 25 yrs).

Lack of effective communication

“I was nervous about him, but I didn’t say anything” (p 5, 39 yrs).

“Now I am satisfied with my life and thank God it is better to listen to people’s words. Now there is someone above me so that people don’t talk behind me” (p 2, 33 yrs).

Some of their other statements regarding the “ Consequences” are listed below:

Harm to children

“My eldest daughter, who was about 7–8 years old, behaved differently. Oh, I was angry. My children are mentally depressed and argue” (p 5, 39 yrs).

After divorce

“Even though I got a divorce, my mother and I came to a remote area due to the fear of what my family would say” (p 2, 33 yrs).

Social harm

“I work at a retirement center for living expenses” (p 2, 33 yrs).

“I had to go to clean the houses” (p 5, 39 yrs).

Non-acceptance in the family

“The children’s relationship with their father became bad. Because every time they saw their father sitting at home smoking, they got angry” (p 7, 55 yrs).

Emotional harm

“When I look back, I regret why I was not careful in my choice” (p 7, 55 yrs).

“I felt very bad. For being married to a man who is not bound by the family and is capricious” (p 9, 36 yrs).

Some of their other statements regarding “ Inefficient supportive systems” are listed below:

Inappropriate family support

“We didn’t have children. I was at my father’s house for about a month. After a month, when I came home, I saw that my husband had married again. I cried a lot that day. He said, God, I had to. I love you. My heart is broken, I have no one to share my words” (p 8, 25 yrs).

“My brother-in-law was like himself. His parents had also died. His sister did not listen at all” (p 4, 54 yrs).

“I didn’t have anyone and I was alone” (p 1, 38 yrs).

Inefficiency of social systems

“That day he argued with me, picked me up and threw me down some stairs in the middle of the yard. He came closer, sat on my stomach, grabbed my neck with both of his hands and wanted to strangle me. Until a long time later, I had kidney problems and my neck was bruised by her hand. Given that my aunt and her family were with us in a building, but she had no desire to testify and was afraid” (p 3, 32 yrs).

Undesired training and advice

“I told my mother, you just said no, how old I was? You never insisted on me and you didn’t listen to me that this man is not good for you” (p 9, 36 yrs).

Quantitative results

In the present study, 376 married women living in Semnan city participated in this study. The mean age of participants was 38.52 ± 10.38 years. The youngest participant was 18 and the oldest was 73 years old. The maximum age difference was 16 years. The years of marriage varied from one year to 40 years. Also, the number of children varied from no children to 7. The majority of them had 2 children (109, 29%). The sociodemographic characteristics of the participants are summarized in the table below (Table  3 ).

The frequency distribution (number and percentage) of the participants in terms of the level of violence was as follows. 89 participants (23.7%) had experienced low violence, 59 participants (15.7%) had experienced moderate violence, and 228 participants (60.6%) had experienced severe violence.

Cronbach’s alpha for the reliability of the questionnaire was 0.988. The mean and standard deviation of the total score of the questionnaire was 143.60 ± 74.70 with a range of 3-244. The relationship between the total score of the questionnaire and its fields, and some demographic variables is summarized in the table below (Table  4 ).

As shown in the table above, the variables of age, age difference and number of years of marriage have a positive and significant relationship, and the variable of number of children has a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). However, the variable of education level difference showed no significant relationship with the total score and any of the fields. Also, the highest average score is related to patriarchal beliefs compared to other fields.

The comparison of the average total scores separately according to each variable showed the significant average difference in the variables of the previous marriage history of the woman, the result of the previous marriage of the woman, the education of the woman, the education of the man, the income of the woman, the income of the man, and the physical disease of the man (p < 0.05).

In the regression model, two variables remained in the final model, indicating the relationship between the variables and violence score and the importance of these two variables. An increase in women’s education and income level both independently show a significant relationship with an increase in violence score (Table  5 ).

The results of analysis of variance to compare the scores of each field of violence in the subgroups of the participants also showed that the experience and result of the woman’s previous marriage has a significant relationship with physical violence and tradition and family upbringing, the experience of the man’s previous marriage has a significant relationship with patriarchal belief, the education level of the woman has a significant relationship with all fields and the level of education of the man has a significant relationship with all fields except tradition and family upbringing (p < 0.05).

According to the results of both quantitative and qualitative studies, variables such as the young age of the woman and a large age difference are very important factors leading to an increase in violence. At a younger age, girls are afraid of the stigma of society and family, and being forced to remain silent can lead to an increase in domestic violence. As Gandhi et al. (2021) stated in their study in the same field, a lower marriage age leads to many vulnerabilities in women. Early marriage is a global problem associated with a wide range of health and social consequences, including violence for adolescent girls and women [ 12 ]. Also, Ahmadi et al. (2017) found similar findings, reporting a significant association among IPV and women age ≤ 40 years [ 19 ].

Two others categories of “Facilitators” in the present study were “Husband’s criminal record” and “Overdependence” which had a sub-category of “Forced cohabitation”. Ahmadi et al. (2017) reported in their population-based study in Iran that husband’s addiction and rented-householders have a significant association with IPV [ 19 ].

The patriarchal beliefs, which are rooted in the tradition and culture of society and family upbringing, scored the highest in relation to domestic violence in this study. On the other hand, in qualitative study, “Normalcy” of men’s anger and harassment of women in society is one of the “Repressors” of women to express violence. In the quantitative study, the increase in the women’s education and income level were predictors of the increase in violence. Although domestic violence is more common in some sections of society, women with a wide range of ages, different levels of education, and at different levels of society face this problem, most of which are not reported. Bukuluki et al. (2021) showed that women who agreed that it is good for a man to control his partner were more likely to experience physical violence [ 20 ].

Domestic violence leads to “Consequences” such as “Harm to children”, “Emotional harm”, “Social harm” to women and even “Non-acceptance in their own family”. Because divorce is a taboo in Iranian culture and the fear of humiliating women forces them to remain silent against domestic violence. Balsarkar (2021) stated that the fear of violence can prevent women from continuing their studies, working or exercising their political rights [ 8 ]. Also, Walker-Descarte et al. (2021) recognized domestic violence as a type of child maltreatment, and these abusive behaviors are associated with mental and physical health consequences [ 21 ].

On the other hand and based on the “Lack of effective communication” category, ignoring the role of the counselor in solving family conflicts and challenges in the life of couples in the present study was expressed by women with reasons such as lack of knowledge and family resistance to counseling. Several pathologies are needed to investigate increased domestic violence in situations such as during women’s pregnancy or infertility. Because the use of counseling for couples as a suitable solution should be considered along with their life challenges. Lin et al. (2022) stated that pregnant women were exposed to domestic violence for low birth weight in full term delivery. Spouse violence screening in the perinatal health care system should be considered important, especially for women who have had full-term low birth weight infants [ 22 ].

Also, lack of knowledge and low level of education have been found as other factors of violence in this study, which is very prominent in both qualitative and quantitative studies. Because the social systems and information about the existing laws should be followed properly in society to act as a deterrent. Psychological training and especially anger control and resilience skills during education at a younger age for girls and boys should be included in educational materials to determine the positive results in society in the long term. Manouchehri et al. (2022) stated that it seems necessary to train men about the negative impact of domestic violence on the current and future status of the family [ 23 ]. Balsarkar (2021) also stated that men and women who have not had the opportunity to question gender roles, attitudes and beliefs cannot change such things. Women who are unaware of their rights cannot claim. Governments and organizations cannot adequately address these issues without access to standards, guidelines and tools [ 8 ]. Machado et al. (2021) also stated that gender socialization reinforces gender inequalities and affects the behavior of men and women. So, highlighting this problem in different fields, especially in primary health care services, is a way to prevent IPV against women [ 24 ].

There was a sub-category of “Inefficiency of social systems” in the participants experiences. Perhaps the reason for this is due to insufficient education and knowledge, or fear of seeking help. Holmes et al. (2022) suggested the importance of ascertaining strategies to improve victims’ experiences with the court, especially when victims’ requests are not met, to increase future engagement with the system [ 25 ]. Sigurdsson (2019) revealed that despite high prevalence numbers, IPV is still a hidden and underdiagnosed problem and neither general practitioner nor our communities are as well prepared as they should be [ 26 ]. Moreira and Pinto da Costa (2021) found that while victims of domestic violence often agree with mandatory reporting, various concerns are still expressed by both victims and healthcare professionals that require further attention and resolution [ 27 ]. It appears that legal and ethical issues in this regard require comprehensive evaluation from the perspectives of victims, their families, healthcare workers, and legal experts. By doing so, better practical solutions can be found to address domestic violence, leading to a downward trend in its occurrence.

Some of the variables of violence against women have been identified and emphasized in many studies, highlighting the necessity of policymaking and social pathology in society to prevent and use operational plans to take action before their occurrence. Breaking the taboo of domestic violence and promoting divorce as a viable solution after counseling to receive objective results should be implemented seriously to minimize harm to women, children, and their families.

Limitations

Domestic violence against women is an important issue in Iranian society that women resist showing and expressing, making researchers take a long-term process of sampling in both qualitative and quantitative studies. The location of the interview and the women’s fear of their husbands finding out about their participation in this study have been other challenges of the researchers, which, of course, they attempted to minimize by fully respecting ethical considerations. Despite the researchers’ efforts, their personal and professional experiences, as well as the studies reviewed in the literature review section, may have influenced the study results.

Data Availability

Data and materials will be available upon email to the corresponding author.

Abbreviations

Intimate Partner Violence

Human Immunodeficiency Virus

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Acknowledgements

The authors of this study appreciate the Deputy for Research and Technology of Semnan University of Medical Sciences, Social Determinants of Health Research Center of Semnan University of Medical Sciences and all the participants in this study.

Research deputy of Semnan University of Medical Sciences financially supported this project.

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Contributions

M.Sh. contributed to the first conception and design of this research; M.Sh., Z.Kh., M.S., R.Gh. and S.H.Sh. contributed to collect data; M.N. and M.Sh. contributed to the analysis of the qualitative data; M.M. and M.Sh. contributed to the analysis of the quantitative data; M.SH., M.N. and M.M. contributed to the interpretation of the data; M.Sh., M.S. and S.H.Sh. wrote the manuscript. M.Sh. prepared the final version of manuscript for submission. All authors reviewed the manuscript meticulously and approved it. All names of the authors were listed in the title page.

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This article is resulted from a research approved by the Vice Chancellor for Research of Semnan University of Medical Sciences with ethics code of IR.SEMUMS.REC.1397.182 in the Social Determinants of Health Research Center. The authors confirmed that all methods were performed in accordance with the relevant guidelines and regulations. All participants accepted the participation in the present study. The researchers introduced themselves to the research units, explained the purpose of the research to them and then all participants signed the written informed consent. The research units were assured that the collected information was anonymous. The participant was informed that participating in the study was completely voluntary so that they can safely withdraw from the study at any time and also the availability of results upon their request.

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Shayestefar, M., Saffari, M., Gholamhosseinzadeh, R. et al. A qualitative quantitative mixed methods study of domestic violence against women. BMC Women's Health 23 , 322 (2023). https://doi.org/10.1186/s12905-023-02483-0

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The Domestic Violence Evidence Project (DVEP) is a multi-faceted, multi-year and highly collaborative effort designed to assist state coalitions, local domestic violence programs, researchers, and other allied individuals and organizations better respond to the growing emphasis on identifying and integrating evidence-based practice into their work. DVEP brings together research, evaluation, practice and theory to inform critical thinking and enhance the field's knowledge to better serve survivors and their families.

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Safe Housing Partnerships , the website of the Domestic Violence and Housing Technical Assistance Consortium , includes the latest research and evidence on the intersection of domestic and sexual violence, housing, and homelessness. You can also find new research exploring different aspects of efforts to expand housing options for domestic and sexual violence survivors, including the use of flexible funding approaches, DV Housing First and rapid rehousing, DV Transitional Housing, and mobile advocacy.

Violence in Families: Assessing Prevention and Treatment Programs (1998)

Chapter: 9 conclusions and recommendations, 9 conclusions and recommendations.

The problems of child maltreatment, domestic violence, and elder abuse have generated hundreds of separate interventions in social service, health, and law enforcement settings. This array of interventions has been driven by the urgency of the different types of family violence, client needs, and the responses of service providers, advocates, and communities. The interventions now constitute a broad range of institutional services that focus on the identification, treatment, prevention, and deterrence of family violence.

The array of interventions that is currently in place and the dozens of different types of programs and services associated with each intervention represent a valuable body of expertise and experience that is in need of systematic scientific study to inform and guide service design, treatment, prevention, and deterrence. The challenge for the research community, service providers, program sponsors, and policy makers is to develop frameworks to enhance critical analyses of current strategies, interventions, and programs and identify next steps in addressing emerging questions and cross-cutting issues. Many complexities now characterize family violence interventions and challenge the development of rigorous scientific evaluations. These complexities require careful consideration in the development of future research, service improvements, and collaborative efforts between researchers and service providers. Examples of these complexities are illustrative:

• The interventions now in place in communities across the nation focus services on discrete and isolated aspects of family violence. They address different aspects of child maltreatment, domestic violence, and elder abuse. Some
• interventions have an extensive history of experience, and others are at a very early stage of development.
• Many interventions have not been fully implemented because of limited funding or organizational barriers. Thus in many cases it is too early to expect that research can determine whether a particular intervention or strategy (such as deterrence or prevention) is effective because the intervention may not yet have sufficient strength to achieve its intended impact.
• The social and institutional settings of many interventions present important challenges to the design of systematic scientific evaluations. The actual strength or dosage of a particular program can be directly influenced by local or national events that stimulate changes in resources, budgets, and personnel factors that influence its operation in different service settings. Variations in service scope or intensity caused by local service practices and social settings are important sources of "noise" in cross-site research studies; they can directly affect evaluation studies in such key areas as definitions, eligibility criteria, and outcome measures.
• Emerging research on the experiences of family violence victims and offenders suggests that this is a complex population composed of different types of individuals and patterns of behavior. Evaluation studies thus need to consider the types of clients served by particular services, the characteristics of those who benefited from them, and the attributes of those who were resistant to change.

In this chapter the committee summarizes its overall conclusions and proposes policy and research recommendations. A key question for the committee was whether and when the research evidence is sufficient to guide a critical examination of particular interventions. In some areas, the body of research is sufficient to inform policy choices, program development, evaluation research, data collection, and theory-building; the committee makes recommendations for current policies and practices in these areas below. In other areas, although the research base is not yet mature enough to guide policy and program development, some interventions are ready for rigorous evaluation studies. For this second tier of interventions, the committee makes recommendations for the next generation of evaluation studies. The committee then identifies a set of four topics for basic research that reflect current insights into the nature of family violence and trends in family violence interventions. A final section makes some suggestions to increase the effectiveness of collaborations between researchers and service providers.

Conclusions

The committee's conclusions are derived from our analysis of the research literature and discussions with service providers in the workshops and site visits, rather than from specific research studies. This analysis takes a client-oriented

approach to family violence interventions, which means that we focus on how existing services in health, social services, and law enforcement settings affect the individuals who come in contact with them.

• The urgency of the need to respond to the problem of family violence and the paucity of research to guide service interventions have created an environment in which insights from small-scale studies are often adopted into policy and professional practice without sufficient independent replication or reflection on their possible shortcomings. Rigorous evaluations of family violence interventions are confined, for the most part, to small or innovative programs that provide an opportunity to develop a comparison or control study, rather than focusing on the major existing family violence interventions.
• This situation has fostered a series of trial-and-error experiences in which a promising intervention is later found to be problematic when employed with a broader and more varied population. Major treatment and prevention interventions, such as child maltreatment reporting systems, casework, protective orders, and health care for victims of domestic violence, battered women's shelters, and elder abuse interventions of all types, have not been the subjects of rigorous evaluation studies. The programmatic and policy emphasis on single interventions as panaceas to the complex problems of family violence, and the lack of sufficient opportunity for learning more about the service interactions, client characteristics, and contextual factors that could affect the impact of different approaches, constitute formidable challenges to the improvement of the knowledge base and prevention and treatment interventions in this filed.
• In all areas of family violence, after-the-fact services predominate over preventive interventions. For child maltreatment and elder abuse, case identification and investigative services are the primary form of intervention; services designed to prevent, treat, or deter family violence are relatively rare in social service, health, and criminal justice settings (with the notable exceptions of foster care and family preservation services). For domestic violence, interventions designed to treat victims and offenders and deter future incidents of violence are more common, but preventive services remain relatively underdeveloped.
• The current array of family violence interventions (especially in the areas of child maltreatment and elder abuse) is a loosely coupled network of individual programs and services that are highly reactive in nature, focused primarily on the detection of specific cases. It is a system largely driven by events, rather than one that is built on theory, research, and data collection. Interventions are oriented toward the identification of victims and the substantiation and documentation of their experiences, rather than the delivery of recommended services to reduce the incidence and consequences of family violence in the community overall. As a result, enormous resources are invested to develop evidence that certain victims or offenders need treatment, legal action, or other interventions, and comparatively limited funds are available for the treatment and support services themselves—a
• situation that results in lengthy waiting lists, discretionary decisionmaking processes in determining which cases are referred for further action, and extensive variation in a service system's ability to match clients with appropriate interventions.
• The duration and intensity of the mental health and social support services needed to influence behaviors that result from or contribute to family violence may be greater than initially estimated. Family violence treatment and preventive interventions that focus on single incidents and short periods of support services, especially in such areas as parenting skills, mental health, and batterer treatment, may be inadequate to deal with problems that are pervasive, multiple, and chronic. Many programs for victims involve short-term treatment services—less than 6 weeks. Services for offenders are also typically of short duration. Yet research suggests that short-term programs designed to alter violent behavior are often the least likely to succeed, because of the difficulties of changing behavior that has persisted for a period of years and has become part of an established pattern in relationships. Efforts to address fundamental sources of conflict, stress, and violence that occur repeatedly over time within the family environment may require extensive periods of support services to sustain the positive effects achieved in short-term interventions.
• The interactive nature of family violence interventions constitutes a major challenge to the evaluation of interventions because the presence or absence of policies and programs in one domain may directly affect the implementation and outcomes of interventions in another. Research suggests that the risk and protective factors for child maltreatment, domestic violence, and elder abuse interact across multiple levels. The uncoordinated but interactive system of services requires further attention and consideration in future evaluation studies. Such evaluations need to document the presence and absence of services that affect members of the same family unit but offer treatment for specific problems in separate institutions characterized by different service philosophies and resources.
• For example, factors such as court oversight or mandatory referrals may influence individual participation in treatment services and the outcomes associated with such participation. The culture and resources of one agency can influence the quality and timing of services offered by another. Yet little information is available regarding the extent or quality of interventions in a community. Clients who receive multiple interventions (especially children) are often not followed through different service settings. Limited information is available to distinguish key features of innovative interventions from those usually offered in a community; to describe the stages of implementation of specific family violence programs, interventions, or strategies; to explain rates of attrition in the client base; or to capture case characteristics that influence the ways in which clients are selected for specific treatment programs.
• The emergence of secondary prevention interventions specifically targeted to serve children, adults, and communities with characteristics that are
• thought to place them at greater risk of family violence than the general population, along with the increasing emphasis on the need for integration and coordination of services, has the potential to achieve significant benefits. However, the potential of these newer interventions to reduce the need for treatment or other support services over the lifetime of the client has not yet been proven for large populations.
• Secondary preventive interventions, such as those serving children exposed to domestic violence, have the potential to reduce future incidents of family violence and to reduce the existing need for services in such areas as recovery from trauma, substance abuse, juvenile crime, mental health and health care. However, evaluation studies are not yet available to determine the value of preventive interventions for large populations in terms of reduction of the need for treatment or other support services over a client's lifetime.
• The shortage of service resources and the emphasis on reactive, short-term treatment have directed comparatively little attention to interventions for people who have experienced or perpetrated violent behavior but who have not yet been reported or identified as offenders or victims. Efforts to achieve broader systemic collaboration, comprehensive service integration, and proactive interventions require attention to the appropriate balance among enforcement, treatment, and prevention interventions in addressing family violence at both state and national levels. Such efforts also need to be responsive to the particular requirements of diverse ethnic communities with special needs or unique resources that can be mobilized in the development of preventive interventions. Because they extend to a larger population than those currently served by treatment centers, secondary prevention efforts can be expensive; their benefits may not become apparent until many years after the intervention occurs.
• Policy leadership is needed to help integrate family violence treatment, enforcement and support actions, and preventive interventions and also to foster the development of evaluations of comprehensive and cross-problem interventions that have the capacity to consider outcomes beyond reports of future violent behavior.
• Creative research methodologies are also needed to examine the separate and combined effects of cross-problem service strategies (such as the treatment of substance abuse and family violence), follow individuals and families through multiple service interventions and agency settings, and examine factors that may play important mediating roles in determining whether violence will occur or continue (such as the use of social networks and support services and the threat of legal sanctions).
• Most evaluations seek to document whether violent behavior decreased as a result of the intervention, an approach that often inhibits attention to other factors that may play important mediating roles in determining whether violence will occur. The individual victim or offender is the focus of most interventions and
• the unit of analysis in evaluation studies, rather than the family or the community in which the violence occurred.

Integrated approaches have the potential to illuminate the sequences and ways in which different experiences with violence in the family do and do not overlap with each other and with other kinds of violence. This research approach requires time to mature; at present, it is not strong enough to determine the strengths or limitations of strategies that integrate different forms of family violence compared with approaches that focus on specific forms of family violence. Service integration efforts focused on single forms of family violence may have the potential to achieve greater impact than services that disregard the interactive nature of this complex behavior, but this hypothesis also remains unproven.

Recommendations For Current Policies And Practices

It is premature to offer policy recommendations for most family violence interventions in the absence of a research base that consists of well-designed evaluations. However, the committee has identified two areas (home visitation and family preservation services) in which a rigorous set of studies offers important guidance to policy makers and service providers. In four other areas (reporting practices, batterer treatment programs, record keeping, and collaborative law enforcement approaches) the committee has drawn on its judgment and deliberations to encourage policy makers and service providers to take actions that are consistent with the state of the current research base.

These six interventions were selected for particular attention because (1) they are the focus of current policy attention, service evaluation, and program design; (2) a sufficient length of time has elapsed since the introduction of the intervention to allow for appropriate experience with key program components and measurement of outcomes; (3) the intervention has been widely adopted or is under consideration by a large number of communities to warrant its careful analysis; and (4) the intervention has been described and characterized in the research literature (through program summaries or case studies).

Reporting Practices

All 50 states have adopted laws requiring health professionals and other service providers to report suspected child abuse and neglect. Although state laws vary in terms of the types of endangerment and evidentiary standards that warrant a report to child protection authorities, each state has adopted a procedure that requires designated professionals—or, in some states, all adults—to file a report if they believe that a child is a victim of abuse or neglect. Mandatory reporting is thought to enhance early case detection and to increase the likelihood that services will be provided to children in need.

For domestic violence, mandatory reporting requirements for professional groups like health care providers have been adopted by the state of California and are under consideration in several other states. Mandatory reports are seen as a method by which offenders who abuse multiple partners can be identified through the health care community for law enforcement purposes. Early detection is assumed to lead to remedies and interventions that will prevent further abuse by holding the abuser accountable and helping to mitigate the consequences of family violence.

Critics have argued that mandatory reporting requirements may damage the confidentiality of the therapeutic relationship between health professionals and their clients, disregard the knowledge and preferences of the victim regarding appropriate action, potentially increase the danger to victims when sufficient protection and support are not available, and ultimately discourage individuals who wish to seek physical or psychological treatment from contacting and disclosing abuse to health professionals. In many regions, victim support services are not available or the case requires extensive legal documentation to justify treatment for victims, offenders, and families.

For elder abuse, 42 states have mandatory reporting systems. Several states have opted for voluntary systems after conducting studies that considered the advantages and disadvantages of voluntary and mandatory reporting systems, on the grounds that mandatory reports do not achieve significant increases in the detection of elder abuse cases.

In reviewing the research base associated with the relationship between reporting systems and the treatment and prevention of family violence, the committee has observed that no existing evaluation studies can demonstrate the value of mandatory reporting systems compared with voluntary reporting procedures in addressing child maltreatment or domestic violence. For elder abuse, studies suggest that a high level of public and professional awareness and the availability of comprehensive services to identify, treat, and prevent violence is preferable to reporting requirements in improving rates of case detection.

The absence of a research base to support mandatory reporting systems raises questions as to whether they should be recommended for all areas of family violence. The impact of mandatory reporting systems in the area of child maltreatment and elder abuse remains unexamined. The committee therefore suggests that it is important for the states to proceed cautiously at this time and to delay adopting a mandatory reporting system in the area of domestic violence, until the positive and negative impacts of such a system have been rigorously examined in states in which domestic violence reports are now required by law.

Recommendation 1: The committee recommends that states initiate evaluations of their current reporting laws addressing family violence to examine whether and how early case detection leads to improved outcomes for the victims or families and promote changes based on sound research. In

particular, the committee recommends that states refrain from enacting mandatory reporting laws for domestic violence until such systems have been tested and evaluated by research.

In dealing with family violence that involves adults, federal and state government agencies should reconsider the nature and role of compulsory reporting policies. In the committee's view, mandatory reporting systems have some disadvantages in cases involving domestic violence, especially if the victim objects to such reports, if comprehensive community protections and services are not available, and if the victim is able to gain access to therapeutic treatment or support services in the absence of a reporting system.

The dependent status of young children and some elders provides a stronger argument in favor of retaining mandatory reporting requirements where they do exist. However, the effectiveness of reporting requirements depends on the availability of resources and service personnel who can investigate reports and refer cases for appropriate treatment, as well as clear guidelines for processing reports and determining which cases qualify for services. Greater discretion may be advised when the child and family are able to receive therapeutic treatment from health care or other service providers and when community resources are not available to respond appropriately to their cases. The treatment of adolescents especially requires major consideration of the pros and cons of mandatory reporting requirements. Adolescent victims are still in a vulnerable stage of development: they may or may not have the capacity to make informed decisions regarding the extent to which they wish to invoke legal protections in dealing with incidents of family violence in their homes.

Batterer Treatment Programs

Four key questions characterize current policy and research discussions about the efficacy of batterer treatment, one of the most challenging problems in the design of family violence interventions: Is treatment preferable to incarceration, supervised probation, or other forms of court oversight for batterers? Does participation in treatment change offenders' attitudes and behavior and reduce recidivism? Does the effectiveness of treatment depend on its intensity, duration, or the voluntary or compulsory nature of the program? Is treatment what creates change, or is change in behavior reduced by multiple interventions, such as arrest, court monitoring of client participation in treatment services, and victim support services?

Descriptive research studies suggest that there are multiple profiles of batterers, and therefore one generic approach is not appropriate for all offenders. Treatment programs may be helpful in changing abusive behavior when they are part of an overall strategy designed to recognize and reduce violence in a relationship, when the batterer is prepared to learn how to control aggressive impulses, and

when the treatment plan emphasizes victim safety and provides for frequent interactions with treatment staff.

Research on the effectiveness of treatment programs suggests that the majority of subjects who complete court-ordered treatment programs do learn basic cognitive and behavioral principles taught in their course. However, such learning requires appropriate program content and client participation in the program for a sufficient time to complete the necessary training. Very few studies have examined matched groups of violent offenders who are assigned to treatment and control groups or comparison groups (such as incarceration or work-release). As a result, the comparative efficacy of treatment is unknown in reducing future violence. Differing client populations and differing forms of court oversight are particularly problematic factors that inhibit the design of rigorous evaluation studies in this field.

The absence of strong theory and common measures to guide the development of family violence treatment regimens, the heterogeneity of offenders (including patterns of offending and readiness to change) who are the subjects of protective orders or treatment, and low rates of attendance, completion, and enforcement are persistent problems that affect both the evaluation of the interventions and efforts to reduce the violence. A few studies suggest that court oversight does appear to increase completion rates, which have been linked to enhanced victim safety in the area of domestic violence, but increased completion rates have not yet led to a discernible effect on recidivism rates in general.

Further evaluations are needed to examine the outcomes associated with different approaches and programmatic themes (such as cognitive-behavioral principles: issues of power, control, and gender; personal accountability). Completion rates have been used as an interim outcome to measure the success of batterer treatment programs; further studies are needed to determine if completers can be identified readily, if program completion by itself is a critical factor in reducing recidivism, and if participation in a treatment program changes the nature, timing, and severity of future violent behavior.

The current research base is inadequate to identify the conditions under which mandated referrals to batterer treatment programs offer a clear advantage over incarceration or untreated probation supervision in reducing recidivism for the general population of male offenders. Court officials should monitor closely the attendance, participation, and completion rates of offenders who are referred to batterer treatment programs in lieu of more punitive sentences. Treatment staff should inform law enforcement officials of any significant behavior by the offender that might represent a threat to the victim. Mandated treatment referrals may be effective for certain types of batterers, especially if they increase completion rates. The research is inconclusive, however, as to which types of individuals should be referred for treatment rather than more punitive sanctions. In selecting individuals for treatment, attention should be given to client history

(first-time offenders are more likely to benefit), motivation for treatment, and likelihood of completion.

Mandated treatment referrals for batterers do appear to provide benefits to victims, such as intensive surveillance of offenders, an interlude to allow planning for safety and victim support, and greater community awareness of the batterer's behavior. These outcomes may interact to deter and reduce domestic violence in the community, even if a treatment program does not alter the behavior of a particular batterer. Treatment programs that include frequent interactions between staff and victims also provide a means by which staff can help educate victims about danger signals and support them in efforts to obtain greater protection and legal safeguards, if necessary.

Recommendation 2: In the absence of research that demonstrates that a specific model of treatment can reduce violent behavior for many domestic violence offenders, courts need to put in place early warning systems to detect failure to comply with or complete treatment and signs of new abuse or retaliation against victims, as well as to address unintended or inadvertent results that may arise from the referral to or experience with treatment.

Further research evaluation studies are needed to review the outcomes for both offenders and victims associated with program content and levels of intensity in different treatment models. This research will help indicate whether treatment really helps and what mix of services are more helpful than others. Improved research may also help distinguish those victims and offenders for whom particular treatments are most beneficial.

Record Keeping

Since experience with family violence appears to be associated with a wide range of health problems and social service needs, service providers are recognizing the importance of documenting abuse histories in their client case records. The documentation in health and social service records of abuse histories that are self-reported by victims and offenders can help service providers and researchers to determine if appropriate referrals and services have been made and the outcomes associated with their use. The exchange of case records among service providers is essential to the development of comprehensive treatment programs, continuity of care, and appropriate follow-up for individuals and families who appear in a variety of service settings. Such exchanges can help establish greater accountability by service systems for responding to the needs of identifiable victims and offenders; health and social service records can also provide appropriate evidence for legal actions, in both civil and criminal courts and child custody cases.

Research evaluations of service interventions often require the use of anonymous case records. The documentation of family violence in such records will

enhance efforts to improve the quality of evaluations and to understand more about patterns of behavior associated with violent behaviors and victimization experiences. Although documentation of abuse histories can improve evaluations and lead to integrated service responses, such procedures require safeguards so that individuals are not stigmatized or denied therapeutic services on the basis of their case histories. Insurance discrimination, in particular, which may preclude health care coverage if abuse is judged to be a preexisting condition, requires attention to ensure that professional services are not diminished as a result of voluntary disclosures. Creative strategies are needed to support integrated service system reviews of medical, legal, and social service case records in order to enhance the quality and accountability of service responses. Such reviews will need to meet the expectations of privacy and confidentiality of both individual victims and the community, especially in cases in which maltreatment reports are subsequently regarded as unfounded.

Documentation of abuse histories that are voluntarily disclosed by victims or offenders to health care professionals and social service providers must be distinguished from screening efforts designed to trigger such disclosures. The committee recommends screening as a strong candidate for future evaluation studies (see discussion in the next section).

Recommendation 3: The committee recommends that health and social service providers develop safeguards to strengthen their documentation of abuse and histories of family violence in both individual and group records, regardless of whether the abuse is reported to authorities.

The documentation of histories of family violence in health records should be designed to record voluntary disclosures by both victims and offenders and to enhance early and coordinated interventions that can provide a therapeutic response to experiences with abuse or neglect. Safeguards are required, however, to ensure that such documentation does not lead to stigmatization, encourage discriminatory practices, or violate assurances of privacy and confidentiality, especially when individual histories become part of patient group records for health care providers and employers.

Collaborative Law Enforcement Strategies

In the committee's view, collaborative law enforcement strategies that create a web of social control for offenders are an idea worth testing to determine if such efforts can achieve a significant deterrent effect in addressing domestic violence. Collaborative strategies include such efforts as victim support and offender tracking systems designed to increase the likelihood that domestic violence cases will be prosecuted when an arrest has been made, that sanctions and treatment services will be imposed when evidence exists to confirm the charges brought against the offender, and that penalties will be invoked for failure to comply with treatment

conditions. The attraction of collaborative strategies is based on their potential ability to establish multiple interactions with offenders across a large domain of interactions that reinforce social standards in the community and establish penalties for violations of those standards. Creating the deterrent effect, however, requires extensive coordination and reciprocity between victim support and offender monitoring efforts involving diverse sectors of the law enforcement community. These efforts may be difficult to implement and evaluate. Further studies are needed to determine the extent to which improved collaboration among police officers, prosecutors, and judges will lead to improved coordination and stronger sanctions for offenders and a reduction in domestic violence.

The absence of empirical research findings of the results of a collaborative law enforcement approach in addressing domestic violence makes it difficult to compare the costs and benefits of increased agency coordination with those achieved by a single law enforcement strategy (such as arrest) in dealing with different populations of offenders and victims. Even though relatively few cases of arrest are made for any form of family violence, arrest is the most common and most studied form of law enforcement intervention in this area. Research studies conducted in the 1980s on arrest policies in domestic violence cases are the strongest experimental evaluations to date of the role of deterrence in family violence interventions. These experiments indicate that arrest may be effective for some, but not most, batterers in reducing subsequent violence by the offender. Some research studies suggest that arrest may be a deterrent for employed and married individuals (those who have a stake in social conformity) and may lead to an escalation of violence among those who do not, but this observation has not been tested in studies that could specifically examine the impact of arrest in groups that differ in social and economic status. The differing effects (in terms of a reduction of future violence) of arrest for employed/unemployed and married/unmarried individuals raise difficult questions about the reliance of law enforcement officers on arrest as the sole or central component of their response to domestic violence incidents in communities where domestic violence cases are not routinely prosecuted, where sanctions are not imposed by the courts, or where victim support programs are not readily available.

The implementation of proarrest policies and practices that would discriminate according to the risk status of specific groups is challenged by requirements for equal protection under the law. Law enforcement officials cannot tailor arrest policies to the marital or employment status of the suspect or other characteristics that may interact with deterrence efforts. Specialized training efforts may help alleviate the tendency of police officers to arrest both suspect and victim, however, and may alert law enforcement personnel to the need to review both criminal and civil records in determining whether an arrest is advisable in response to a domestic violence case.

Two additional observations merit consideration in examining the deterrent effects of arrest. First, in the research studies conducted thus far, the implementation

of legal sanctions was minimal. Most offenders in the replication studies were not prosecuted once arrested, and limited legal sanctions were imposed on those cases that did receive a hearing. Some researchers concluded that stronger evidence of effectiveness might be obtained from proarrest policies if they are implemented as part of a law enforcement strategy that expands the use of punitive sanctions for offenders—including conviction, sentencing, and intensive supervised probation.

Second is the issue of reciprocity between formal sanctions against the offender and informal support actions for the victims of domestic violence. The effects of proarrest policies may depend on the extent to which victims have access to shelter services and other forms of support, demonstrating the interactive dimensions of community interventions. A mandatory arrest policy, by itself, may be an insufficient deterrent strategy for domestic violence, but its effectiveness may be enhanced by other interventions that represent coordinated law enforcement efforts to deter domestic violence—including the use of protective orders, victim advocates, and special prosecution units. Coordinated efforts may help reduce or prevent domestic violence if they represent a collaborative strategy among police, prosecutors, and judges that improves the certainty of the use of sanctions against batterers.

Recommendation 4: Collaborative strategies among caseworkers, police, prosecutors, and judges are recommended as law enforcement interventions that have the potential to improve the batterer's compliance with treatment as well as the certainty of the use of sanctions in addressing domestic violence.

The impact of single interventions (such as mandatory arrest policies) is difficult to discern in the research literature. Such practices by themselves can neither be recommended nor rejected as effective measures in addressing domestic violence on the basis of existing research studies.

Home Visitation and Family Support Services

Home visitation and family support programs constitute one of the most promising areas of child maltreatment prevention. Studies in this area have experimented with different levels of treatment intensity, duration, and staff expertise. For home visitation, the findings generally support the principle that early intervention with mothers who are at risk of child maltreatment makes a difference in child outcomes. Such interventions may be difficult to implement and maintain over time, however, and their effectiveness depends on the willingness of the parents to participate. Selection criteria for home visitation should be based on a combination of social setting and individual risk factors.

In their current form, home visitation programs have multiple goals, only one of which is the prevention of child abuse and neglect. Home visitation and family

support programs have traditionally been designed to improve parent-child relations with regard to family functioning, child health and safety, nutrition and hygiene, and parenting practices. American home visiting programs are derived from the British system, which relies on public health nurses and is offered on a universal basis to all parents with young children. Resource constraints, however, have produced a broad array of variations in this model; most programs in the United States are now directed toward at-risk families who have been reported to social services or health agencies because of prenatal health risks or risks for child maltreatment. Comprehensive programs provide a variety of services, including in-home parent education and prenatal and early infant health care, screening, referral to and, in some cases, transportation to social and health services. Positive effects include improved childrearing practices, increased social supports, utilization of community services, higher birthweights, and longer gestation periods.

Researchers have identified improvements in cognitive and parenting skills and knowledge as evidence of reduced risk for child maltreatment; they have also documented lower rates of reported child maltreatment and number of visits to emergency services for home-visited families. The benefits of home visitation appear most promising for young, first-time mothers who delay additional pregnancies and thus reduce the social and financial stresses that burden households with large numbers of young children. Other benefits include improved child care for infants and toddlers and an increase in knowledge about the availability of community services for older children. The intervention has not been demonstrated to have benefits for children whose parents abuse drugs or alcohol or those who are not prepared to engage in help-seeking behaviors. The extent to which home visitation benefits families with older children, or families who are already involved in abusive or neglectful behaviors, remains uncertain.

Recommendation 5: As part of a comprehensive prevention strategy for child maltreatment, the committee recommends that home visitation programs should be particularly encouraged for first-time parents living in social settings with high rates of child maltreatment reports.

The positive impact of well-designed home visitation interventions has been demonstrated in several evaluation studies that focus on the role of mothers in child health, development, and discipline. The committee recommends their use in a strategy designed to prevent child maltreatment. Home visitation programs do require additional evaluation research, however, to determine the factors that may influence their effectiveness. Such factors include (1) the conditions under which home visitation should be provided as part of a continuum of family support programs, (2) the types of parenting behaviors that are most and least amenable to change as a result of home visitation, (3) the duration and intensity of services (including amounts and types of training for home visitors) that are necessary to achieve positive outcomes for high-risk families, (4) the experience

of fathers in general and of families in diverse ethnic communities in particular with home visitation interventions, and (5) the need for follow-up services once the period of home visitation has ended.

Intensive Family Preservation Services

Intensive family preservation services represent crisis-oriented, short-term, intensive case management and family support programs that have been introduced in various communities to improve family functioning and to prevent the removal of children from the home. The overall goal of the intervention is to provide flexible forms of family support to assist with the resolution of circumstances that stimulated the child placement proposal, thus keeping the family intact and reducing foster care placements.

Eight of ten evaluation studies of selected intensive family preservation service programs (including five randomized trials and five quasi-experimental studies) suggest that, although these services may delay child placement for families in the short term, they do not show an ability to resolve the underlying family dysfunction that precipitated the crisis or to improve child well-being or family functioning in most families. However, the evaluations have shortcomings, such as poorly defined assessment of child placement risk, inadequate descriptions of the interventions provided, and nonblinded determination of the assignment of clients to treatment and control groups.

Intensive family preservation services may provide important benefits to the child, family, and community in the form of emergency assistance, improved family functioning, better housing and environmental conditions, and increased collaboration among discrete service systems. Intensive family preservation services may also result in child endangerment, however, when a child remains in a family environment that threatens the health or physical safety of the child or other family members.

Recommendation 6: Intensive family preservation services represent an important part of the continuum of family support services, but they should not be required in every situation in which a child is recommended for out-of-home placement.

Measures of health, safety, and well-being should be included in evaluations of intensive family preservation services to determine their impact on children's outcomes as well as placement rates and levels of family functioning, including evidence of recurrence of abuse of the child or other family members. There is a need for enhanced screening instruments that can identify the families who are most likely to benefit from intensive short-term services focused on the resolution of crises that affect family stability and functioning.

The value of appropriate post-reunification (or placement) services to the child and family to enhance coping and the ability to make a successful transition

toward long-term adjustment also remains uncertain. The impact of post-reunification or post-placement services needs to be considered in terms of their relative effects on child and family functioning compared with the use of intensive family preservation services prior to child removal. In some situations, one or the other type of services might be recommended; in other cases, they might be used in some combination to achieve positive outcomes.

Recommendations For The Next Generation Of Evaluations

Determining which interventions should be selected for rigorous and in-depth evaluations in the future will acquire increased importance as the array of family violence interventions expands in social services, law, and health care settings. For this reason, clear criteria and guiding principles are necessary to guide sponsoring agencies in their efforts to determine which types of interventions are suitable for evaluation research. Recognizing that all promising interventions cannot be evaluated, public and private agencies need to consider how to invest research resources in areas that show programmatic potential as well as an adequate research foundation. Future allocations of research investments may require agencies to reorganize or to develop new programmatic and research units that can inform the process of selecting interventions for future evaluation efforts, determine the scope of adequate funding levels, and identify areas in which program integration or diversity may contribute to a knowledge base that can inform policy, practice, and research. Such agencies may also consider how to sustain an ongoing dialogue among research sponsors, research scientists, and service providers to inform these selection efforts and to disseminate evaluation results once they are available.

In the interim, the committee offers several guiding principles to help inform the evaluation selection process.

• meet the preconditions for experimentation that are described in the other principles outlined below.

With these principles in mind, the committee has identified a set of interventions that are the focus of current policy attention and service innovation efforts but have not received significant attention from research. In the committee's judgment, each of these nine interventions has reached a level of maturation and preliminary description in the research literature to justify their selection as strong candidates for future evaluation studies.

Training for Service Providers and Law Enforcement Officials

Training in basic educational programs and continuing education on all aspects

of family violence has expanded for professionals in the health care, legal, and social service systems. Such efforts can be expected to enhance skills in identifying individual experiences with family violence, but improvements in training may improve other outcomes as well, including the patterns and timing of service interventions, the nature of interactions with victims of family violence, linkage of service referrals, the quality of investigation and documentation for reported cases, and, ultimately, improved health and safety outcomes for victims and communities.

Training programs alone may be insufficient to change professional behavior and service interventions unless they are accompanied by financial and human resources that emphasize the role of psychosocial issues and support the delivery of appropriate treatment, prevention, and referral services in different institutional and community settings. Evaluations of their effectiveness therefore need to consider the institutional culture and resource base that influence the implementation of the training program and the abilities of service providers to apply their knowledge and skills in meeting the needs of their clients.

Evaluation research is needed to assess the impact of training programs on counseling and referral practices and service delivery in health care, social service, and law enforcement settings. This research should include examination of the effects of training on the health and mental health status of those who receive services, including short- and long-term outcomes such as empowerment, freedom from violence, recovery from trauma, and rebuilding of life. Evaluations should also examine the role of training programs as catalysts for innovative and collaborative services. They should consider the extent to which training programs influence the behavior of agency personnel, including the interaction of service providers with professionals from other institutional settings, their participation in comprehensive community service programs, and the exposure of personal experiences in institutions charged with providing interventions for abuse.

Universal Screening in Health Care Settings

The significant role of health care and social service professionals in screening for victimization by all forms of family violence deserves critical analysis and rigorous evaluation. Early detection of child maltreatment, spousal violence, and elder abuse is believed to lead to an infusion of treatment and preventive services that can reduce exposure to harm, mitigate the negative consequences of abuse and neglect, improve health outcomes, and reduce the need for future health services. Screening programs can also enhance primary prevention efforts by providing information, education, and awareness of resources in the community. The benefits associated with early detection need to be balanced against risks presented by false positives and false negatives associated with large-scale screening efforts and programs characterized by inadequate staff training and responses.

Such efforts also need to consider whether appropriate treatment, protection, and support services are available for victims or offenders once they have been detected.

The use of enhanced screening instruments also requires attention to the need for services that can respond effectively to the large caseloads generated by expanded detection activities. The child protective services literature suggests that increased reporting can diminish the capacity of agencies to respond effectively if additional resources are not available to support enhanced services as well as screening.

The use of screening instruments in health care and social service settings for batterer identification and treatment is more problematic, given the lack of knowledge about factors that enhance or discourage their violent behavior. Screening only victims may be insufficient to provide a full picture of family violence; however, screening batterers may increase the danger for their victims, especially if batterer treatment interventions are not available or are not reliable in providing effective treatment and if support services are not available for victims once a perpetrator is identified. Screening adults for histories of childhood abuse, which may help prevent future victimization of the patient or others, may also be problematic without adequate training or mental health services to deal with the possible resurgence of trauma.

Evaluation studies of family violence screening efforts could build on the lessons derived from screening research in other health care areas (such as HIV detection, lead exposure, sickle cell, and others). This research could provide data that would support or contradict the theory that early identification is a useful secondary prevention intervention, especially in areas in which appropriate services may not be available or reliable. The cost issues associated with universal screening need to be considered in terms of their implications for savings in possible cost reductions from consequent conditions (such as the health consequences of HIV infection, sexually transmitted diseases, unplanned pregnancy, substance abuse, post-traumatic stress disorder, depression, and the exacerbation of other medical conditions) that may occur in other health care areas. Finally, the risks associated with screening (such as the establishment of a preexisting condition that may influence insurance eligibility) require consideration; such issues are already being addressed by some advocacy groups, insurance corporations, and regulatory bodies in the health care area.

Mental Health and Counseling Services

Little is known at present regarding the comparative effectiveness of different forms of therapeutic services for victims of family violence. Findings from recent studies of child physical and sexual abuse suggest that certain approaches (specifically cognitive-behavioral programs) are associated with more positive outcomes for parents, such as reducing aggressive/coercive behavior, compared

with family therapy and routine community mental health services. No treatment outcome studies have been conducted in the area of child neglect. Interventions in this field generally draw on approaches for dealing with other childhood and adolescent problems with similar symptom profiles.

For domestic violence, research evaluations are in the early stages of design and empirical data are not yet available to guide analyses of the effectiveness of different approaches. Major challenges include the absence of agreement regarding key psychosocial outcomes of interest in assessing the effectiveness of interventions, variations in the use of treatment protocols designed for post-traumatic stress for individuals who may still be experiencing traumatic situations, tensions between protocol-driven models of treatment (which are easier to evaluate) and those that are driven by the needs of the client or the context in which the violence occurred, the co-occurrence of trauma and other problems (such as prior victimization, depression, substance abuse, and anxiety disorders) that may have preceded the violence but require mental health services, and the difficulty of involving victims in follow-up studies after the completion of treatment. Variations in the context in which mental health services are provided for victims of domestic violence (such as isolated services, managed care programs, and services that are incorporated into an array of social support programs, including housing and job counseling) also require attention. Topics of special interest include contextual issues, such as the general lack of access to quality mental health services for women without sufficient independent income, and the danger of psychiatric diagnoses being used against battered women in child custody cases.

Collaborative efforts are needed to provide opportunities for the exchange of methodology, research measures, and designs to foster the development of controlled studies that can compare the results of innovative treatment approaches with routine counseling programs in community services.

Comprehensive Community Initiatives

Evaluations of batterer treatment programs, protective orders, and arrest policies suggest that the role of these individual interventions may be enhanced if they are part of a broad-based strategy to address family violence. The development of comprehensive, community-based interventions has become extremely widespread in the 1990s; examples include domestic violence coordinating councils, child advocacy centers, and elder abuse task forces. A few communities (most notably Duluth, Minnesota, and Quincy, Massachusetts) have developed systemwide strategies to coordinate their law enforcement and other service responses to domestic violence.

Comprehensive community-based interventions must confront difficult challenges, both in the design and implementation of such services, and in the selection of appropriate measures to assess their effectiveness. Many evaluations of comprehensive community-based interventions have focused primarily on the

design and implementation process, to determine whether an individual program had incorporated sufficient range and diversity among formal and informal networks so that it can achieve a significant impact in the community. This type of process evaluation does not necessarily require new methods of assessment or analysis, although it can benefit from recent developments in the evaluation literature, such as the empowerment evaluations discussed in Chapter 3 .

In contrast, the evaluation challenges that emerge from large-scale community-based efforts are formidable. First, it may be difficult to determine when an intervention has reached an appropriate stage of implementation to warrant a rigorous assessment of its effects. Second, the implementation of a community-wide intervention may be accompanied by a widespread social movement against family violence, so that it becomes difficult to distinguish the effects of the intervention itself from the impact of changing cultural and social norms that influence behavior. In some cases, the effects attributed to the intervention may appear weak, because they are overwhelmed by the impact of the social movement itself. Third, the selection of an appropriate comparison or control group for community-wide interventions presents formidable problems in terms of matching social and structural characteristics and compensating for community-to-community variation in record keeping.

These challenges require close attention to the emerging knowledge associated with the evaluation of comprehensive community-wide interventions in areas unrelated to family violence, so that important design, theory, and measurement insights can be applied to the special needs of programs focused on child maltreatment, domestic violence, and elder abuse. Although no single model of service integration, comprehensive services, or community change can be endorsed at this time, a range of interesting community service designs has emerged that have achieved widespread popularity and support at the local level. Because their primary focus is often on prevention, rather than treatment, comprehensive community interventions have the potential to achieve change across multiple levels of interactions affecting individuals, families, communities, and social norms and thus reduce the scope and severity of family violence as well as contribute to remedies to other important social problems.

A growing research literature has appeared in other fields, particularly in the area of substance abuse and community development, that identifies the conceptual frameworks, data collection, and methodological issues that need to be considered in designing evaluation studies for community-based and systemwide interventions. As an example, the Center for Substance Abuse Prevention in the federal Substance Abuse and Mental Health Services Administration has funded a series of studies designed to improve methodologies for the evaluation of community-based substance abuse prevention programs that offer important building blocks for the field of family violence interventions.

Developing effective evaluation strategies for comprehensive and systemwide programs is one of the most challenging issues for the research community

in this field. No evaluations have been conducted to date to examine the relative advantages of comprehensive and systemwide community initiatives compared with traditional services. Evaluations need to consider the mix of components in comprehensive interventions that determine their effectiveness and successful implementation; the comparative strengths and limitations of inter- and intra-agency interventions; community factors, such as political leadership, historical tensions, diversity of ethnic/cultural composition, and resource allocation strategies; and the impact of comprehensive interventions on the capacity of service agencies to provide traditional care and effective responses to reports of family violence.

Shelter Programs and Other Domestic Violence Services

Over time, most battered women's shelters have expanded their services to encompass far more than the provision of refuge. Today, many shelters have support groups for women residents, support groups for child residents, emergency and transitional housing, and legal and welfare advocacy. Nonresidential services also have expanded, so that any battered woman in the community is able to attend a support group or request advocacy services. Many agencies now offer educational groups for men who batter, as well as programs dealing with dating violence. Some communities have never opened a shelter yet are able to offer support groups, advocacy, crisis intervention, and safe homes (neighbors sheltering a neighbor, for example) to help battered women and their families in times of crisis. In addition to providing services for victims, the battered women service organizations also define their goal as transforming the conditions and norms that support violence against women. Thus these organizations work as agents of social change in their communities to improve the community-wide response to battered women and their children.

Shelter services and battered women's support organizations are ready for evaluations that can identify program outcomes and compare the effectiveness of different service interventions. Research studies are also needed that can describe the multiple goals and theories that shape the program objectives of these interventions, provide detailed histories of the ways in which different service systems have been implemented, and examine the characteristics of the women who do or do not use or benefit from them.

Protective Orders

Protective orders can be an important part of the prevention strategy for domestic violence and help document the record of assaults and threatening actions. The low priority traditionally assigned to the handling of protective orders, which are usually treated as civil matters in police agencies, requires attention, as do the procedural requirements of the legal system. Courts have

accepted alternative forms of due process, including public notice, notice by mail, and other forms of notification that do not require personal contact. Efforts are needed now to compare the effectiveness of short-term (30-day) restraining orders with a longer (1-year) protective order in reducing violent behavior by offenders and securing access to legal and support services for the complainants.

In-depth case studies and interviews with victims who have had police and court contacts because of domestic violence are needed to highlight individual, social, and institutional factors that facilitate or inhibit victim use of and perpetrator compliance with protective orders in different community settings. Such studies could (1) reveal patterns of help-seeking contacts and services that affect the use of protective orders and compliance with their requirements, (2) highlight the forms of sanctions that are appropriate to ensure compliance and to deter future violent behavior, (3) explore the extent to which the effects of protective orders are enhanced in reducing violence if victim advocates, shelter services, or other social support resources are available and are used by the victim in redefining the terms of her relationship with her partner, and (4) examine the extent to which protective orders can mitigate the consequences of violence for children who may have been assaulted or who may have witnessed an assault against their mother.

Child Fatality Review Panels

The emergence of child fatality review teams in 21 states since 1978 represents an innovative effort in many communities to address systemwide implications of severe violence against children and infants. Child fatality review teams involve a multiagency effort to compile and integrate information about child deaths and to review and evaluate the record of caseworkers and agencies in providing services to these children when a report of abuse or neglect had been made prior to a child's death. These review teams can provide an opportunity to examine the quality of a community's total approach to child abuse and neglect prevention and treatment.

The experience of child fatality review teams in identifying systemic features that enhance or weaken agency efforts to protect children needs to be evaluated and made accessible to individual service providers in health, legal, and social service agencies. Key research issues include: the effect of review team actions on the protection of family members of children who have died as a result of child maltreatment; the impact of child fatality review reports on the prosecution of offenders; the influence of review team efforts on the routine investigation, treatment, and prevention activities of participating agencies; the impact of review teams on other community child protection and domestic violence prevention efforts; and the identification of early warning signals that emerge in child homicide investigations that represent opportunities for preventive interventions.

Child Witness to Violence Programs

Child witness programs represent an important development in the evolution of comprehensive approaches to family violence, but they have not yet been evaluated. Evaluation studies of these programs should examine the experience with symptomatology among children who witness family violence, to determine whether and for whom early intervention influences the course of development of social and mental health consequences, such as depression, anxiety, emotional detachment, aggression and violence, and post-traumatic stress symptoms. Such studies could also compare variations in the developmental histories of children who witness violence with those of children who are injured or otherwise are directly victimized by their parents or who witness violence in their communities. Evaluation studies should consider the recommended forms of treatment for these children, the standards of eligibility that determine their placement in treatment programs, and the impact of institutional setting (hospital, shelter, or social service agency) and reimbursement plans on the quality of the treatment.

Elder Abuse Services

Only seven program evaluation studies have been published on elder abuse interventions, none of which includes random groups and most of which involve small sample sizes. Three major issues challenge effective interventions in this area: the degree of dependence between perpetrators and victims, restricted social services budgets, general public distrust of social welfare programs, and the relationship between judgments about competence and the application of the principles of self-determination and privacy to the problem of elder abuse.

Evaluation studies should consider the different types and multiple dimensions of elder abuse in the development of effective interventions. The benefits of specific programs need to be compared with integrated service systems that are designed to foster the well-being of the elderly population without regard to special circumstances. Evaluation research should be integrated into community service programs and agency efforts on behalf of elderly persons to foster studies that involve the use of comparison and control groups, common measures, and the assessment of outcomes associated with different forms of service interventions.

Topics For Basic Research

The committee identified four basic research topics that require further development to inform policy and practice. These topics raise fundamental questions about the approaches that should be used in designing treatment, prevention, and enforcement strategies. As such, they highlight important dimensions of family violence that should be addressed in a research agenda for the field.

birth, infancy, and adolescence. Other issues linked to family formation include the use of corporal punishment in child discipline, gender roles, privacy, and strategies for resolving conflict among adults or siblings.

A third approach would be studies to discern the protective factors inside and outside families that enable some children who are exposed to violence to not only survive but also to develop coping mechanisms that serve them well later in life. This analysis would have widespread implications for assessing the impact of biological and experiential factors in specific domains, such as fear, anxiety, self-blame, identity formation, helplessness, and help-seeking behaviors. Such research could also identify abuse-related coping strategies (such as excessive distrust of or overdependence on others) that may contribute to other problems that emerge in the course of adolescent and adult development.

first-time parents, victims and offenders who have substance abuse histories, etc.)

Forging Partnerships Between Research And Practice

Although it is premature to expect research to offer definitive answers about the relative effectiveness of the array of current service and enforcement strategies, the committee sees valuable opportunities that now exist to accelerate the rate by which service providers can identify the types of individuals, families, and communities that may benefit from certain types or combinations of service and enforcement interventions. Major challenges must be addressed, however, to improve the overall quality of the evaluations of family violence interventions and to provide a research base that can inform policy and practice. These challenges include issues of study design and methodology as well as logistical concerns that must be resolved in order to conduct research in open service systems where the research investigator is not able to control factors that may weaken the study design and influence its outcome. The resolution of these challenges will require collaborative partnerships between researchers, service providers, and policy makers to generate common approaches and data sources.

The integration of research and practice in the field of family violence, as in many other areas of human services, has occurred on a haphazard basis. As a result, program sponsors, service providers, clients, victims, researchers, and community representatives have not been able to learn in a systematic manner from the diverse experiences of both large and small programs. Mayors, judges, police officers, caseworkers, child and victim advocates, health professionals, and others must make life-or-death decisions each day in the face of tremendous

uncertainty, often relying on conflicting reports, anecdotal data, and inconsistent information in judging the effectiveness of specific interventions.

The development of creative partnerships between the research and practice communities would greatly improve the targeting of limited resources to specific clients who can benefit most from a particular type of intervention. Yet significant barriers inhibit the development of such partnerships, including disagreements about the nature and origins of family violence, broad variations in the conceptual frameworks that guide service delivery, differences over the relative merits of service and research, a lack of faith in the ability of research to inform and improve services, a lack of trust in the ability of service providers to inform the design of research experiments and the formation of theoretical frameworks, and concerns about fairness and safety in including victims and offenders in experimental treatment groups. These fundamental differences obscure identification of outcomes of interest in the development of evaluation studies, which are further complicated by limitations in study design and access to appropriate subjects that are necessary for the conduct of research.

Even if greater levels of trust fostered more interaction between the research community and service providers, collaborative efforts would be challenged by factors such as the lack of funding for empirical studies, the availability of limited resources to support studies over appropriate time frames, and the social and economic characteristics of some of the populations served by family violence interventions that make them difficult to follow over extended periods of time (chaotic households, high mobility of the client population, concerns for safety, lack of telephones and permanent residences, etc.).

Service providers and program sponsors have often been skeptical of efforts to evaluate the impact of a selected intervention, knowing that critical or premature assessments could jeopardize the program's future and restrict future opportunities for service delivery. Service providers have also been less than enthusiastic in seeking program evaluations, knowing that the programs to be evaluated have been underfunded and are understaffed and present a less than ideal situation; in their view, the assessment may diminish future resources and affect the development of a particular strategy or programmatic approach. The tremendous demand for services and the limited availability of staff resources create a pressured environment in which the staff time involved in filling out forms for research purposes is seen as being sacrificed from time that might be used to serve people in need. In some cases, research funds support demonstration programs that are highly valued by a community, yet few resources are available to support them once the research phase has been completed.

Researchers and service providers need to resolve the programmatic tensions that have sometimes surfaced in contentious debates over the type of services that should be put into place in addressing problems of family violence. The mistrust and skepticism present major challenges that need to resolved before the technical challenges to effective evaluations can be addressed. A reformulation of the

research process is needed so that, while building a long-term capacity to focus on complex issues and conduct rigorous studies, researchers can also provide useful information to service providers.

The committee has identified three major principles to help integrate research and practice in the field of family violence interventions:

• Evaluation should be an integral part of any major intervention, particularly those that are designed to be replicated in multiple communities. Interventions have often been put into place without a research base to support them or rigorous evaluation efforts to guide their development. Evaluation research based on theoretical models is needed to link program goals and operational objectives with multiple program components and outcomes. Intensive marketing and praise for a particular intervention or program should no longer be a substitute for empirical data in determining the effectiveness of programs that are intended to be replicated in multiple sites.
• Coordinating policy, program, and research agendas will improve family violence interventions. Evaluation research will help program sponsors and managers clarify program goals and experience and identify areas in need of attention because of the difficulties of implementation, the use of resources, and changes in the client base. Research and data-based analysis can guide ongoing program and policy efforts if evaluation studies are integrated into the design and development of interventions. The knowledge base can be improved by (1) framing key hypotheses that can be tested by existing or new services, (2) building statistical models to explore the system-wide effects of selected interventions and compare these effects with the consequences of collaborative and comprehensive approaches, (3) using common definitions and measures to facilitate comparisons across individual studies, (4) using appropriate comparison and control groups in evaluation studies, including random assignment, when possible, (5) developing culturally sensitive research designs and measures, (6) identifying relevant outcomes in the assessment of selected interventions, and (7) developing alternative designs when traditional design methodology cannot be used for legal, ethical, or practical reasons.
• Surmounting existing barriers to collaboration between research and practice communities requires policy incentives and leadership to foster partnership efforts. Many interventions are not evaluated because of limited funds, because the individuals involved in service delivery consider research to be peripheral to the needs of their clients, because the researchers are disinterested in studying the complexity of service delivery systems and the impact of violence in clients' lives, or because research methods are not yet available to assess outcomes that result from the complex interaction of multiple systems. This situation will continue until program sponsors and policy officials exercise leadership to build partnerships between the research and practice communities and to provide funds for rigorous evaluations in the development of service and law enforcement
• interventions. Additional steps are required to foster a more constructive dialogue and partnership between the research and practice communities.

Partnership efforts are also needed to focus research attention on the particular implementation of an individual program rather than the strategy behind the program design. Promising intervention strategies may be discarded prematurely because of special circumstances that obstructed full implementation of the program. Conversely, programs that offer only limited effectiveness may appear to be successful on the basis of evaluation studies that did not consider the significant points of vulnerability and limitations in the service design or offer a comparative analysis with the benefits to be derived from routine services.

The establishment and documentation of a series of consensus conferences on relevant outcomes, and appropriate measurement tools, will strengthen and enhance evaluations of family violence interventions and lead to improvements in the design of programs, interventions, and strategies. May opportunities currently exist for research to inform the design and assessment of treatment and prevention interventions. In addition, service providers can help guide researchers in the identification of appropriate domains in which program effects may occur but are currently not being examined. Ongoing dialogues can guide the identification and development of instruments and methods that can capture the density and distribution of relevant effects that are not well understood. The organization of a series of consensus conferences by sponsors in public and private agencies that are concerned with the future quality of family violence interventions would be an important contribution to the development of this field.

Reports of mistreated children, domestic violence, and abuse of elderly persons continue to strain the capacity of police, courts, social services agencies, and medical centers. At the same time, myriad treatment and prevention programs are providing services to victims and offenders. Although limited research knowledge exists regarding the effectiveness of these programs, such information is often scattered, inaccessible, and difficult to obtain.

Violence in Families takes the first hard look at the successes and failures of family violence interventions. It offers recommendations to guide services, programs, policy, and research on victim support and assistance, treatments and penalties for offenders, and law enforcement. Included is an analysis of more than 100 evaluation studies on the outcomes of different kinds of programs and services.

Violence in Families provides the most comprehensive review on the topic to date. It explores the scope and complexity of family violence, including identification of the multiple types of victims and offenders, who require different approaches to intervention. The book outlines new strategies that offer promising approaches for service providers and researchers and for improving the evaluation of prevention and treatment services. Violence in Families discusses issues that underlie all types of family violence, such as the tension between family support and the protection of children, risk factors that contribute to violent behavior in families, and the balance between family privacy and community interventions.

The core of the book is a research-based review of interventions used in three institutional sectors—social services, health, and law enforcement settings—and how to measure their effectiveness in combating maltreatment of children, domestic violence, and abuse of the elderly. Among the questions explored by the committee: Does the child protective services system work? Does the threat of arrest deter batterers? The volume discusses the strength of the evidence and highlights emerging links among interventions in different institutional settings.

Thorough, readable, and well organized, Violence in Families synthesizes what is known and outlines what needs to be discovered. This volume will be of great interest to policymakers, social services providers, health care professionals, police and court officials, victim advocates, researchers, and concerned individuals.

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ORIGINAL RESEARCH article

Evaluating the impact of a family violence transformational change project in a major trauma hospital: a three-year follow-up comparison study of knowledge, confidence, and family violence response skills in clinical staff.

• 1 Allied Health, Family Safety Team, Royal Melbourne Hospital, Melbourne, VIC, Australia
• 2 Allied Health, Psychology, Royal Melbourne Hospital, Melbourne, VIC, Australia
• 3 Neuropsychology Service, The Melbourne Clinic, Melbourne, VIC, Australia
• 4 Clinical Psychology, Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia

Family violence is a significant public health issue. Healthcare systems have an important role to play in recognising and responding to current family violence experiences in their patients. However, many healthcare workers and systems remain underprepared to fulfil this role. The current study evaluated the impact of a transformational change project in family violence clinical response at a major adult trauma hospital in Australia. Clinician self-rated knowledge, confidence, and family violence clinical skills were evaluated at three years post implementation of a family violence initiative at the Royal Melbourne Hospital, Melbourne. The three years post survey results ( N  = 526) were compared to baseline ( N  = 534) using Mann Whitney U and χ 2 analyses. Self-reported clinician family violence knowledge, confidence and patient screening were all significantly improved from baseline. Specific family violence skills, including knowledge of key indicators, enquiry with patients and disclosure response were also all significantly improved. The most common clinician identified barriers to working effectively in the area were similar to baseline and included the presence of a suspected perpetrator during the clinical interaction, clinicians perceiving patients would be reluctant to disclose, and time limitations. However, significantly fewer staff endorsed a lack of knowledge or supporting policies and procedures as a barrier. The findings indicate that investment in a transformational change project comprised of the establishment of response policies and clinical work-flow, broad-scale training, a clinical champions program, a secondary consultation service and links with partner organisations, was effective at improving clinician self-rated rated family violence skills, across the hospital. However, one quarter of clinicians still reported having not received any family violence training, and half endorsed having little or no confidence in their skills to identify and respond to patient family violence experiences. This indicates ongoing and sustained work is required to optimise clinician skills in responding to family violence.

Introduction

Family violence is behaviour perpetrated by someone in a kinship structure that causes fear and/or physical, emotional, psychological or financial harm ( 1 ). This includes intimate partner violence, domestic violence, interpersonal violence, neglect, elder abuse, and child abuse. It is predominantly perpetrated by men against women and children, but can affect people of any gender, sexual orientation and age ( 2 ). Globally, violence by a male intimate partner is the most prevalent form of violence against women ( 3 ). In Australia, family violence disproportionately affects first nations people, women with disabilities, people from the LGBTIQA+ community, those from culturally diverse linguistic backgrounds and older people ( 2 , 4 , 5 ).

Violence in an intimate partner context is the highest contributing risk factor to disease burden (death, disability, illness) in women aged 25–44 years in Australia ( 6 ). In many parts of the world, the wide-spread and devastating impact of family violence has been highlighted through a series of comprehensive reports. In Australia commissions by state governments include the Not Now, Not Ever report in Queensland ( 7 ), and the Royal Commission into Family Violence in Victoria ( 8 ). Similar work has been undertaken internationally in Spain, South Africa, the United Kingdom, and the United States ( 9 – 12 ).

The reports generated from these investigations all highlight the importance health systems play in identifying and assisting victim/survivors. This includes healthcare workers implementing either universal or targeted family violence screening and providing support and care planning in situations of moderate and high risk ( 7 – 10 , 12 ). The reports also highlight the devastating health and well-being consequences of family violence on victim survivors ( 7 – 10 ). Previous research has indicated that 70% of women killed through family violence utilised medical healthcare services in the 12 months prior to their death, and 25% mental healthcare, whilst very few (3%) sought help from family violence specific services ( 13 ). This underscores the importance of healthcare services assisting in family violence situations.

While many communities acknowledge the role healthcare services have in addressing family violence, what is less clear is the effectiveness of service level reforms implemented to address these needs. The evaluation of several pilot trials introducing new family violence screening and support programs in healthcare services have recently been published. A trial of a nurse-delivered intervention addressing intimate partner violence in government-led community health clinics in Mexico found reductions in violence for both female service users that received family violence screening, health/safety risk assessments and supportive referrals, and those that receive a less comprehensive service of family violence screening and referral cards ( 14 ). Qualitative research has also been published investigating the experiences of clinical staff participating in the Assessing for Domestic Violence in Sexual Health Environments (ADVISE) trial ( 15 ). This indicated that staff trained in the identification and referral to improve safety program went on to prioritise enquiring about family violence in their practice, adapted enquiry to the characteristics of patients, and were comfortable with providing quick on-referrals in low-risk cases. However, challenges were reported working through time-consuming high-risk cases, with modifications to training, regular updates and more resourcing recommended.

How healthcare staff are trained to improve their family violence clinical response is also important to consider. Where this has been evaluated, the results indicate mixed outcomes ( 16 – 18 ). Evaluation of an intervention in a maternal and sexual health service in the United Kingdom resulted in improved knowledge and practice in the short-term, however harms were reported to have occurred during the evaluation period ( 16 ). This intervention included implementing guidelines, clinician education, a framework for routine enquiry with all patients, and on-referral to an advocacy service. Despite improved clinician knowledge, issues including failure to document, negative labelling and stereotyping from staff, breaches of confidentiality, and failing to preventing situations of risk including discharging a mother a baby home with an abusive partner, where indicated. In another study, a system's change model was evaluated that utilised a team training approach across several hospitals in the United States ( 17 ). In this study, no increase was found in the rates of identification of patients experiencing domestic violence in the emergency departments of participating hospitals; however, improved patient satisfaction and significant and sustained culture change in the emergency departments was indicated.

Both establishing the learning framework, and evaluating the outcomes, in family violence healthcare clinician training scenarios is not straight-forward. The majority of the studies reported above used multiple methods and modalities to effect change within the services, employing broad transformational change or systems change approach to tackle the problem. Thus, success can be determined by looking at any number of broad and specific factors, including clinician knowledge levels, patient screening rates, patient satisfaction, uptake of on-referrals and patient outcomes. Generally, most approaches fall into the framework of cognitivism based instrumental learning theory approaches, with some elements of experiential, transformative and social learning principles utilised as well ( 19 ).

In Victoria, Australia, the Strengthening Hospital Responses to Family Violence (SHRFV) initiative was launched by the state government to directly implement Royal Commission recommendations for public health services to provide a whole-of-hospital response to family violence ( 8 ). This included three to five years of grant funding for all state health services to implement a transformational change project to improve their family violence response. Several baseline studies have been published from hospitals within this program about staff family violence knowledge and patient perceptions of screening, as well as pilot research on a family violence clinical champions program ( 20 – 26 ). This research indicated that there was general under preparedness to respond to family violence and a wide range of knowledge and skill levels in healthcare clinicians across services and disciplines prior to the implementation of SHRFV. Similarly, the rate at which clinicians screened patients for family violence across services was also inconsistent ( 20 , 23 , 26 ). However, when patients disclosed family violence concerns, the majority indicated that they were happy with the support they received from clinicians ( 22 , 26 ). The research further indicated some promise for healthcare worker family violence clinical champions programs ( 24 , 25 ). Evaluations with clinicians in an adult trauma hospital who had participated in a clinical champions program found significant and sustained improvements in self-reported family violence knowledge and skills in both allied health and nursing clinicians. However, knowledge levels and engagement with the initiative were stronger over time in allied health clinicians ( 24 , 25 ).

In addition to selected SHRFV sites conducting baseline research, an audit tool was recently developed by the Royal Women's Hospital, in conjunction with the University of Melbourne. The tool was designed for whole-of-system evaluation to assess the impact of the SHRFV program at individual hospitals ( 27 ). Eighteen SHRFV health services participated in piloting the tool, between November 2019 and 2021 (occurring two to three years after the launch of SHRFV at the services). The tool ranked services across a range of domains and the report from this pilot research suggests that the SHRFV program improved the ability of the services to identify and respond to family violence. However, improvements in patient facing aspects of the program were recommended.

The baseline studies and audit tool report provide useful information; however, to date, no research containing both pre and post SHRFV implementation data to evaluate the effectiveness of the SHRFV program at a healthcare service has been provided. The current study attempts to address this gap by providing a comparison analysis of staff family violence knowledge and clinical skills in a large tertiary adult trauma hospital prior to the implementation of the SHRFV informed transformational change project (baseline), and at 3-years post implementation (follow-up). It is the first study, to our knowledge, to comprehensively evaluate the impact of the SHRFV initiative with both baseline and follow-up measures in a large clinical staff cohort (with N  = 500+ participating in the survey research in both phases).

This study aimed to evaluate the impact of a transformational change project in family violence clinical response at a major trauma hospital in Melbourne, Australia. The study assessed clinician self-rated knowledge, confidence, and family violence clinical skills three-years following the implementation of a family violence initiative at the Royal Melbourne Hospital.

The paper presents data collected in November-December 2020, from a whole of hospital clinician survey at Royal Melbourne Hospital and compares the survey results to those obtained at baseline in the same health service in November-December 2017 ( 21 ), prior to the implementation of service-wide clinician training in family violence.

The Royal Melbourne Hospital was awarded state government grant funding under the SHRFV initiative (described above). Prior to the commencement of the project, the Royal Melbourne Hospital had no family violence clinical response policy or procedure to guide staff when assisting patients experiencing family violence. There was also no internal, hospital-provided, training in family violence clinical response, and no standardised method for screening patients or responding to disclosures. Further, there was no way of tracking, or evaluating, the number of clients presenting to the hospital due to family violence injuries or trauma, or those experiencing family violence being treated at the hospital. Evaluation of the baseline, pre-initiative environment, in regard to clinician family violence skills, patient experiences of family violence screening and clinician responses has been documented in previous studies ( 21 – 23 , 28 ).

Details of the Royal Melbourne Hospital design and implementation of the transformational change project to address these issues are presented in Fisher et al (2022) ( 29 ). To summarise, this included the development a family violence clinical response policy in 2018, establishment of a specialist multidisciplinary family violence team (the Family Safety Team) to provide training in family violence to both clinical and non-clinical staff hospital wide, and the introduction of a secondary consultation service for all clinicians assisting patients experiencing family violence. Standardised family violence screening and response workflow was also built into the hospital's new electronic medical record (rolled out across the service in 2019 and 2020). This included best practice guideline “pop-ups” to aid clinicians when screening patients for family violence concerns and supporting them following disclosures. Links were made with family violence community service partners and police to facilitate safe patient discharge and care-planning after leaving hospital. A family violence support program was established for staff experiencing family violence, and a family violence research and evaluation program was embedded. Data for the current study were collected at the 3-year follow-up time point when there had been 5,398 staff attendances at family violence training provided by, or sourced through, the Family Safety Team, over the preceding three years. This included the training of 232 Family Safety Advocates clinical champion who had received a minimum of 9 h training and were supported by a community of practice ( 24 , 25 ).

Materials and methods

The setting was a large, Tier 1, adult trauma hospital in Melbourne, Australia. The survey methodology was the same as in the baseline study [data collected in 2017], ( 21 ), except for some minor adjustments to the survey tool, detailed below. The available work email addresses of all clinical staff were collated (Nursing = 1,829; Medical = 660; Allied Health = 549), and an invitation/reminder to participate in the online survey was sent to staff a maximum of three times over 4 weeks. The survey was open for a total of six weeks. Consent was implied on participation as approved by the Royal Melbourne Hospital Human Research Ethics Committee. The Melbourne Health Human Research Ethics Committee was the approving body: HREC Reference Number: HREC/17/MH/283; SSA Reference Number: SSA/17/MH/390; Research Title: Assisting Patients/Clients Experiencing Family Violence: Clinician Survey.

Survey tool

The Assisting Patients/Clients Experiencing Family Violence: Royal Melbourne Hospital Clinician Survey was used ( 21 ). It is an 11-question survey tool enquiring about the knowledge, the confidence of clinical skills of clinicians in the area of FV. It also surveys clinician endorsed barriers to addressing DFV. The survey consists of Likert-type ordinal responses, forced choice categorical responses (Yes, No, Somewhat) and qualitative free-text response sections (please see ( 21 ) Designed for the Victorian context, this survey has been used in three previous studies (with combined clinician participants of N  = 754) ( 20 , 21 , 30 ). It has good internal consistency, as indicated in previous studies (Withiel et al., 2021, Cronbach's Alpha −0.83; Fisher et al., 2022, Cronbach's alpha of 0.77). It is also capable of differentiating between professions with higher levels of FV training and experience, and is sensitive to changes in knowledge following training ( 24 ). Minor modifications were made to the survey at follow-up. Specifically, sections on respondent gender identity and age were added to allow for greater demographic characterisation of the sample. Self-report of prior family violence training was also modified to indicate the specific type(s) of Royal Melbourne Hospital training respondents had attended since the initiative commenced. Finally, a question asking clinicians to estimate their total number of family violence training hours was added ( 23 , 30 ).

Descriptive statistics are provided for all demographic data. Due to the cross-sectional nature of data collection, changes in ordinal outcomes between baseline and follow up were analysed using a series of Mann Whitney U analyses. Differences in nominal outcomes were analysed using a series of χ 2 analyses. A two-tailed alpha of 0.05 was set for the determination of statistical significance. The free-text data obtained in the survey has also been analysed and will be presented in a subsequent paper using qualitative thematic analysis ( 31 ).

A total of 526 clinicians completed the survey at the 3-year follow-up 2020 data collection phase. This was compared to the data provided by 534 participants in the baseline 2017 phase. The nature of the ethics approval obtained for the study (anonymous, not identifiable data collection) did not allow the research team to track clinicians that had participated at both baseline and 3-year follow-up. However, it is likely that some respondents participated in the survey at both time points. Characteristics and demographics are provided in Table 1 . Similar to the baseline cohort, almost half the sample had worked in their clinical profession for 10 years or more. More than three quarters identified as having a female gender identity, and 30–39 was the most common age bracket. As with the baseline study, the strongest response rate was seen from allied health clinicians, although unlike baseline, allied health also made up the highest number of respondents, with more participants than nursing and medical clinicians. More clinicians had participated in prior family violence training in the follow-up cohort, and considerably more had participated in training in the past two years. Overall, 48.67% of the follow-up sample endorsed completing at least one specific type of family violence training provided at the Royal Melbourne Hospital since the transformational change project began. Just over a quarter had completed one form of training (27.57%), 16.53% had completed two forms of training, and 4.56% three forms or more. A total of 94 respondents had completed the Royal Melbourne Hospital's Family Safety Advocate training (clinical champions program), providing 9 h+ training (for further information about the types of training provided see ( 24 , 29 ).

Table 1 . Sample demographics across baseline and 3-year follow-up.

Mann Whitney U analyses revealed statistically significant improvement in clinician ratings of their family violence knowledge, confidence and screening rates, and frequency of working clients with family violence experiences. See Table 2 for the comparison of results and statistical significance levels for specific questions. Comparatively, just 23.96% of clinicians rated their family violence knowledge level as Moderate or above, at baseline, while at follow-up this had increased to 55.7%. Similarly, those rating their confidence working in the area of family violence as Moderate or above, stood at 27.71 percent at baseline, compared to 49.82% at follow-up. Clinicians who had completed training more recently provided stronger confidence ratings (Confidence mean rank: >2 years ago training −126.35, ≤2 year ago training −219.88; Mann Whitney U  = 18,695.50, p  < 0.001). However, this is likely to have also been mediated by training amount, with clinicians who had completed training more recently also endorsing a significantly higher number of training hours [Mean (SD) training hours: >2 years ago training −2.97 (9.54); ≤2 years ago training −6.14 (7.46); Independent samples t -test, t (400) = −3.19009, p  = 0.002]. For screening, those rating their frequency of screening at Sometimes , Often or Always , increased from 31.05% to 50.00%. However, clinician ratings of their frequency of working with patients experiencing family violence, was not significantly different across the two time points.

Table 2 . Comparison of clinician's self-ratings of skills and experience in the area of family violence by survey question and survey time-point.

Similar to the baseline data set, secondary analysis of the 3-year follow-up survey results revealed differences in mean rankings according to profession grouping (see Table 3 for results and Kruskal-Wallis analysis). Allied health clinicians self-rated knowledge and confidence levels were higher than medical and nursing clinicians. However, medical staff endorsed working with patients who had experienced family violence more frequently than the other profession groups.

Table 3 . Mean ranks for self-reported family violence skills between professional groups.

Consistent with the knowledge and confidence results, a similar trajectory of improvement was observed between the baseline and 3-year follow-up time points, in the areas of specific family violence response skills. Results are graphically represented in Figure 1 . On χ 2 comparisons, significantly more clinicians responded Yes , or Somewhat to questions about knowledge of key family violence indicators, how to ask patients about family violence, and how to respond to disclosures, at follow-up, compared to baseline. These differences remained significant after Bonferroni correction.

Figure 1 . Clinician self-ratings of family violence key indicators, enquiry skills, and managing disclosures.

The final section of the survey relates to barriers that impact on the capacity of clinicians to address patient family violence issues (see Table 4 ). As an overall trend, fewer barriers were identified by clinicians, with all 13 pre-specified barriers showing a reduction in endorsement at the follow-up time point. The barriers with the most notable decreases in endorsement were lack of clinician knowledge for asking, concerns about rapport, lack of policies/procedures, impact on staff safety, and access to supervision/reflective practice. These five areas showed significant changes in levels of endorsement across the two time points.

Table 4 . Challenges in addressing family violence endorsed by respondents.

The three most commonly endorsed pre-specified barriers remained the same across time points. There was some change in the least commonly endorsed barriers, however, with Lack of supporting policies and procedures the least commonly endorsed barrier at follow-up, a change from baseline. This was also the pre-specified barrier that showed the highest magnitude of change, across the two time points.

Further analysis of the follow-up data set is being conducted, including an analysis stratifying the respondents into groups according to the amount of family violence training they had received (i.e., none, some, Family Safety Advocate/clinical champion training) for both the quantitative and qualitative data portions of the survey. To generalize, at a very broad level, results from the qualitative analysis of the text box response data indicates that staff trained in the clinical champions program show a greater depth of knowledge, and skills that are more aligned with best-practice guidelines, relative to staff with short-duration, or not training. However, staff with shorter-duration training still generally demonstrate stronger family violence clinician response knowledge than those with no training. This analysis will be presented in subsequent papers.

The data presented in this paper indicates that overall, the SHRFV initiative and the transformational change project at the Royal Melbourne Hospital was effective in improving family violence knowledge and skills in clinical staff. Whilst training was a large component of the initiative, the project went beyond training and encompassed policy implementation, clinical workflow, a secondary consultation service, awareness raising, and a clinical champions' model including a community of practice. In most areas, statistically significant improvements in self-rated family violence skills proficiency were observed. This provided promising evidence that a large health service, starting from a low knowledge base, can make meaningful gains in clinician family violence knowledge with appropriate funding, skills and resources, and a clear project plan and direction.

Importantly, at 3-year follow-up, the clinician cohort self-ratings indicated significantly greater knowledge about family violence relative to the baseline cohort, and the screening of patients more frequently. Clinician confidence working in the area also improved from baseline – but continued to lag behind self-rated knowledge levels. This suggests that even with increased training and knowledge clinicians may not be confident in their capacity to apply these skills clinically when working with patients. Improvement in clinicians endorsing the frequency with which they work with clients experiencing family violence did not reach statistical significance. At a surface level, this may suggest that clinicians are still not recognising that family violence may be occurring for their clients, and thus not screening when it is indicated. However, it could be that clinicians are interpreting this question to refer to patients who come to see them with a known and documented history of family violence, prior to any screening conducted by the individual clinician, themself. Future research, via auditing the uptake use of the family violence screening tool in the electronic medical record, will assist to evaluate actual clinician behaviour with screening.

At 3-year follow-up Allied Health staff tended to rate their family violence skills more strongly than Nursing or Medical staff. This is likely to reflect the fact that the majority of the Family Safety Advocates (clinical champions) who had received more in-depth training, came from Allied Health. Further the professions of Social Work and Psychology sit within this professional grouping, and all staff in these teams were required to undertake the advocate training as part of their job role.

Encouragingly, clinician self-ratings of specific family violence skills improved in all three assessed areas. This included knowledge of key indicators, asking about family violence, and responding to disclosures. The data on clinician-identified barriers to working effectively in the area of family violence also yielded interesting results. Notably, there was a large and significant decrease in staff identifying a lack of supporting policies and procedures to do this work and far fewer staff endorsed the barrier of not knowing what to do or say, at follow-up. This is likely to reflect the fact that the Royal Melbourne Hospital had established a family violence policy and response procedure to guide clinical staff practice at the time of follow-up; something that had not existed at baseline. It also suggests that both the awareness raising and training in the response procedure were beneficial to improve staff knowledge with both asking and responding.

Notable also, the three most highly endorsed barriers to working effectively in the area remained the same across time points. A suspected perpetrator being present during the clinical interaction is a safety risk that impacts on the capacity of staff to enquire safety with victim/survivors. Family violence training at the hospital has included brainstorming about how to separate suspected victim/survivors and suspected perpetrators, so that safe family violence enquiry can occur. However, data from the current study suggests further work could be done in this area. Similarly, nearly 50% of clinicians continue to believe that clients will be reluctant to disclose when asked. Thus, future training should continue to reinforce that multiple occasions of asking may be required, and that many victim/survivors want to be asked and provided with support ( 22 , 26 , 32 ). The issue of time limitations also continued to be raised by busy clinicians who struggle to fit in family violence screening with other routine care procedures. Reinforcement with staff that family violence impacts significantly on physical and mental health may assist with further reducing this barrier, as well as increased effort by the Royal Melbourne Hospital to make identifying signs and screening a required part of routine clinical care.

While the overall results of this research are promising, they also indicate that further and ongoing resourcing is needed in this area. Twenty-five percent of the clinician respondents at follow-up indicated that they had never undertaken any training in family violence. This is far from optimal, as it suggests that one-quarter of the clinical staff patients encounter have had no training in this area. Thus, many staff may miss key indicators that patients are experiencing family violence, and/or responding inadequately, or inappropriately, if patients choose to disclose family violence issues to them. Further, sizeable proportions of staff still rate their knowledge and confidence working clinically in the area of family violence as low, and respond with a definitive No , when asked if they have an understanding of specific family violence clinical skills (indicators, asking and responding). Thus, despite the progress made over three-years at the Royal Melbourne Hospital, further and ongoing work is needed to optimise staff knowledge levels.

The local environment of the hospital at the time of the follow-up study should also be considered. In contrast to baseline, the follow-up was conducted in the midst of the COVID-19 pandemic. Data collection was undertaken several weeks after a four-month, government-imposed lock-down. The hospital at which this study was conducted was the most heavily impacted by COVID-19 in the country in 2020, with the highest number of patient deaths and staff infections, affecting staff wellbeing ( 33 , 34 ). This impacted on the capacity of the Family Safety Team to continue with the family violence training schedule, with a reduction in the provision of training and fewer attendances at training, compared to the previous calendar year (4,309 attendances at training in 2019; 1,089 in 2020; ( 29 ). Members of the team were also redeployed to acute clinical and staff COVID-19 support roles during the COVID-19 surges, with some converted to work-from-home arrangements to minimise infection in non-frontline staff. The follow-up survey was administered at a time when the clinical workforce was impacted by fatigue and burnout from the COVID-19 surge. This may have affected engagement levels. It was anticipated by the study team that participation would be higher at follow-up, relative to baseline, due to the levels of awareness raising in the area over the previous three years. In contrast to this, a small drop in participation numbers was seen.

Limitations to this study also include the overall survey response rate in the follow-up cohort of 17.31%. This response rate is not optimal for confidently generalising the results to the broader clinical staff cohort. However, it is commensurate with the baseline survey response rate, and with other online only healthcare worker surveys administered via email contact only, with large (>2,000) participant contact pools ( 35 , 36 ). The response rate to the survey is also far greater than several other recent family violence knowledge surveys in healthcare worker cohorts ( 37 , 38 ).

The majority of the training provided fit within a cognitivism based instrumental learning framework. However, the lengthier clinical champions training (Family Safety Advocates) also included transformative and social learning principles, and participants were required participants to undertake experiential exercises. Overall, this study cannot be considered a direct assessment of any individual family violence training type, module, or program, as many different types were employed during the course of the Family Safety Team SHRFV initiative at the Royal Melbourne Hospital, including some sourced through external providers. Rather, it is reflective of the impact of the entire multi-faceted transformational change project at the service. However, it does sit within the broader context of evaluating staff training in family violence. Previous studies have indicated that healthcare worker family violence clinical training seminars of 1–2 days duration have some effect in improving knowledge of family violence skills, attitudes to screening, service culture and patient satisfaction, but that these may have small effect sizes and may not translate to any increase in the identification of family violence in the patient cohort ( 16 , 17 , 39 ). Sustained and comprehensive initiatives, where options for repeated and in-depth training are available, in services with wrap-around policies and procedures in family violence, may be more effective at improving family violence knowledge and practices, albeit more costly and labour intensive.

What remains to be determined at the Royal Melbourne Hospital is whether there has been direct and measurable improvement in care for patients with current family violence situations attending the service. A repeat of the baseline patient survey has been hampered due to the fluctuating and ongoing COVID-19 situation, limiting the majority of non-essential research from face-to-face settings. However, a systematic audit of the uptake and utilisation of the family violence screening and clinical workflow is planned, as well as an evaluation of use of family violence alerts placed on patient files by clinicians. Further research in progress at the service includes a psychometric study of the test-retest validity of the clinician survey tool to supplement the internal consistency evaluations that have already been undertaken.

Family violence remains a significant problem that impacts on the health and wellbeing of victim-survivors and conveys a high economic burden ( 40 , 41 ). The role of healthcare systems in identifying and supporting people experiencing family violence is well recognised in many countries; although healthcare workers remain under educated and supported to do this work at best-practice standards. The results of the current study suggest that measurable improvement can be made in healthcare worker family violence clinical skills knowledge, when a comprehensive, transformational change project is implemented in a large relatively well resourced, adult hospital. To achieve this, comprehensive service changes and supports are required, in addition to wide-scale training. Findings underscore the need for ongoing resourcing in family violence training and supporting structures, such as secondary consultation and a community of practice, to assist clinicians to continue to provide an effective family violence response to patients.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by Melbourne Health Human Research Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author contributions

CF: designed, coordinated and completed data collection for the study. TW, KT and CF: analysed the data. All authors provided intellectual input to the contents of the manuscript. CF and TW: wrote the manuscript. KT, CR and KF: provided editing input to the manuscript. All authors contributed to the article and approved the submitted version.

This research was supported by Strengthening Hospital Responses to Family Violence funding provided to the study hospital by the Victorian State Government.

Acknowledgments

The study team would like to acknowledge the contribution of all the clinicians at Royal Melbourne Hospital who participated in the survey research.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: domestic violence, family violence, hospital, healthcare, intimate partner violence, screening, training

Citation: Fisher CA, Troy K, Rushan C, Felmingham K and Withiel TD (2023) Evaluating the impact of a family violence transformational change project in a major trauma hospital: A three-year follow-up comparison study of knowledge, confidence, and family violence response skills in clinical staff. Front.Health Serv. 2:1016673. doi: 10.3389/frhs.2022.1016673

Received: 11 August 2022; Accepted: 18 November 2022; Published: 6 January 2023.

Reviewed by:

© 2023 Fisher, Troy, Rushan, Felmingham and Withiel. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Caroline A. Fisher [email protected]

Specialty Section: This article was submitted to Implementation Science, a section of the journal Frontiers in Health Services

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Family violence: contemporary research findings and practice issues

Affiliation.

• 1 School of Social Work, University of South Florida, Tampa 33620.
• PMID: 1486766
• DOI: 10.1007/BF00754196

The purpose of this paper is to describe recent empirical research findings about family violence, and to explore selected social work treatment issues in the light of these findings. The last two decades has seen a proliferation of research about family violence. Most of the early research used small clinical samples and so generalizing findings to other groups has been difficult. However, the recent research has examined a number of important psychosocial correlates of family violence using more methodologically sound methods. As a result, we now know quite a bit about how and why family violence occurs. Also, within the last decade a number of studies have explicated the kinds of treatments and approaches that are most effective in dealing with abusive people. This paper summarizes these treatment strategies.

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Violence against women and girls – what the data tell us

Trigger warnings: rape, sexual violence, domestic violence/abuse.

Gender-based violence takes many forms: physical, sexual, emotional, and psychological. Examples include female genital mutilation, killing in the name of so-called ‘honor’, murder, forced and early marriage, and sex trafficking. Two of the most prevalent types of violence that women experience are  intimate partner violence  (IPV) and non-partner sexual violence (NPSV).

Almost one in three women  across the world have experienced one or both of these forms of violence at least once in their lifetime. This story presents the latest findings based on the  WHO study published in 2021  that estimated global and regional prevalence of intimate partner violence and non-partner sexual violence against women.

Slow and steady progress in building the evidence base

As prevalent as violence against women is, building the global evidence base on it has been a slow process.

It was not until long ago that women’s rights to bodily integrity were fully recognized and enshrined in international law. The United Nations’ (UN) first Convention on the Elimination of Discrimination Against Women ( CEDAW ) wasn’t published until 1979, recording the UN’s action plan on gender equality. Violence against women was officially added as a form of gender-based discrimination in the updated 1992 version, recognizing this as a violation of women’s human rights ( OHCHR ).

VIOLENCE AGAINST WOMEN WAS FIRST RECOGNIZED AS A VIOLATION OF HUMAN RIGHTS IN 1992.

Data on gender based violence, and sexual violence in particular, has been extremely important in putting this development issue at the center of gender equality efforts. With support from the World Health Organization (WHO), and the United States Agency for International Development (USAID), economies have significantly scaled up efforts to collect data on violence against women. Whereas in 2010 only 82 economies had survey  data available  on the subject, that number has since risen to 161 ( WHO 2021 ).

The new  World Bank Gender Data Portal , curates these data, making them accessible to policymakers, alongside research-informed resources on tackling the problem. The first step in designing essential prevention and support services for survivors of gender based violence is understanding the full magnitude of the problem. Who is experiencing violence? When is violence most likely to occur? And where?

Here is what the data tell us about gender based violence perpetrated by partners and non-partners.

Intimate partner violence

Intimate Partner Violence (IPV) includes psychological, sexual, and physical violence committed by a current or former intimate partner or husband. All IPV statistics refer to ‘ever-partnered’ women. This means that the denominator for calculating these estimates only includes women who have ever been in an intimate relationship or in a marriage.

More than 1 in 4 women (26%) aged 15 years and older have suffered violence at the hands of their partners at least once since the age of 15. Applying this percentage to the 2018 population data from  World Population Prospects , the WHO estimates that 641 million women have been affected. And an estimated 245 million (or 10% of women ages 15 and above) have  experienced IPV in the last 12 months alone .

245 MILLION WOMEN AGES 15 AND ABOVE HAVE EXPERIENCED INTIMATE PARTNER VIOLENCE IN THE LAST 12 MONTHS ALONE.

These estimates are large, yet the true figures are likely to be even larger because of the difficulties women face in being open about experiences of violence. Evidence shows that violence from an intimate partner can often go unrecorded, due to social stigma and women not wanting to make things worse for themselves ( WHO ).

Women in every single economy where data are collected have experienced IPV in the last year.

The two regions with the highest-known prevalence of IPV are Sub-Saharan Africa, where 33% of women aged 15–49 years have suffered IPV in their lifetime and 20% in the last year alone, and South Asia, where 35% of women in the same age bracket have experienced it in their lifetime and 19% in the last year.

Adolescent girls are more at risk than adult women

Young women aged 15 to 19 are the most affected by IPV. By the time they are 19 years old, almost 1 in 4 adolescent girls (24%) who have been in a relationship have already been physically, sexually, or psychologically abused by a partner ( WHO ).

BY THE TIME THEY ARE 19 YEARS OLD, 1 IN 4 ADOLESCENT GIRLS WHO HAVE BEEN IN A RELATIONSHIP WILL ALREADY HAVE BEEN PHYSICALLY, SEXUALLY, OR PSYCHOLOGICALLY ABUSED BY A PARTNER.

IPV among teenagers is most common in Sub-Saharan Africa and South Asia: 1 in 5 of them have experienced IPV in the last 12 months. And in some regions, such as East Asia and the Pacific, teenagers aged 15 to 19 are three times more likely than women over 45 to face IPV.

Non-partner sexual violence

In addition to violence from intimate partners, non-partner sexual violence (NPSV) poses a risk to women’s safety and bodily integrity. NPSV refers to acts of sexual violence committed by any person that is not a current or former husband or male intimate partner. NPSV can be perpetrated by a family member, friend, acquaintance, or stranger. Since all women can be exposed to this type of violence, the denominator for calculations includes all women and not only those who have ever been married or had an intimate partner.

Worldwide, an estimated 6% of women and girls aged 15 to 49 years have been subject to sexual violence from a non-partner at least once since age 15.

6% OF WOMEN WORLDWIDE HAVE BEEN SUBJECT TO SEXUAL VIOLENCE FROM A NON-PARTNER.

The reported occurrence of NPSV is very different to intimate partner violence. It is more common in higher-income economies, especially Australia and New Zealand, where it has affected 19% of women, and North America, where 15% of women have been affected ( WHO ). In contrast, the estimated prevalence rates in Southern Asia (2%) and Sub-Saharan Africa (6%) are much lower.

However, these estimates need to be interpreted with caution. This form of violence is also stigmatized, and in traditional or patriarchal societies, survivors are often blamed and so might avoid disclosure to reduce potential consequences. As such, actual rates are likely to be much higher than estimated for low- and middle-income economies ( WHO ).

Drivers of sexual violence

The drivers of violence against women are complex and multi-faceted. Research has identified several factors at the individual, family, community, and national level that are associated with higher risks of experiencing IPV.

Growing up in an abusive household can create a cycle of violence. Studies show that boys who witness their mothers being abused are more likely to become perpetrators of IPV later in life and girls who witness the same are twice as likely to experience IPV in adulthood (Kishor and Johnson 2004). Experience of childhood family aggression communicates the acceptability of family aggression, increasing the likelihood of its occurrence in the next generation ( Kalmuss, D. 1984 ).

A woman’s risk of experiencing IPV differs by type of marriage. Polygamous marriage (where one person has multiple spouses) and getting married before the age of 18 each increase the odds by 22%. A husband that often drinks to excess is also dangerous, increasing a woman’s risk fivefold ( Voice and Agency report ).

A HUSBAND THAT DRINKS TO EXCESS INCREASES A WOMAN’S RISK OF INTIMATE PARTNER VIOLENCE FIVEFOLD.

Cultural norms, laws, and individual attitudes are deeply intertwined and shape the acceptability of violence against women. In economies where IPV is outlawed, women’s acceptance of it is lower, and fewer women experience violence ( Voice and Agency report ). In contrast, in economies such as Guinea, Mali and Timor-Leste, more than 3 in 4 people think that wife beating is justified, for as little as burning the food or going out without telling their husband. Women who agree with these justifications for wife beating are 45% more likely to experience violence ( Voice and Agency report ).

Sexual violence is more prevalent in areas experiencing conflict. In these situations, unequal gender norms can be predominant and unchallenged. Other unstable situations, such as displacement and natural disasters, can also increase sexual violence. For example, a multi-economy study found that forcibly displaced women in Colombia and Liberia were at 40% and 55% greater risk, respectively, of experiencing IPV in the past year compared to non-displaced women ( World Bank ).

Consequences of gender based violence

Violence causes lifelong damages to women, affecting their physical, mental, sexual, and reproductive health.

Physical consequences associated with experiencing IPV include acute injuries, chronic pain, gastrointestinal illness, gynaecological problems, substance abuse, sexually transmitted infections including HIV, a two- to three-fold increased risk of depression ( Beydoun, Hind A et al. ,  World Bank ), and even suicide ( Devries, Karen et al. ).

IPV has severe consequences for women’s reproductive control and health. Two decades of research have documented that IPV is linked to adverse reproductive outcomes for women and girls. In some studies, women subjected to IPV are twice as likely to report an unintended pregnancy than women who do not experience violence in their relationships ( Silverman and Raj, 2014 ). One study found that women in Ukraine, Moldova and Azerbaijan who have experienced IPV not only had higher risk of unintended pregnancies, but also a higher risk of their last pregnancy ending in abortion or an unwanted baby ( USAID ).

A global pandemic requiring local solutions

The data are clear: gender based violence is a pandemic. Thirty years since the landmark UN CEDAW commitment to end all forms of violence against women and girls, the problem remains immense. Understanding the prevalence of sexual violence and associated risk factors, however, is only the first step in developing essential prevention and support services for survivors.

The challenge is to put those data into action to help women and girls ( World Bank ). Combining data sources and examining multiple risk factors can help understand why violence against women and girls is still so pervasive.

Gender based violence is more prevalent when there are no legal consequences, sexist and patriarchal cultural norms, and in humanitarian emergencies or conflict. Younger people are more at risk, as are girls who grow up in abusive households. Women who married before 18 or are one of many wives are also more at risk.

Addressing these risk factors will require a close look at local circumstances as effective prevention and survivor services are built on contextual knowledge. An upcoming data story will look at successful interventions and how they potentially enable better outcomes for survivors of gender based violence. Such  initiatives and investments  are fundamental for effective protection for women and girls against violence.

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Child and Teen Firearm Mortality in the U.S. and Peer Countries

Matt McGough , Krutika Amin, Nirmita Panchal , and Cynthia Cox Published: Jul 18, 2023

Editor’s Note: This brief was updated on July 18, 2023, with newer data.

In 2020 and 2021, firearms contributed to the deaths of more children ages 1-17 years in the U.S. than any other type of injury or illness. The child firearm mortality rate has doubled in the U.S. from a recent low of 1.8 deaths per 100,000 in 2013 to 3.7 in 2021.

The United States has by far the highest rate of child and teen firearm mortality among peer nations. In no other similarly large, wealthy country are firearms in the top four causes of death for children and teens, let alone the number one cause. U.S. states with the most gun laws have lower rates of child and teen firearm deaths than states with few gun laws. But, even states with the lowest child and teen firearm deaths have rates much higher than what peer countries experience.

In 2020 and 2021, firearms were involved in the deaths of more children ages 1-17 than any other type of injury or illness, surpassing deaths due to motor vehicles, which had long been the number one factor in child deaths. In 2021, there were 2,571 child deaths due to firearms—a rate of 3.7 deaths per 100,000 children, which is an increase of 68% in the number of deaths since 2000 and 107% since a recent low of 2013.

While the rate of firearm deaths among children has increased since 2000, the rate of motor vehicle deaths is now significantly lower than it had been. The number of motor vehicle deaths among children in 2021 was 49% lower than in 2000, though it did grow during the pandemic by 22% from 2019. Though fewer in number than firearm deaths among children, deaths due to poisonings, which include drug overdoses, have also grown, increasing 186% since 2000 and 103% since 2019.

Provisional CDC data from 2022 indicate that firearms continued to be the number one factor in child deaths for the third year in a row.

Because peer countries’ mortality data are not available for children ages 1-17 years old alone, we group firearm mortality data for teens ages 18 and 19 years old with data for children ages 1-17 years old in all countries for a direct comparison.

On a per capita basis, the firearm death rate among children and teens (ages 1-19) in the U.S. is over 9.5 times the firearm death rate of Canadian children and teens (ages 1-19). Canada is the country with the second-highest child and teen firearm death rate among similarly large and wealthy nations.

As might be expected, teenagers have higher firearm mortality rates than children. In the U.S., teens ages 18 and 19 have a firearm mortality rate of 25.2 per 100,000, compared to a rate of 3.7 per 100,000 for children ages 1-17 in the U.S. Even so, the child firearm mortality rate in the U.S. (3.7 per 100,000 people ages 1-17) is 5.5 times the child and teen mortality rate in Canada (0.6 per 100,000 people ages 1-19).

If the child and teen firearm mortality rate in the U.S. had been brought down to rates seen in Canada, we estimate that approximately 30,000 children’s and teenagers’ lives in the U.S. would have been saved since 2010 (an average of about 2,500 lives per year). This would have reduced the total number of child and teenage deaths from all causes in the U.S. by 13%.

The child and teen (ages 1-19 years) firearm mortality rate varies by state in the U.S. from 2.1 deaths per 100,000 in New York and New Jersey to 17.6 deaths per 100,000 in Louisiana. Even in New York and New Jersey, which have the lowest child and teen firearm mortality rates among those with available data, the rate is still over three times that in Canada.

Because there is no comprehensive national firearm registry, it is difficult to track gun ownership in the U.S. Instead, we look at the correlation between the number of child and teen firearm deaths and the number of gun laws in U.S. states (based on the State Firearm Law Database , which is a catalog of the presence or absence of 134 firearm law provisions across all 50 states).

States with more restrictive firearm laws in the U.S. generally have fewer child and teen firearm deaths than states with fewer firearm law provisions. Even so, these states on average have a much higher rate of child and teen firearm deaths than that of Canada and other countries. Among comparably large and wealthy countries, Canada has the second highest child and teen firearm death rate to the U.S. However, Canada generally has more restrictive firearm laws and regulates access to guns at the federal level. In the U.S., guns may be brought to states with strict laws from out-of-state or unregistered sources .

In 2020 and 2021, firearms were involved in more deaths for children and teens (ages 1-19 years) in the United States than any other type of injury or illness. In 2021, firearms were involved in 4,733 child and teen deaths.

With the exception of Canada, in no other peer country were firearms among the top five causes of childhood and teenage death. Motor vehicle accidents and cancer are the two most common causes of death for this age group in all other comparable countries.

The categories in the chart above are more specific than CDC’s rankable causes of death. We use CDC’s data grouped by injury mechanism and illness. However, given differences in how deaths are grouped by CDC and IHME, we adapt CDC data to be comparable to IHME data. For example, pedestrian deaths are included with motor vehicle and pedestrian deaths in the chart above. See Methods for more details.

Combining all child and teen firearm deaths in the U.S. with those in other OECD countries with above median GDP and GDP per capita, the U.S. accounts for 97% of gun-related child and teen deaths, despite representing 46% of the total population in these countries. Combined, the eleven other similarly large and wealthy countries account for only 153 of the total 4,886 firearm deaths for children and teens ages 1-19 years in these nations, and the U.S. accounts for the remainder.

Firearms account for 20% of all child and teen deaths in the U.S., compared to an average of less than 2% of child and teen deaths in similarly large and wealthy nations.

The U.S. also has the highest rate of each type of child and teen firearm death—suicides, assaults, and unintentional or undetermined intent—among similarly large and wealthy countries.

In 2021 in the U.S., the overall child and teen firearm assault rate was 3.9 per 100,000 children and teens. In the U.S., the overall suicide rate among children and teens was 3.8 per 100,000; and 1.8 per 100,000 child and teen suicide deaths were by firearms. In comparable countries, on average, the overall suicide rate is 2.8 per 100,000 children and teens, and 0.2 per 100,000 children and teens suicide deaths were by firearms.

If the U.S. child and teen suicide by firearm rate was brought down to the same level as in Canada, the peer country with the next highest rate, over 1,000 fewer children and teens would have died in 2021 alone.

The spike in 2020 and 2021 in child and teen firearm deaths in the U.S. was primarily driven by an increase in violent assault deaths. The child and teen firearm assault mortality rate reached a high in 2021 with a rate of 3.9 per 100,000, a 7% increase from the year before and a 50% increase from 2019. The firearm suicide mortality rate among children and teenagers in the U.S. increased 21% from 2019 to 2021.

Exposure and use of firearms also have implications for mental health.  Research suggests that youth may experience symptoms of post-traumatic stress disorder and anxiety in response to gun violence. Specifically, survivors of firearm-related injuries, including youth survivors, may be at increased risk of mental health conditions and substance use disorders. Furthermore, gun violence disproportionately affects many children of color , particularly Black children, and children living in areas with a high concentration of poverty .

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• U.S. Has the Highest Rate of Gun Deaths for Children and Teens Among Peer Countries

Also of Interest

• Americans’ Experiences With Gun-Related Violence, Injuries, And Deaths
• The Impact of Gun Violence on Children and Adolescents
• States with Firearm Laws Designed to Protect Children
• Deaths Due to Firearms per 100,000 Population by Age
• What is Driving Widening Racial Disparities in Life Expectancy?
• KFF Health News Coverage on Guns

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Q&A: Understanding and Preventing Youth Firearm Violence

Jessika Bottiani discusses her research on the significant disparities in youth firearm violence and how understanding those gaps can help future prevention efforts.

Leslie Booren

August 26, 2024

This summer the United States Surgeon General Dr. Vivek Murthy released a landmark advisory on firearm violence , declaring it a public health crisis. According to the advisory, gun violence reaches across the lifespan and is currently the leading cause of death for children and adolescents in America.

Researchers at Youth-Nex, the UVA Center to Promote Effective Youth Development, have been examining some of the root causes of youth firearm violence disparities to better understand this crisis and how future prevention efforts may work.

Recently, the Society for Research on Adolescence (SRA) recognized Dr. Jessika Bottiani, an associate research professor at the UVA School of Education and Human Development and faculty affiliate at Youth-Nex, and her co-authors with the 2024 Social Policy Publication Award for a paper on the prevention of youth firearm violence disparities . SRA highlighted this review as work that should be read by all policymakers.

We sat down with Bottiani to learn more about this research review.

Q: Your paper examined research on youth firearm violence and firearm risk. What did you find?

A: Our review and synthesis of data demonstrated striking differences in firearm risk across intersectional identities. We separated out different types of firearm violence (e.g., homicide, suicide, injury), which revealed distinctions in risk across different demographic groups–most saliently gun homicide among Black boys and young men in urban settings.

A staggering degree of inequity in firearm fatalities is shouldered by Black boys and young men in this country, where the rate of firearm homicide is more than 20 times higher among Black boys and young men ages 15-24 than for white boys and young men in the same age groups. We also saw higher rates of gun suicide among white and Indigenous American boys and young men in rural areas of the United States.

When we examined rates by geography, we identified intersectional differences in risk that are important for policymakers to understand. For example, we saw that higher rates of firearm homicide among Black boys and young men were most salient in urban areas of the Midwest and south of the United States. Overlaying data onto maps demonstrated how young male suicide by firearm is also clustered geographically, for example, in rural counties in the Midwest and west for Indigenous young males, and in in rural counties in the west for White male youth (who have the second highest rate of suicide by firearm after Indigenous young males).

Q: Why was a review of the research specifically focused on disparities in youth firearm violence needed?

A: A lot of systematic and scoping reviews on firearm violence had come out in the literature around this time, but none of them focused on understanding why Black boys and young men in urban areas were so disproportionately affected, or why we were also seeing gaps affecting rural White boys and young men. This paper presented data that revealed the degree of these disparities and tried to understand the root causes.

We don’t pay enough attention to the role of racist historical policies and regulations that have calcified into today’s racially segregated geographies and poverty. With this paper, we wanted to reveal the way in which youth gun violence is inextricably bound to the history of race, place, and culture in the United States. The paper also delves into cultural norms around guns and masculinity. We feel insights on these aspects of context are vital for understanding how to address youth firearm violence.

Q: What future prevention efforts do you suggest in your paper?

A: We put forth a number of evidence-based solutions for settings ranging from emergency rooms to schools to address firearm violence at the individual level. Yet perhaps more importantly, we also provide suggestions for tackling the structural and sociocultural factors that underlie firearm violence.

At the community level, our recommendations range from violence interrupters to programs and policies that seek to disrupt racial segregation and redress housing inequities. We also note the potential for media campaigns addressing sociocultural norms to be a tool for prevention.

We provided a review of gun restriction and safety policies, and their potential effectiveness in addressing youth firearm violence (while also acknowledging the political climate wherein such policies have been increasingly challenged). We point out that some recent firearm related policies, purportedly race neutral in their language, had harmful impacts specifically on communities and people of color.

Individual level interventions or policies that seek to address only one piece of the puzzle are bound to be ineffective at scale. Rather, what is required are multisector, place-based initiatives that address structural factors related to poverty and the built environment in under-resourced segregated neighborhoods.

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Adolescent-to-Parent Violence and Family Environment: The Perceptions of Same Reality?

The use of several sources of information (parents and children) is scarce in family studies. Child-to-parent violence (CPV) is still considered the most hidden and stigmatized form of family violence. One objective of this study was to analyze the prevalence of child-to-parent violence and perceptions of family environment as a function of the informant (parent or child), child’s sex, and parents’ sex in a community population. The study also aimed to analyze the predictive power of family conflict and aggressive family discipline in child-to-parent violence depending on the informant. A sample of 586 adolescents (49% boys, aged between 12 and 18) and their parents (40%) participated in the study. The Family Environment Scale and the Conflict Tactics Scales were administered. Results showed good consistency between adolescent reports and parent reports for physical CPV, but adolescents perceived worse family environments than their parents. Multiple regression models revealed that aggressive family discipline and family are important risk factors for CPV. Early intervention to prevent CPV is recommended, focused on promoting family relationships and avoiding harsh discipline practices. It is important that parents are able to ask for help when they need it.

1. Introduction

Family violence research over the last two decades has largely focused on child abuse and intimate partner violence. An issue that has received limited attention until recent years, however, is child-to-parent violence (CPV). In the current study, CPV is defined as violence, including physical and psychological violence, perpetrated by children or adolescents and directed toward their parents or caregivers. In this definition, the intention to control parents, which appears in the definitions of different experts (e.g., [ 1 ]), has been eliminated. Pereira et al. [ 2 ] have developed a practical definition which includes repeated violent behaviors of children towards their parents or caregivers when the child has a relationship of dependency with respect to the parent. Most studies have focused exclusively on community samples and children reports [ 3 , 4 ]. Findings based on adolescent reports indicate prevalence rates ranging from 7.2% to 22% for physical aggression, and from 65.8% to 93.5% for psychological aggression [ 5 ]. In community populations, in which levels of physical CPV are expected to be low, the results of some studies indicate that the differences between sons and daughters as perpetrators are non-existent or negligible, but girls are more likely to have higher levels of psychological CPV [ 3 , 6 , 7 ]. In legal contexts, where physical CPV can be more serious, sons are more frequent perpetrators than daughters [ 8 ]. In a recent systematic review, Simmons et al. [ 9 ] concluded that there was an overall trend towards gender symmetry of the perpetrator in self-reported physical CPV in community samples, but in offender samples, males accounted for 59–87%. However, community research studies report that daughters tend to use more psychological or verbal abuse toward parents than sons [ 3 , 4 ]. With respect to target gender, mothers are reported more frequently than fathers in offender samples [ 9 ]. For example, in a study by Ibabe and Jaureguizar [ 8 ], the most frequent victim of the aggression was the mother (97%) in both cases (when the perpetrator was the son or the daughter) and 83% of mother-abusers were sons. This could be due to the possible modeling of aggressive behavior when children witness intimate partner violence toward their mother, and it could also be because the children are frightened of their father. Although both parents are living in the household, the mother is still usually the victim [ 8 ]. However, some community studies found that fathers are as likely to be targeted as mothers [ 9 ]. This could mean that the victimization of the mother is related to the severity of the physical abuse involved.

The use of various sources of information (parents and children) in this type of study has been scarce. Recent research carried out in Spain by Calvete et al. [ 5 ] examined the consistency between parent reports and child reports when reporting on child-to-parent violence in a community sample. The results indicate that parents may underestimate the violence of which they are victims in a community population, although the effect size was small. The prevalence rates of psychological violence found in parent reports and adolescent reports were 93% and 89%, respectively, while the rates for physical violence were 22% and 11%. Some parents may blame themselves for their children treating them aggressively. In fact, society often interprets CPV as a failure in parental education and setting limits on their children [ 5 ], although other causes or explanations may be involved, such as children’s personal factors (problematic substance use or psychological disorders) [ 10 ]. However, in the most serious cases, the opposite may be obtained. On the one hand, in legal contexts, adolescents may report lower levels of violence than parents in order not to incriminate themselves, and as far as possible, to avoid any consequences their actions may have. On the other hand, in such situations, parents are driven to report child-to-parent violence because they do not feel able to control the situation and are seeking a solution. Both adolescents and parents are key sources of information about family environment, and adolescent and parent reports of family relationships rarely converge [ 11 ]. De los Reyes, Ohannessina, and Raez [ 12 ] indicate that studying discrepancies between adolescent and parent reports of their relationships provides relevant information about family functioning and adolescent development. Divergence between adolescent reports and parent reports on family relationships, with adolescent reports being the more negative, predicts more internalizing problems in adolescents [ 13 ]. It would be interesting to study associations between adolescent–parent discrepancies in family relationships and adolescent adjustment.

One of the peculiarities of CPV is that parents seek protection from the same children they are responsible for protecting. Moreover, depending on the children’s age, occasional conflict is likely to occur between children and parents living together, and there may be situations where aggression and violence are accepted as normal [ 14 ]. From a psychological perspective, conflict in parent–adolescent relationships arises due to the need of adolescents to detach themselves emotionally from parents or parental figures [ 15 ]. Adolescents perceive that their privacy has been invaded [ 16 ]. Family conflict generally arises from disagreements over everyday, routine issues [ 17 ], and this type of conflict has the potential to lead to violence and abuse [ 18 ]. Among the many potential risk factors analyzed in different studies, parent-to-child violence and marital violence are highly relevant when considering community samples [ 6 , 10 , 19 , 20 ] and offender samples (child-to-parent offenders and other offenders) [ 21 ]. Numerous studies have shown that child abuse, exposure to inter-parental violence, and both in combination (e.g., dual exposure) increase a child’s risk of internalizing and externalizing outcomes in adolescence [ 22 , 23 ]. In fact, there is a great deal of empirical evidence for the hypothesis of bidirectionality of family violence [ 20 , 24 , 25 ]: children who have experienced parental abuse or have observed inter-parental violence tend to be more violent toward parents. In a community population, child aggression could represent a functional response to family strain or an attempt to cope with inadequate parental education [ 24 ]. Although there is a recognized relationship between family violence and child-to-parent violence, the mechanisms by which family violence affects child-to-parent violence are less well studied. In their review, Simmons et al. [ 9 ] concluded that exposure to family violence can have an indirect effect on child-to-parent violence by affecting social information processing and making an individual more vulnerable to violent behavior.

There is some evidence that family conflict is an important risk factor for psychological child-to-parent violence (e.g., [ 4 ]) and antisocial behavior [ 26 , 27 ]. The escalation of a parent–child conflict can lead to the use of aggressive discipline [ 28 , 29 ]. Three forms of aggressive discipline by parents can be distinguished: verbal aggression, physical aggression in the form of corporal punishment (CP), and physical abuse [ 29 ]. Aggressive discipline and child abuse can be considered variants of parental aggression, with most cases of child abuse emerging from the routine practice of physical discipline strategies [ 30 ]. In no case can aggressive parental discipline ever be justified as a way of controlling children. Aggressive parental disciplinary practices—including both physical punishment and harsh psychological discipline—can be viewed as clear forms of child maltreatment with significant consequences for both individuals and society [ 31 ]. Three forms of parental aggression toward children (psychological aggression, physical aggression, and physical abuse) represent different levels of severity on a continuum of parental aggression [ 32 ]. In this context, the use of physical force with the intention of causing a child pain or discomfort in order to correct or control the child’s behavior is usually termed corporal punishment (CP) [ 33 ], while parental aggression causing visible injuries to children constitutes “crossing the line” from discipline to abuse [ 34 ]. However, in the present study, corporal punishment is also considered to be a form of child abuse because, as Straus [ 35 ] has indicated, many child-abuse injuries are the result of corporal punishment.

Inappropriate parental discipline strategies have negative consequences on the psychological adjustment of children [ 36 , 37 ]. Specifically, discipline strategies administered inconsistently [ 38 ], power-assertive disciplinary methods (where a child’s inappropriate behavior results in a negative consequence without explanation or justification) [ 4 , 6 ], and especially corporal punishment have been related to CPV [ 3 , 38 , 39 ]. In a longitudinal study, Hoyo–Bilbao et al. [ 3 ] found that corporal punishment is related to CPV regardless of the context in which it is used or the age and sex of the child. In this study, 43% of the adolescents admitted that their parents had used corporal punishment during the previous year. However, earlier studies with Spanish samples indicated higher prevalence rates of corporal punishment (approximately 60%) (for a review, see Reference [ 37 ]). Although the use of CP may be decreasing in recent years in Spain and other countries, educational interventions should be applied to reduce this type of family socialization practice. For those raised in violent homes, conflict can escalate from a disagreement to abuse or use of violence, rather than move toward a resolution of differences through talking and involvement.

General strain theory [ 24 , 40 ] and coercion theory [ 41 ] emphasize the instrumental functions of child-to-parent violence. Coercion theory describes a process of mutual reinforcement during which parents inadvertently reinforce children’s difficult behaviors, which in turn elicits parent negativity, etc., until the interaction is discontinued when one of the members imposes him- or herself on the other. These theories assume that children respond violently to aversive family interactions, and such behavior serves to reduce strain presented by parents or family members. Forms of parental discipline aim to correct or monitor the child’s behavior, ensure short-term obedience, and promote the internalization of long-term values [ 39 ]. An emphasis on child well-being and child rights can also be seen in the prohibition of corporal punishment [ 42 ], in place in the majority of European countries. However, in the United States, the approval of hitting children and adolescents is ingrained in cultural norms and supported by legal statutes [ 43 , 44 ]. According to UNICEF (United Nations Children’s Fund) [ 45 ], around 6 in 10 children between the ages of 2 and 14 worldwide (almost a billion) are subjected to physical punishment by their caregivers on a regular basis. Diverse studies have found that more frequent use of corporal punishment is related to a higher prevalence of violence and endorsement of violence at a societal level [ 46 ]. Gámez–Guadix and Almendros [ 47 ] found that Spanish parents tended to apply more discipline strategies to their children than Anglo-Saxon parents.

Objectives and Hypothesis

The present study aims to analyze whether the prevalence of child-to-parent violence and perception of family environment changes as a function of the informant (parent or child), child’s sex, and parents’ sex in a community population. We hypothesize that the prevalence rate of physical and psychological violence found in adolescent reports will be slightly higher than in parent reports, consistent with the findings of Calvete et al. [ 38 ]. In line with these findings, higher levels of family conflict and lower levels of family cohesion will be expected in adolescent reports compared to parent reports. Daughters are expected to claim a higher prevalence of psychological aggression than sons, based on study samples in non-clinical populations, but no difference is expected between sons and daughters in terms of physical aggression [ 3 , 4 ]. Parent sex is examined in aggressive family discipline because one parent could be more likely to use aggressive discipline practices than the other. The study also aims to evaluate the predictive power of family conflict and aggressive family discipline in child-to-parent violence depending on the informant (adolescent, father, and mother). In a structural equation model of child-to-parent violence based on family relationship, power-assertive discipline, and age of perpetrators, the explained variance was 57% [ 4 ]. In contrast to previous studies, which only contained adolescent reports, the present study will compare three models according to adolescent reports, mother reports, and father reports. Additionally, associations between adolescent–parent discrepancies in family conflict and cohesion will be explored with respect to child-to-parent violence (an indicator of adolescent maladjustment) and the children’s interest in their studies (an indicator of adolescent adjustment). The inclusion of adolescent and parent reports may contribute to a better understanding of child-to-parent violence, thereby improving adolescent health and well-being.

2. Materials and Methods

2.1. participants.

A sample of 586 adolescents (49% boys, aged 12 to 18) and their parents ( n = 398, aged 27 to 65) from eight schools in the Basque Country participated in the study. The sample of parents was composed of 161 pairs of parents, 60 single mothers and 16 single fathers. Forty-three percent of the students were from state (public) schools and the rest were from private schools. A total of 75% lived in nuclear families, 14% in single-mother families, with 7% in step-families, and 4% in extended or other types of family.

2.2. Instruments and Variables

Socio-Demographic Data. A questionnaire was used to collect socio-demographic data on the children. Among the variables studied were sex, age, country of birth, family structure, educational level, and parental occupation. In order to measure the interest in studies, adolescents were required to indicate their level of interest in their studies on a Likert scale (1 = Very low; 5 = Very high).

Family Environmental Scale. (FES [ 48 ], Spanish version [ 49 ]). Two subscales of the Family Environmental Scale were administered to parents and children. These two subscales contained 18 items with a true/false response format: Cohesion (the degree of commitment and support family members offer each other, a sample item being: “In my family we really help and support each other”) and Conflict (the degree of explicitly expressed anger and conflict among family members). In general, the alpha reliability coefficients in this study were acceptable: adolescents (Cohesion α = 0.76; Conflict α = 0.60), mothers (Cohesion α = 0.65; Conflict α = 0.51), and fathers (Cohesion α = 0.65; Conflict α = 0.50).

Conflict Tactics Scale Child–Parents (CTS1 [ 50 ]). This scale contains 13 items from three dimensions: psychological violence (e.g., “Insult or threaten my father/mother” or “My child insulted me or threatened me”), mild physical violence, and serious physical violence. Parents and children were asked to take the previous year as a reference and use a scale with the following values: 0 (Never), 1 (Hardly ever), 2 (Sometimes), 3 (Frequently), and 4 (Almost always). In general, internal consistency results were quite acceptable in the sample of adolescents (psychological violence, α = 0.85; physical violence, α = 0.86), mothers (psychological violence, α = 0.75; physical violence, α = 0.67), and fathers (psychological violence, α = 0.71; physical violence, α = 0.49).

Dimensions of Discipline Inventory (DDI-C [ 42 ], Spanish adaptation [ 51 ]). Although this inventory measures four general dimensions, the present study only measured punitive discipline (corporal punishment and psychological aggression). Family discipline was assessed from the children’s point of view in their relationship with their father and mother. Items described different situations related to life and family upbringing, to which children were required to respond on a 5 point Likert scale, from 0 (Never) to 4 (Almost always). The subscales for corporal punishment (e.g., “How often did your father/mother shake or grab you to get your attention?”) and psychological aggression (e.g., “How often did your father/mother shout at you?”) had four questions each. In this study, the internal consistency for this dimension (α = 0.86) and two subscales (psychological aggression α = 0.81 and corporal punishment α = 0.82) was excellent. Furthermore, internal consistency alphas for corporal punishment by father (α = 0.70) and by mother (α = 0.74) were tolerable, as was the reliability of psychological aggression by father and (α = 0.77) by mother (α = 0.66) scales.

2.3. Procedure

This study was conducted in accordance with relevant international (American Psychological Association) and national (Código Deontológico del Psicólogo) ethics guidelines. The selection of the adolescent sample was performed using cluster sampling in secondary schools in the Basque Country. Eight schools participated after they had confirmed their availability and the willingness of their staff to take part in the research. Before collecting the data, head teachers were given detailed information about the objectives of the research in a one-hour presentation. A letter describing the study was sent to parents requesting that they indicate in writing whether or not they agreed to have their children participate in the research project. Participants were given guarantees of confidentiality and anonymity regarding their responses. In the classroom, the instructions for each questionnaire were read aloud before the students completed them. The questionnaires were administered during normal class time in one-hour sessions. Data collection was conducted during 2011, and administration time for the instruments was approximately 45 minutes. The order of presentation of the instruments was counterbalanced.

The procedure for collecting parent reports included the submission of an information sheet and evaluation protocol with an identification code linking them to their children. Once parents agreed to participate, they had to submit the completed questionnaire to the child’s tutor or by post within one week.

2.4. Data Analysis

Univariate data analysis was conducted using IBM SPSS Statistics version 23 (IBM Corporation, Bilbao, Spain). First, two variables on violence toward parents (physical and psychological violence) were dichotomized in terms of the response format (0 = Never, 1 = Hardly ever, 2 = Sometimes, 3 = Frequently, 4 = Almost always), with participants who chose option 1 or higher being considered as exercising or having exercised some form of violence towards their parents in the previous year. These dichotomous variables were used only to calculate the prevalence of two types of child-to-parent violence. Data analyses on the consistency of parent reports and child reports are presented in Table 1 . These data analyses were done with 161 pairs of parents (161 fathers and 161 mothers) and their children. Family environment variables were analyzed by applying the paired sample t -test; in parent reports, the average of the father reports and the mother reports was calculated. The Wilcoxon test was applied to family environment, and differences were significant for family conflict ( z = 2.75, p = 0.006) as well as for family cohesion ( z = 3.05, p = 0.002). The results were not different from the t -test results. Differences between the prevalence of child-to-parent violence according to the sex of the children based on adolescent and parent reports were calculated. In order to examine whether victimization changes depending on parent sex, the perpetration rates of CPV toward fathers and toward mothers were calculated, taking into account adolescent reports and parent reports. The prevalence rates for corporal punishment by parents and psychological aggression by parents were computed, as well as the means comparisons depending on the parent’s sex and children’s sex.

Prevalence rates of different types of child-to-parent violence (CPV) and family environment perception by informant.

Note: Zero tolerance criteria (when the response “Hardly ever” or more in terms of frequency was given in response to any item) was used to measure child-to-parent violence; * p < 0.05; ** p < 0.001. a Effect size was evaluated by Cramer’s V for chi-square analysis while Cohen’s d was calculated for t -test analysis.

In order to analyze associations between adolescent–parent discrepancies in reports of family conflict and family cohesion, the patterns of informant discrepancies were analyzed. In terms of family conflict, when an adolescent report > parent report, it was considered a negative adolescent report, which was also the case for family cohesion when the adolescent report < parent report. Dichotomous variables (negative report (NR) versus non-negative report (NNR)) for family conflict and cohesion, respectively, were thus created. Means comparisons of child-to-parent violence and interest in studies according to adolescent reports were subsequently explored as a function of informant discrepancies.

Cramer’s V was calculated as a measurement of effect size for the chi-square test of independence. A small effect was reflected by values around 0.10, a medium effect by values around 0.30, and a large effect above 0.50. In order to study the differences in the means of family environment perception and frequency of child-to-parent violence, the Student’s t -test was applied with Cohen’s d for effect size.

Next, a correlation matrix was determined (see Table 2 ), in which ten quantitative variables were included. Finally, multiple regression analyses were carried out, entering family conflict and aggressive family discipline as independent variables, and female sex, children, and age as control variables with CPV (adolescent reports, mother reports, and father reports) as dependent variables (see Table 3 ).

Correlation matrix of family variables studied.

* p < 0.05; ** p < 0.0l; *** p < 0.001.

Multiple regression models for child-to-parent violence depending on informant.

3.1. Prevalence Rates of Child-to-Parent and Family Environment Perception

Table 1 shows prevalence rates of CPV and family environment averages by informant (adolescent or parent). The prevalence rate of child-to-parent violence found in adolescent reports was higher than in parent reports for psychological violence against the father (81% versus 76, χ 2 (1, N = 168) = 4.85, p = 0.03, Cramer’s V = 0.17), while in the other types of child-to-parent violence the differences were not significant. Adolescents reported significantly higher scores in family conflict ( M = 3.03) than their parents ( M = 2.57), t (134) = 3.10, p = 0.002, d = 0.35, 95% CI (0.75, 0.17), and lower scores in family cohesion ( M = 7.00) than their parents ( M = 7.58), t (160) = 3.82, p < 0.001, d = 0.35, 95% CI (0.28, 0.88).

On the one hand, the differences between males and females as perpetrators of child-to-parent violence were analyzed. When adolescents were the informants, daughters were psychologically slightly more abusive toward their mothers (88%) than were sons (81%), χ2(1, N = 548) = 5.70, p = 0.017, Cramer’s V = 0.10. Taking into account means comparisons, daughters were psychologically slightly more abusive toward their mothers ( M = 0.79) and fathers ( M = 0.67) than were sons ( M = 0.53 and M = 0.51), t (546) = 5.31, p < 0.001, d = 0.28, 95% CI (0.35, 0.16); t (508) = 3.14, p = 0.002, d = 0.46, 95% CI (0.26, 0.06). On the other hand, we also analyzed the differences between fathers and mothers as victims of child-to-parent violence. With respect to adolescent reports, the perpetration of psychological child-to-parent violence toward mothers (84%) was slightly more frequent than toward fathers (81%), χ2(1, N = 518) = 209.22, p < 0.001, Cramer’s V = 0.64. According to parent reports, the prevalence rate of psychological violence toward mothers (82%) was also higher than toward fathers (76%), χ2(1, N = 155) = 64.40, p < 0.001, Cramer’s V = 0.67. In means comparison, mother victimization ( M = 0.64) was more frequent than father victimization ( M = 0.59) for psychological violence, t (518) = 2.46, p = 0.014, d = 0.10, 95% CI (0.09, 0.01). When parents were the informants, the difference was almost significant, p = 0.059. Moreover, according to means comparisons of family environment measures, girls perceived a greater level of family conflict ( M = 3.26) than boys ( M = 2.69), t (568) = 3.76, p < 0.001, d = 0.31, 95% CI (0.86, 0.27), while fathers perceived ( M = 2.63) a greater level of family conflict than mothers ( M = 2.45), t (146) = 2.09, p = 0.038, d = 0.18, 95% CI (0.34, 0.01).

3.2. Relation between Child-to-Parent Violence and Other Family Variables

Aggressive family discipline was among the family variables studied. The prevalence rate for corporal punishment was 44% and 89% for psychological aggression by parents. Psychological aggressive discipline by the mother ( M = 0.93) was more frequent than by father ( M = 0.86), t (519) = 2.38, p = 0.018, d = 0.10, 95% CI (0.01, 0.14). Moreover, aggressive discipline by the mother was directed more frequently at daughters ( M = 1.02) than sons ( M = 0.86), t (549) = 2.25, p = 0.025, d = 0.19, 95% CI (0.30, 0.02).

To examine these relationships and influences, correlations between the family variables of the study were computed (see Table 2 ). The first three columns of correlations show that the CPV of different informants was related to aggressive family discipline (corporal punishment and psychological aggression) according to adolescent reports. It is evident that children’s perception of family conflict was related positively to aggressive family discipline. Moreover, the mother’s perception of family conflict was associated with aggressive family discipline by the mother.

3.3. Child-to-Parent Violence Models

Table 3 shows the results of the multiple regression analysis testing the hypothesis that family conflict perception and aggressive family discipline are related to CPV. Three independent variables turned out to be significant predictors of CPV according to adolescent reports: corporal punishment by the father ( β = 0.309, p < 0.001), family conflict ( β = 0.245, p < 0.001), and psychological aggression by the mother ( β = 0.214, p < 0.001). However, two variables were significant predictors of CPV according to mother reports: family conflict ( β = 0.331, p < 0.001) and corporal punishment ( β = 0.299, p < 0.001). Finally, Model 3 shows that family conflict ( β = 0.303, p < 0.001) and psychological aggression ( β = 0.218, p < 0.01) were significant predictors of CPV according to father reports.

Child-to-parent violence was higher in the negative report group (NR) of family conflict ( M = 0.47) than the non-negative report group (NNR) ( M = 0.22), t (73.02) = 3.70, p < 0.001, d = 0.68, 95% CI (0.38, 0.11), while interest in studies was lower in the NR group ( M = 2.55) than the NNR group ( M = 3.13), t(132) = 3.82, p < 0.001, d = 0.65, 95% CI (0.28, 0.89). Child-to-parent violence was higher in the NR group of family cohesion ( M = 0.43) than the NNR group ( M = 0.23), t (90.51) = 3.74, p < 0.01, d = 0.56, 95% CI (0.31, 0.08), when interest in studies was lower in the NR group ( M = 2.64) than the NNR group( M = 2.99), t (158) = 2.38, p < 0.05, d = 0.37, 95% CI (0.06, 0.65).

4. Discussion

One objective of this study was to analyze whether the prevalence of child-to-parent violence and perception of family environment changed depending on the sex of the informant (parent or child) in a community population. As was expected, adolescent reports indicated higher prevalence rates of psychological CPV among daughters than sons, but no difference was found in physical aggression between sons and daughters. There are hardly any studies based on parent reports, but Calvete et al. [ 5 ] found that the prevalence rate in physical CPV of sons was higher than the prevalence rate of daughters, although the effect size was small ( V Cramer = 0.16). These results are consistent with previous studies based on non-clinical populations and adolescent reports [ 3 , 4 , 6 ]. Gallagher [ 52 ] found that the survey data’s overall gender symmetry for CPV contrasted markedly with the almost three-to-one gender imbalance in studies with clinical, medical, police, and court data. Curiously, this pattern of results is similar to that identified in the intimate partner violence literature: gender symmetry in community samples and gender asymmetry in legal samples [ 53 ]. An important reason why the results from community-based surveys are different from those based on medical attendance, police or court files could be the severity of the physical abuse involved.

Moreover, in this study, the target gender was examined for physical and psychological CPV as a function of the informant (adolescents and parents) with three categories (CPV toward mother only, CPV toward father only, and CPV toward both parents). A notable finding was that 77% of children direct psychological violence toward both parents. However, as was found in similar studies with a community population [ 19 , 25 ], there was no difference in the victimization of fathers or mothers. Although most studies on this family problem (based on the evidence from clinical and legal fields) unequivocally agree that mothers are more likely to be victims of abuse by their adolescent children [ 8 , 9 ], some studies focusing on serious CPV (e.g., parricide) have found that fathers are more likely to be victims of CPV than mothers (e.g., [ 54 ]). It would be interesting to discover whether the different findings regarding target gender are due to the severity of CPV or to different ways of measuring CPV. In any case, future research should consider gender-sensitive designs with reliable measures of two dimensions (i.e., frequency and severity) [ 9 ].

It was hypothesized that the prevalence rate of CPV in adolescent reports would be higher than in parent reports, but this hypothesis was only confirmed for psychological child-to-father violence. Moreover, as expected, family conflict scores in adolescent reports were higher than parent report scores, while the family cohesion scores of adolescent reports were lower than parent report scores. There were hardly any differences between adolescent reports and parent reports for CPV. However, the results of the present study indicated that parents underestimated the level of family conflict, perhaps due to the shame and blame their feelings of a negative family environment have on their own poor parenting practices. The perception of family environment varied by sex of the adolescent, with daughters indicating higher levels of family conflict and lower levels of family cohesion compared to sons. These findings are consistent with those of other studies [ 55 , 56 ]. According to Nelson et al. [ 56 ], perceived family characteristics differed by gender; female participants reported higher levels of family conflict and parental monitoring, as well as lower levels of family social support. Female adolescents may experience an increased tendency towards interpersonal connectedness and concern for the well-being of others [ 55 ], which may cause them to be more sensitive when observing family processes [ 52 ]. Additionally, it has been found that the perceived family environment in which adolescents are raised plays an important role in their adoption of health risk behaviors (e.g., increased risk for substance use disorders), this being particularly true for female adolescents with respect to family conflict and family social support [ 55 , 57 ]. Divergence between adolescent reports and parent reports on family relationships were analyzed. Negative reports of adolescents with respect to family conflict and family cohesion were associated with more child-to-parent violence, and less interest in studies. Measuring the distance between adolescent and parent reports of family relationships could help predict adolescent adjustment, but it is important to take into account the direction of adolescent–parent discrepancies. Particularly, when adolescents’ perceptions are more negative than parents’ perceptions, they appear to be relevant to adolescent functioning [ 13 ]. It is an emerging research field, and recent work supports the hypothesis that divergence between reports may not always predict negative adolescent outcomes [ 12 ].

In the present study, the corporal punishment prevalence rate was 44%, while for psychological aggression it was 89%. Aggressive discipline by parents may evoke feelings of fear, anxiety, and anger in children, and these emotions could interfere with a positive parent–child relationship, as was found in previous studies of corporal punishment [ 58 ]. In fact, aggressive family discipline was a valid predictor of children’s family conflict perceptions. The regression model of child-to-parent violence based on family conflict and aggressive family discipline based on adolescent reports explained 38% of the variance. It is an excellent and parsimonious statistical model. The results of the present study corroborated the relevance of aggressive family discipline and family conflict as risk factors for child-to-parent violence. Numerous studies had previously indicated that aggressive family discipline and family conflict are valid predictors of child-to-parent violence [ 3 , 4 , 35 , 36 ]. A longitudinal study with a national survey of male adolescents [ 31 ] analyzed whether child aggression represents a functional response to family strain, with results indicating a reciprocal relationship between parent-to-child violence and CPV, characterized by countervailing effects. Aggression by the adolescent may prove to be a partially successful means of combating family strain or negative intervention. Child-to-parent violence is, thus, not necessarily a form of pathology because it could be a survival response by children when their well-being is threatened [ 14 ].

The main limitation of this research is that it is a cross-sectional study. Cross-sectional data make it difficult to identify exactly how aggressive family discipline influences child-to-parent violence over time. It would be preferable to conduct longitudinal studies in clinical contexts. Aggressive family discipline was only measured through adolescent reports. The internal consistency of family environment subscales is lower than desirable (α ≥ 0.70) because this scale has positive and reversed items. When combinations of positive and reversed items are used in the same test, the reliability of the test is flawed [ 59 ]. However, it should be noted that father reports of physical CPV was low. A high proportion of missing data in father reports and mother reports was found, although missing data are frequent in studies based on multiple informant data. The fact that parents in the study represent a volunteer sample means that those parents who are most violent to their children were unlikely to participate. Such a skewed sample is, thus, likely to have had an impact on results. As sons and daughters were not from the same family, it was not possible to assume that we were analyzing the same family processes. Thus, we cannot be sure that daughters were more sensitive when observing family processes than sons.

Future research should obtain more detailed data on parental and child aggression in the events which occurred, including mild and severe forms of aggression, by using clinical or legal samples. Additionally, it would be interesting to study the directionality of interpersonal violence in child–parent relationships in order to know to what extent CPV is bidirectional or unidirectional violence.

5. Conclusions

In conclusion, there was consistency between adolescent reports and parent reports for CPV, and aggressive family discipline can be considered an important risk factor for child-to-parent violence. Nowadays, CPV is still considered the most hidden, misunderstood, and stigmatized form of family violence, and an early-help approach to stop problems from spiraling is recommended [ 60 ]. In answer to the question “why parents hide their child-to-parent violence situation instead of asking for help”, Concordia Gabinete [ 61 ] suggests five reasons for not requesting help: (1) parents do not really know the extent of the problem they have at home; (2) they are afraid; (3) they are ashamed to talk about the problem; (4) they have had bad experiences with professionals in the past; and (5) they do not want anything bad to happen to their son or daughter. The findings of this study could be applied to multiple disciplines and potentially lead to policy changes. Child and family services should take into account that parents may underestimate the levels of violence toward them and of family conflict, and in the future, it would be interesting to use a multi-informant approach to assess child-to-parent violence or family environment. Additionally, to prevent abusive family relations, including the occurrence of CPV, parents could benefit from training to reduce harsh discipline. However, when teenage and younger girls and boys use physical, psychological, emotional, and financial abuse and violence over time to the extent that parents live in fear of their child, parents need to be empowered to find a way out of such a situation.

Author Contributions

Conceptualization, I.I.; methodology, I.I.; software, I.I.; validation, I.I.; formal analysis, I.I.; investigation, I.I.; resources, I.I.; data curation, I.I.; writing—original draft preparation, I.I.; writing—review and editing, I.I.; visualization, I.I.; supervision, I.I.; project administration, I.I.; funding acquisition, I.I.

This research was funded by Eusko Jaurlaritza/Basque Government, grant number M115/10.

Conflicts of Interest

The author declares no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Creditor-on-Creditor Violence and Secured Debt Dynamics

Secured lenders have recently demanded a new condition in distressed debt restructurings: competing secured lenders must lose priority. We model the implications of this “creditor-on-creditor violence” trend. In our dynamic model, secured lenders enjoy higher priority in default. However, secured lenders take value-destroying actions to boost their own recovery: they sell assets inefficiently early. We show that this creates an ex-ante tradeoff between secured and unsecured debt that matches recent empirical evidence. Introducing the recent creditor-conflict trend in this model endogenously increases secured credit spreads. Importantly, it also increases ex-ante total surplus: restructurings endogenously introduce efficient state-contingent debt reduction.

We have nothing to disclose. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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