In her study of Hispanic victims of intimate partner abuse in the U.S.-Mexico border city of Brownsville, Texas, nurse researcher Nora Montalvo-Liendo, PhD, RN, wanted to learn about the factors influencing the women’s decisions to disclose the abuse and seek help.
She will never forget the story of one mother, who had denied the abuse when questioned by her doctor. Yet years later, sitting in the interview for the study, the woman handed Montalvo-Liendo a business card for a battered women’s shelter, given to her at a health care clinic. The dog-eared card was smudged and wrinkled and looked ready for the trash.
But for the woman, that 2-by-3½-inch piece of paper symbolized a lifeline. She secretly hung on to it for two years before she finally called the number and got herself and her children out of their horrendous living situation. Today the woman keeps the card as a reminder, and Montalvo-Liendo, an assistant professor in the associate degree nursing program at the University of Texas at Brownsville, remembers it as a testament to the impact health care providers, including nurses, can make on patients who are victims of intimate partner violence (IPV), even if they don’t see the effects of that impact immediately.
According to a 2008 report by the Centers for Disease Control and Prevention (CDC), 1,510 people in the United States died at the hands of a spouse or other intimate partner in 2005 and 2 million women suffered injuries from IPV. Besides the immediate physical injuries sustained by victims, IPV can lead to depression, hypertension, eating disorders, substance abuse and other long-term health problems. The estimated annual cost of IPV—including medical care, mental health services and lost productivity—is more than $8.3 billion. And that figure doesn’t take into account the toll on children who witness the abuse.
"It’s not just a personal issue. It’s a real health issue," says Phyllis Sharps, PhD, RN, FAAN, professor and chair of the Department of Community Public Health at Johns Hopkins University School of Nursing. "The [problem] is multifaceted and cuts across all elements of society."
Almost one out of every four women has experienced intimate partner violence sometime during her life. The CDC’s definition of IPV includes four types of abusive behaviors:
Although intimate partner violence can affect women of all races, ethnicities and socioeconomic backgrounds, minority women experience IPV at disproportionately high rates. Consider these statistics compiled by the Women of Color Network, a national grassroots advocacy initiative responding to violence against minority women and families:
Nurses can play an important role in addressing these disparities, both alone and in collaboration with other health care providers, social services agencies, community organizations, police officers, attorneys, legislators and educators. And minority nurses in particular can bring cultural knowledge, linguistic competence, sensitivity and passion to the task of creating IPV interventions in communities of color.
Intimate partner violence is often shrouded in secrecy and shame, so Montalvo-Liendo wanted to learn more about what encourages Hispanic women to disclose abuse and what prevents them from doing so. As part of her qualitative study, she interviewed 26 women served by a shelter and an outreach agency for battered and sexually assaulted women in Brownsville. Nineteen were Mexican immigrants,
12 of whom disclosed that they were in the United States illegally, and seven were U.S.-born women of Mexican descent.
Among the most disturbing findings: Most of the women—17 of the 26—reported that they were never asked about the abuse in their interactions with the health care system. "In my opinion, for that many women to not be asked by a health care provider is not acceptable," Montalvo-Liendo says.
As for the nine women who did have nurses or doctors ask them about possible abuse, none were willing to admit it. And in many cases, other women in the study shied away from even telling neighbors or friends. Why were they so determined to keep the abuse a secret? The answer, Montalvo-Liendo explains, is that the women were afraid their partners, their partners’ families, the legal system or immigration officials would take their children away from them.
"When it came down to the main reason [for not disclosing], it was to keep the family together," she says.
How can nurses break down these barriers of secrecy and fear? Montalvo-Liendo’s study found that women were more likely to disclose abuse to friends, co-workers or neighbors who asked general questions sensitively and without judgment. Questions such as "Why do you stay?" or "Why don’t you leave him?" aren’t helpful, says Montalvo-Liendo, who recently presented her findings at the 2009 International Nursing Research Conference in Spain.
Nurses also need to be aware that different women may have different perceptions of what constitutes abuse. One woman in the study said she hadn’t thought she was "abused." Her reasoning: "I was only thrown out of a car. He never hit me."
There is a great need for more nurse-led research to identify other factors influencing minority women’s disclosure of intimate partner abuse. In the meantime, Montalvo-Liendo says nurses should keep in mind the fears women harbor of losing their kids. "We need to assure them that there is help for them and their children."
And nurses shouldn’t get discouraged if women don’t disclose right away, she adds. Like the woman who kept the battered women’s shelter card for two years, they may absorb the information to use later. "More than anything, by asking you have shown an interest in the safety and well-being of that woman, not just on the physical level but on the emotional level," Montalvo-Liendo emphasizes.
Many resources are available to help nurses and health care organizations develop culturally appropriate IPV prevention, screening and intervention programs (see "Online Resources" sidebar). For example, the CDC’s 2007 monograph Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC’s Demonstration Projects showcases eight successful model programs, targeted to specific minority populations, that nurses can adapt to meet the needs of the communities they serve.
In the 1980s, Jacquelyn Campbell, PhD, RN, FAAN, a professor at Johns Hopkins University School of Nursing and a nationally recognized leader in IPV research and advocacy, developed the Danger Assessment (DA), a widely used screening tool that assesses the severity and frequency of abuse as well as the risk for intimate partner homicide. The DA’s effectiveness has been validated across a broad spectrum of racial and ethnic groups, she says, and it can be tailored slightly to women’s individual needs.
For instance, recent immigrants may need to be reassured that reporting abuse will not affect their immigration status. In fact, non-citizen IPV victims who are married to or recently divorced from U.S. citizens or legal residents can self-petition for permanent resident status without the help or knowledge of their abusive spouses.
Examples like this demonstrate why cultural sensitivity is so important, Campbell says. "On the one hand, you need to strive to make [IPV] interventions culturally appropriate. Nurses need to find out as much as they can about patients they serve." But on the other hand, she adds, "you [can’t expect to] be culturally competent in every culture."
In other words, nurses shouldn’t shy away from addressing the issue just because they are not immersed in the culture of their patient. They can still intervene, using the appropriate screening tools and their knowledge of community resources to refer patients for help.
Nurses can also tap into the expertise of groups like the Women of Color Network that are addressing IPV in minority populations at the community level. Sacred Circle, for instance, is an advocacy organization that provides training, develops policy and provides technical assistance for ending IPV and sexual assault in American Indian/Alaska Native communities.
Sharps believes being sensitive to cultural differences involves more than just issues of race and ethnicity. For instance, a woman living in a small town rather than a large urban area might be hesitant to report abuse because she’s likely to be acquainted with the responding police officer or a staff member at the local social services agency.
Establishing rapport and trust with patients who are in abusive relationships is essential, too. Nurses need to project a non-judgmental attitude when discussing intervention options.
"We become culturally relevant when we start [at the same emotional place] where the woman is," Sharps says. "We should never, ever start with, ‘What is your plan for leaving?’ We should start with, ‘How can we help you be safe?’"
Sharps has focused most of her research on how IPV affects the health of pregnant women, infants and very young children. She became interested in the topic when she was a labor and delivery nurse who was troubled by the high rate of infant mortality among African Americans. The number of African American babies who die before they reach their first birthday is two to three times higher than the national average, she says. In fact, the infant death rate for white mothers with only a high school education is lower than for black women with college degrees.
"I realized that how healthy a baby is at the time of delivery had a lot more to do with the nine months it lives [in utero] in the community than with [the labor and delivery care the mother receives]," Sharps says. "[The disparity in infant mortality rates] is a very complicated picture for African Americans. Unfortunately, intimate partner violence is part of the [problem], along with other risk factors, such as disparities in access to health care."
Sharps is currently testing the effectiveness of an intervention called the Domestic Violence Enhanced Visitation Program (DOVE), in which specially trained nurses visit new and expecting mothers at risk for IPV and teach them how to keep themselves and their babies safe. The nurses provide information about breaking the cycle of IPV, risk factors that increase a woman’s danger of being killed by an abusive partner, options for leaving the abuser and safety planning, including phone numbers of local support services. The program is funded by a $3.5 million grant from the National Institutes of Health and will be tested in Baltimore, Kansas City and rural Missouri.
The DOVE project grew out of an earlier program Sharps developed called Passport to Health, which used the nurse home visitation model to help minority women transition from battered women’s shelters to healthy living situations. Of the nine women in that program, seven were able to re-establish their lives without further abuse.
"The best home visitors are nurses [rather than social services workers], because their professional training and background gives them the ability to look holistically at the situation," Sharps says.
Still other minority nurse researchers are investigating IPV prevention strategies targeted to other vulnerable populations, such as younger women of color, children, and even men who are at high risk of abusing their female partners.
Angela Frederick Amar, PhD, APRN, BC, an assistant professor at Boston College’s William F. Connell School of Nursing, has conducted a variety of studies focusing on dating violence among college-aged women from diverse racial and ethnic backgrounds. The research, she says, is like slowly turning a kaleidoscope. Each study provides one more view into a complex and changing picture.
According to Amar, girls and young women ages 16 to 24 are at the greatest risk for sexual assault and IPV, and those who experience violence are more likely to suffer from depression and other mental health disorders.
Young women living on college campuses are at greater risk for dating violence than their off-campus counterparts, Amar says. The high rate of alcohol consumption among college students is often a factor, as are some young people’s attitudes about sexual consent. Commenting on whether he would ask a woman for permission to have sex, one young man told Amar: "Of course I’m not going to ask, because she’ll say no."
In her current research as a Robert Wood Johnson Foundation Nurse Faculty Scholar, Amar is exploring the factors that encourage young women on college campuses to report gender-based violence. She hopes to use the results to guide development of campus IPV prevention programs.
Not surprisingly, most IPV interventions focus on the women who are victims of partner abuse, rather than the men who commit it. But there is also a need for more research to establish screening assessments and interventions for abusers, says Christina Cardenas Wei, PhD, RN. Wei conducted a qualitative study of seven Hispanic and non-Hispanic men who were taking part in a batterers’ intervention program in San Antonio, where she recently completed her doctorate at the University of Texas Health Science Center.
Nursing literature makes a correlation between substance abuse and IPV, but Wei found other underlying problems among the men, such as depression and post-traumatic stress disorder. Five of the men reported experiencing trauma or violence in childhood, including parental abandonment.
"I would like to see this work continue and to do [more] research to develop interventions with men," Wei says, noting that there is no standard screening tool for men who use violence in their intimate relationships.
The most vulnerable and innocent victims of IPV are, of course, children. From the one sample of 26 women Montalvo-Liendo interviewed in her study in Brownsville, 73 children were exposed to domestic violence. Children who witness IPV are likely to continue the cycle as adults or internalize what they’ve seen, unless they get help. While some middle schools have developed programs to help students address the issue of unhealthy relationships, Montalvo-Liendo says, "I feel very strongly that we need to get [this information] into the elementary schools."
The Centers for Disease Control and Prevention (CDC)’s Intimate Partner Violence site, www.cdc.gov/Features/IntimatePartnerViolence, offers many resources for developing IPV interventions, including assessment tools and a database of evidence-based prevention strategies.
Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC’s Demonstration Projects can be downloaded free of charge at www.cdc.gov/ncipc/dvp/PreventingIntimatePartnerViolence.htm.
Online training in using the Danger Assessment is available at www.dangerassessment.org.
The Women of Color Network, http://womenofcolornetwork.org, offers fact sheets on IPV issues affecting communities of color and provides leadership training, cultural competency training and technical assistance for individuals and organizations working to end violence against minority women.
The U.S. Department of Justice’s Office on Violence Against Women (OVW), www.ovw.usdoj.gov, has many violence prevention grant funding programs, including grants for tribal governments, faith-based and community organizations, and projects that provide culturally and linguistically specific services for victims of IPV.
The Department of Health and Human Services, Office on Women’s Health (OWH), www.womenshealth.gov/violence/programs/index.cfm, offers IPV prevention resources for women in English and Spanish, including information on safety planning, obtaining a court order of protection and how to help a friend who is being abused.
Sacred Circle is a national resource center for ending violence against American Indian and Alaska Native women.
The Family Violence Prevention Fund, www.fvpf.org, provides a wealth of free resources for health care professionals and patients, including culturally sensitive patient education materials targeted to Native Americans, Asian Americans and other minority populations.
The National Asian Women’s Health Organization has developed "Breaking the Silence: Preventing Violence Against Asian American Women," a free three-module curriculum designed to educate college-aged Asian women about IPV and dating violence. It can be downloaded from www.nawho.org (click on "Issues," then "Violence Prevention").
The Asian & Pacific Islander Institute on Domestic Violence, www.apiahf.org/apidvinstitute, is a national resource center and clearinghouse on gender violence in Asian American, Native Hawaiian and Pacific Islander communities.
The Nursing Network on Violence Against Women, International (www.nnvawi.org) encourages the development of nursing practice that focuses on health issues relating to the effects of violence on women’s lives.