Challenging Dogma - Fall 2008

Tuesday, December 16, 2008

Improving Interventions for Domestic Violence: A Community-Based Ethnographic Approach – Rachel Stein

Current Interventions for Domestic Violence

Nearly one third of American women become victims of domestic violence at some point during their lifetimes (1). The true prevalence of domestic violence is likely higher than the percentage reported, as many women are reluctant to admit to being victimized and abused (2). Their reluctance demands an explanation. What is it about how domestic violence is screened that prevents women from disclosing their experiences? Current approaches to screening have multiple limitations, and their weaknesses are evident in three key areas: the setting of the screening, the questions asked, and the recommended interventions for a positive screen. These approaches to domestic violence are deeply rooted in the individualistic notions of western biomedicine, and it is this paradigm that renders these approaches inadequate to address this pervasive public health problem.


Most screening for domestic violence occurs in a clinical setting, usually between a physician and a patient. Doctors are trained to ask questions about domestic violence as part of taking a patient’s social history. As the average time allotted for primary care appointments is fifteen minutes, this screening must elicit the necessary information in the shortest amount of time possible. Moreover, the social history tends to be the last element of a patient’s history that is taken, and many physicians, pressured by their chronically overbooked schedules, are not able to find time to ask these questions. Consequently, only one to fifteen percent of all women are asked about domestic violence by their primary care doctors (3).

When a physician is able to make the time to screen for domestic violence, women may not feel comfortable sharing this intimate aspect of their lives. It has been reported that over 90 percent of women screened for domestic violence feel comfortable answering the questions that clinicians ask them (4). Public health practitioners subscribing to the western biomedical paradigm would find this screening intervention an enormous success. These practitioners, however, may not take into account that most of the women in the sample studied were low-income African American women who were employed and unmarried, as the biomedical paradigm neglects the social factors that contribute to an individual’s health behavior. Given this sociocultural context, it may not be accurate to assume that 90 percent of all women feel comfortable answering screening questions about domestic violence.

Domestic violence transcends race, ethnicity, class, and other sociocultural factors, and women that belong to different subtypes of these categories have different conceptions of and levels of comfort with disclosing information about their intimate relationships. For example, although African American women may confide in their physicians readily, as in the example given above, Orthodox Jewish women may not. Orthodox Jewish culture discourages speaking about private issues and life experiences, including marriage and intimacy, outside of one’s immediate family. In this culture, it is also shameful to admit to having marital problems. An Orthodox Jewish woman is therefore less likely to report domestic violence and to seek help (5).

In addition to considering cultural differentials in privacy, it is important to be aware of how a woman would feel answering questions about domestic violence when her children are with her, which is often the case in a clinical setting. Overall, women are more comfortable answering questions about domestic violence when they are alone than when they are with their children, particularly when the questions refer to feeling unsafe. Latina women tend to be less comfortable disclosing incidences of domestic violence when their children are present than White and Black women. Their higher level of discomfort may be explained the desire to adhere to the “machismo” culture, to be loyal to their families, and to maintain their privacy in front of their children (6).

These findings suggest that the clinical setting may not be the most appropriate place to screen for domestic violence for all women. Practitioners who subscribe to the biomedical approach may not come to this realization, and many women and children may wrongfully be assumed to be safe in their home environments.


Domestic violence screening based on the western biomedical paradigm not only occurs in an inopportune setting but also may ask inappropriate questions. Two screening tools that are recommended in the clinical setting, likely because of their brevity, are the HITS (Hurt-Insult-Threaten-Scream) and the WAST (Woman Abuse Screening Tool). The HITS asks women about the frequency of physical violence, insults, threats, and screaming or cursing in their relationships. The WAST inquires about the amount of tension in a relationship, degree of difficulty in resolving arguments, feelings of self worth, fear, and physical, emotional, and sexual abuse (7). These questions are problematic on multiple levels: the various ways that they can be interpreted, their potential to be considered disrespectful in certain cultures, and their disregard for context.

People of different backgrounds have different understandings of what domestic violence entails and have different expectations for what they will be asked to disclose to a stranger, including to a physician. Latina women, who report greater discomfort than White and Black women when answering questions about domestic violence in the presence of their children, have different conceptions of domestic violence than White and Black women. They perceive it as physical and emotional abuse more than sexual and financial abuse, all of which health care providers define as domestic violence. Latina women also recognize men’s expectations of women to shoulder a greater burden of household work as a form of abuse, while most providers do not (8). The questions asked in the HITS and WAST may therefore be confusing and disconcerting for Latina women because they ask about experiences that these women may not consider domestic violence. The screening questions may imply that certain experiences that Latina women consider normal are pathological and may suggest that certain experiences that these women find problematic are of no concern.

Latina women may also interpret the precise words used in the questions differently from their physicians. For example, the HITS asks how often a woman’s partner curses at her. This use of the word “curse” refers to swearing or using insulting language. In Latino culture, however, “curse” refers to the invocation of evil spirits against another person (9). This question would likely not elicit the information about which a health care provider had intended to inquire.

In addition to understanding cultural differences in conceptions of domestic violence and in interpretations of the screening questions, the structure of and manner of asking these questions is also important and may present a barrier to screening. Modes of communication are highly culturally specific, and disregarding these differences may pose severe problems in addressing domestic violence. This inadequacy is clearly delineated in the experience of American Indian women. The prevalence of domestic violence is higher among American Indian/Alaska Native women than among White, Black, and Asian/Pacific Islander women (10). Screening American Indian women for domestic violence, however, may be more harmful than helpful to them. According to Mescalero Apache culture, it is impolite to ask direct questions because they force an individual to give a forthright and potentially embarrassing answer (11). The HITS and WAST, which are designed to be concise and direct to accommodate the short amount of time allotted for primary care appointments, would be inappropriate and disrespectful to ask to a Mescalero Apache woman and may prevent her from seeking medical care in the future.

The questions asked in the HITS and WAST reflect the western biomedical paradigm in their disregard for cultural differences and decontextualization of domestic violence. It is important for clinicians to be aware that the questions they ask and the manner in which they ask those questions may be interpreted differently by women from various backgrounds. Additionally, the questions do not enable clinicians and patients to understand what the other means by “domestic violence.” These discrepancies limit the ability of domestic violence screening to accurately assess the prevalence of domestic violence and prevent clinicians from helping and empowering women to escape abuse and victimization.


The lack of cultural competency in screening for domestic violence, both in the setting of the screening and in the questions asked, deters women from disclosing their true life experiences. Even if these limitations are overcome and a woman admits to being victimized, a clinician may not be equipped with appropriate resources to help her. Many clinicians do not screen for domestic violence because they would not know what to do if the screen was positive. Furthermore, the interventions that are recommended are directed towards individual women in isolated circumstances, failing to address the context of domestic violence and to approach this issue at the group or societal level.

The United States Preventive Task Force has identified certain criteria to evaluate the effectiveness of a screening tool. A test is required to have a certain degree of accuracy, measured by sensitivity and specificity, and the screening as well as the subsequent action taken must lead to improved outcomes. Regarding the second criteria for follow-up care, unlike a positive screening for cervical cancer, which is followed by a standard protocol consisting of repeat pap smears and possibly a colposcopy, the follow-up for a positive screening for domestic violence is an intimidating enigma for many physicians (12). In response to this uncertainty, a group of clinicians in California developed the AVDR – Asking, Validation, Documentation, and Referring – model for physicians to follow when confronted with a case of domestic violence. In the first step, physicians are encouraged to ask women about safety in general and specifically in their relationships. If they disclose that they are not safe, the model then suggests that the physician state clearly that abuse is not acceptable, express concern for the patient, and explain to her that she is not to blame. In the third step, a clinician is to document signs and symptoms of abuse and record the patient’s story. Finally, the model provides physicians with a list of resources where they may refer a patient, including local agencies, hotlines, and shelters, and suggests that they create a plan to follow up with her (13).

Although the AVDR model demonstrates compassion and encourages a doctor-patient relationship based on support and trust, it fails to contextualize domestic violence. Women do not exist in a vacuum, and without taking into account sociocultural determinants of behavior, physicians cannot fully understand why a woman would not disclose being victimized or would not leave an abusive relationship. The model does not suggest that providers inquire about cultural worldviews or social policies that may unintentionally permit domestic violence, such as the emphasis of gender role separation in Orthodox Jewish culture (14). The AVDR model also holds individual women responsible for taking action, while in many cultures, change at a group or societal level would be more beneficial. The biomedical approach to societal problems views society as “individuals en masse” rather than as a whole being, and this conception is not effective “when the target [domestic violence] is a social entity with its own laws and dynamics” (15).

The current approach to screening for domestic violence is inadequate in its setting, in the content and manner of the questions asked, and in the recommended interventions for a positive screen, as is evident by the reluctance of many women to disclose this information even when their own and their children’s well-being are at risk. The limitations of this screening are rooted in its foundation in the western biomedical paradigm, which neglects the sociocultural determinants of behavior and which approaches behavior change at the individual level rather than at the group or societal level. Only by considering these crucial factors and by confronting domestic violence at these multiple levels can effective screening tools and interventions be designed to empower women to ensure the safety of themselves and their children.

An Alternative Intervention for Domestic Violence

Given the limitations of current approaches to domestic violence based on the western biomedical paradigm, alternative screening interventions founded upon theories of the social sciences may be more effective. These interventions would directly address the context of domestic violence and would approach this issue at the individual and group levels. In doing so, they would construct comfortable settings for screening, develop appropriate screening questions, and recommend proper interventions.


Screening for domestic violence in a medical setting is often not conducive to eliciting disclosures of domestic violence. To locate more appropriate settings for screening women, it may be helpful for public health practitioners to conduct field work in the targeted communities, as recommended by the Cultural Theory. This theory emphasizes the influence of society and culture on human behavior, and fieldwork is one method of data collection that enables investigators to discover the social and cultural nuances of specific communities.

By immersing themselves in the community, observing people and events, and interviewing community members, public health practitioners may find that rather than screening women in primary care clinics and health centers, screening women in settings where they spend time on a regular basis and where they feel most comfortable may be more effective. Screening could take place in schools, community centers, and religious institutions. In Early Intervention programs, which seek to help children at risk for developmental, emotional, social, behavioral, and school problems, ongoing service coordinators meet regularly with the children’s caretakers in their homes and at the children’s day care centers to ensure that they are receiving the services that they need (16,17). Head Start programs, which help prepare low-income pre-school children for school and provide social services to their families, have a similar design. Each family is assigned a family case manager, who supports families with issues of employment, housing, immigration, health care, education, finances, and family communication and relations. Family case managers meet with the children’s caretakers regularly at the Head Start sites (18). Screening for domestic violence in Early Intervention sites, Head Start preschools, and other locations where women regularly spend time would not place a great burden on them in terms of travel, and these locations are familiar places where women may feel more at ease.

Screening interventions for domestic violence may also benefit from modeling the Early Intervention and Head Start programs’ employment of community members as ongoing service coordinators and family case managers. One third of Head Start staff members were initially involved as parents of children in Head Start programs (19), which places them in a unique position to help other parents in their communities. Women may feel more comfortable sharing personal information with their peers than with their doctors. There are also cultural differences in notions of privacy that impose barriers to the disclosure of domestic violence. While African American women may feel more comfortable sharing intimate aspects of their lives with their physicians (20), Orthodox Jewish women may not. The pressure that the Orthodox Jewish community places on avoiding a shanda, a shame that brings disgrace to all Jews by revealing the imperfections of the community, discourages women from disclosing incidences of domestic violence to their health care providers. Providing these women with peer counselors and advocates may empower them to speak freely about the more intimate aspects of their lives without causing a shanda (21). Domestic violence screening conducted in settings such as Early Intervention and Head Start sites and implemented by service coordinators and case managers who are members of the target community would thus likely improve the accuracy of the screening and ensure that women who are victims of domestic violence are receiving the services that they need.


The ethnographic focus of the Cultural Theory could also be used to design more culturally appropriate and respectful domestic violence screening questions. Conducting fieldwork among the Mescalero Apache has taught anthropologists that members of this community find direct inquiries disrespectful and discourteous because they force the individuals being questioned to reveal personal information that they may not feel comfortable sharing (22). Asking less direct and more open-ended questions may not only help women feel more at ease but also elicit more complete and helpful responses. These types of questions are those for which physicians strive yet often fail to ask due to time constraints, but they are questions that anthropologists are experts in asking. They directly address social context and past experiences, and they enable domestic violence screening to unravel a woman’s true story.

Pediatricians, child psychiatrists, and early childhood experts have suggested taking a similar ethnographic approach to parenting. They encourage parents to reflect back on their own childhoods, as unresolved fears and experiences from the past may compromise their relationships with their children (23). The questions they recommend that parents ask themselves and that pediatricians address inquire about their most vivid memories, their relationships with their parents, how they felt when they were separated from their parents, how they were disciplined, their experiences of trauma and loss, their meaningful relationships with people other than their parents, and how they see their own childhoods influencing how they interact with their children (24).

Applying this model to domestic violence, screening questions could be designed to provide greater context of women’s past and current situations. These questions would be asked in a sequence from least to most intrusive, allowing women to feel more comfortable with and to begin to trust their peers, service coordinators, or case managers implementing the screening. First, women may be asked whether they feel safe in their current relationships, and, as the Cultural Theory would recommend, what they mean by “safe.” Subsequent questions may ask women whether they experienced domestic violence as a child, whether they know others who are or were in abusive relationships (although perhaps using a more mild term), how they feel that their relationships with their partners affect their children, and other open-ended questions. Such questions would promote a strong relationship between women and their peers conducting the screening, and the stories that these questions elicit will enable their peers to connect them to appropriate and effective resources.


Many physicians do not screen for domestic violence because they would not know what to do if confronted with a positive result. Additionally, the resources that they are able to offer women are often limited. Problem Solving Education (PSE) is an alternative intervention, currently used to treat depression, that addresses many of the inadequacies of current interventions. PSE draws from both the Cultural Theory and Maslow’s Hierarchy of Needs and can be effectively implemented by peer counselors in informal settings.

PSE consists of seven steps that an individual and counselor work through together to help that individual overcome the daily challenges contributing to his or her depressed mood. These steps include defining the problem, setting realistic and tangible goals for problem resolution, brainstorming multiple solutions to achieve those goals, creating guidelines for decision-making, using those guidelines to evaluate potential solutions, enacting the solution chosen, and evaluating the outcome. PSE is conducted over four to six 30-minute sessions, and individuals and their counselors focus on a different problem or challenge during each session. Reflecting principles of Maslow’s Hierarchy of Needs, these problems must be simple, specific, and describable in objective terms, such that lower order needs are met before higher order needs are addressed (25). PSE has been shown to be successful in treating depression in the primary care setting (26) and is currently being evaluated as an intervention for depression among mothers with infants in neonatal intensive care units (I acquired most of the information about PSE discussed in this paper through my experience working with the pediatrician conducting this clinical trial). Applying this model to interventions for domestic violence, women and their peer counselors, or problem solving educators, could take small steps to ultimately work towards the goal of leaving an abusive relationship.

As suggested by the Cultural Theory, culture is a crucial factor motivating behavior change, and in designing PSE as an intervention for domestic violence, it is important to take culture into account. Problem solving educators would ideally be members of their clients’ communities. They may be familiar with the challenges that these women face, be well-informed about available resources, and be able to help these women devise creative and culturally acceptable solutions to their problems. Problem solving educators from the women’s communities would also be able to meet them in accessible and familiar places. Furthermore, because PSE requires only a few hours to complete, service coordinators and case managers from Early Intervention, Head Start, and similar programs could serve as problem solving educators and, after having screened women for domestic violence, could integrate PSE into their existing counseling sessions.

To improve upon the inadequacies of current domestic violence screening and interventions, which are rooted in the individualistic principles of western biomedical theory, public health practitioners may employ social science theories to design more culturally acceptable and effective interventions. These alternative interventions would be implemented in appropriate and comfortable settings for women, would ask culturally sensitive and open-ended questions based on ethnographic techniques, and would promote a community-based team approach to overcoming the daily challenges that women face. These interventions would address the larger context underlying cases of domestic violence and would approach the issue at both the individual and group levels. In doing so, these alternative interventions would be able to more accurately screen women for domestic violence and more successfully meet the needs of women who screen positively.


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