The Policy Implications of Stigma in Relation to Mental Illness - Tim Washburn

Approximately twenty-six percent of Americans age eighteen and older suffer from a diagnosable mental disorder in any given year. When extrapolated to the census data this means we have approximately fifty seven million people with mental disorders in this country (1). The current treatment of those with mental illness tends to be contrary to public health methods. Public health is defined as the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals (2). Our current health care system tends to medicalize mental illness by treating the symptoms with a reactionary approach rather than a preventative approach. In the words of Michael F. Hogan, Ph.D., Chairman of the New Freedom Commission on Mental Health, “Too often, today's system simply manages symptoms and accepts long-term disability (3).”
The stigma toward mental health in this country lies beneath the framework of mental health care. Stigma is a barrier to care and an influencing factor in public opinion and policy making. This paper criticizes the approach taken to mental health care and examines the role that stigma plays in resource allocation, media influence and the role of public health professionals. Stigma is defined as an attribute, behavior, or reputation that is socially discrediting in a particular way (4). When defined by mental health experts the definition becomes, “the negative effects of a label placed on any group including those who have been diagnosed as having mental health problems (5).” Stigma results in people distancing themselves from the mentally ill by avoiding living, socializing, or working with the identified person. Stigma deprives people of their dignity leading to low self-esteem, isolation, and hopelessness as well as deterring those with mental illness from seeking care to avoid being labeled as mentally ill.
A Segregated History of Mental Health
The field of mental health has been segregated from the rest of healthcare for a number of reasons starting with the work of Rene Descartes in the seventeenth century. Descartes viewed the mind as completely separate from the body. The mind was seen to be the business of organized religion where the body was the concern of physicians. This definition ushered in the separation of mental health and physical health that persists today (6). The separation has been exacerbated by the advances in medical technology in health care that led to the cure of two specific mental illnesses. First, tertiary syphilis is an advanced stage of syphilis that occurs when the bacterium invade the brain and causes neurological deterioration, paralysis, and death. When it was discovered that penicillin would cure this illness the medical field was awarded credibility over the mental health field for the treatment (7). Similarly, pellagra was traced to a nutrient deficiency that was treated with nutritional supplementation of niacin eliminating the patient’s delirium (8). These cases gave credibility to the medical field while leaving the unexplainable mental disorders to the mental health field. We know today that mental health and physical health are inseparable and are essentially one in the same yet the stigma of an inferior field of mental health still exists.
Lack of Resource Allocation for Mental Health Care
The idea of an inferior methodology of treatment for mental illness lends itself to the social theory of Skitka and Tetlock. Their theory explains the decision making process of a policy maker when allocating resources outlined below:
(9)
To summarize, policy makers are given limited resources and typically allocate funds based on the need for the program, the effectiveness of the program and the responsibility of the participants regarding their need for the program (10). If policy makers view mental health services to be inferior and therefore less effective they may be less willing to fund such programs.
Research shows that psychiatric disorders are viewed as more blameworthy than physical health conditions like cancer and heart disease (11). Using Skitka and Tetlock’s model we see that a view of blaming those with mental illness for their condition may lead to a decrease in allocation of funds as well.
Finally, policy makers often make their decisions of resource allocation within healthcare by what population is experiencing the greatest hardship. This is typically on a scale of which group is more likely to die from their condition (12). This process does not lend itself well to mental illness where death is not an easy way to characterize the need. The mental health field may use activities of daily living (ADL’s) and quality-adjusted life years (QALY’s) instead of risk of death for a more accurate picture.
When we apply Skitka and Tetlock’s model to the resource allocation for mental health funds we see three distinct disadvantages inherent in the nature of mental illness and the impact that stigma can have on policymaking and resource allocation.
Eighty five to ninety percent of the mentally ill are unemployed. Since health insurance is linked to employment in this country the majority of the mentally ill are also uninsured. This creates a downward spiral for the mentally ill of being unemployed, therefore not having health insurance, therefore not getting treatment for their mental illness, therefore having further difficulty finding a job due to mental illness and so on.
There is no current return on investment (ROI) analysis of where healthcare dollars should be allocated. The economic cost of untreated mental illness is more than $100 billion each year in the U.S. (13). The majority of the mentally ill can be treated and live productive lives and contribute to society. This realization, follow by a ROI analysis, should lead to a higher funding of mental health services given the reduction of cost to society of untreated mental illness.
Media’s Role in Stigma of the Mentally Ill
Anthropologists use the term enculturation to refer to the process of internalizing the culture of the society. The media plays an important role in depicting the language, beliefs, customs and traditions of a society (14). Over-reporting negative stories about people with mental illness can be misleading and create an implied link between mental illness and violence and further the stigmatization of those with mental illness (15). The idea that “if it bleeds it leads” in news organizations creates a formula of sensationalizing and stigmatizing the mentally ill. The Hollywood portrayal of the mentally ill with such characters as Norman Bates in Psycho and Dr. Hannibal Lecter in The Silence of the Lambs further exacerbates this stigma of the mentally ill being violent.
Studies show that news reports focus on violent behavior and dangerousness regarding people with mental illness but the mentally ill are rarely violent and account for only three to five percent of all violence in the country (16). The news media almost never include statistical facts and context with any story of violence perpetrated by a mentally ill person. The exclusion of people with mental illness speaking on their own behalf in the press leads the watcher to believe that the mentally ill are too disturbed and dysfunctional to communicate.
The role of the media in defining our society is powerful and is currently counterproductive toward the mentally ill, only serving to further the stigma. The media sensationalizes violence from mental illness when it could be used to reshape popular opinion and advocate for funding and programs to help the mentally ill.
Public Health and the Mentally Ill
Unmet mental health need among adolescents is alarmingly high, as more than seventy percent of teens that require mental health care do not receive services. Given that twenty percent of adolescents suffer from a mental health disorder and that unmet need is a critical problem, removal of stigma as a barrier to care should be a priority of the public health community (17). Studies show that the initial mental health intervention experience of teens greatly influences their willingness to use mental health care services in the future (18). The first contact is typically a guidance counselor in a school setting that is more than likely overworked, underpaid, and undertrained to meet the needs of and provide care for a mentally ill teen. The public health community should be focusing their efforts toward ensuring this crucial first point of contact is successful to ensure future use of mental health resources if needed.
Given that stigma is a barrier to seeking care for mental illness the public health community should also make a priority of both reducing that stigma and putting in place a proactive approach to dealing with mental illness. It has been demonstrated that proactive interventions to identify those at risk for mental illness can be effective. A coordinated effort between schools, law enforcement officers, domestic violence specialists, community residents, early childhood educators and care providers, court personnel, child welfare workers, and mental health practitioners can lead to early intervention and improved outcomes in mental health care (19). The current approach of treating mental illness in emergency rooms, or worse yet jails, goes against the principles of public health.
The school dropout rate begins to increase sharply in 9th grade; therefore addressing youth when they are still in school seems to be the best venue for screening. The public health community should be focusing on community based, proactive interventions as a preventative measure to treating mental illness rather than leaving the medical profession to reactively treat the symptoms.
The three critiques summarized in this paper are inextricably linked. We can view the three arguments in a sequence. The media’s influence can have an effect upon the opinions of the public and therefore the opinions of the policy makers. This leads to reduced funding for mental health programs in turn leads to the public health professionals not having the adequate funding to implement mental health programs.
Proposed Intervention
Given the media’s effect on public opinion and the resulting poor resource allocation toward mental health programs, my suggestion is to launch a media campaign to alter public opinion. A media campaign can serve two purposes: media advocacy and enculturation through social diffusion. Media advocacy’s goals are to influence public opinion, policy makers and ultimately policy (20). Social diffusion theory can be utilized in tandem with the media to help shape culture and to reduce stigma.
Media advocacy focuses on changing the behavior of policy makers and not on changing the behaviors of individuals. Its goal is to influence policy makers to vote a certain way and to set the agenda for the issue of concern. Media advocacy is done through advertising campaigns, news media, radio, press releases, opinion pieces, You Tube and any other mass media outlet. The details of the policy agenda will be addressed later in the proposed intervention.
Social diffusion theory explains how media can be used to reduce the stigma that surrounds mental illness by altering the perceptions of the public and influencing the culture of society. Under the social diffusion umbrella, the theories of diffusion of innovation and social marketing theory are highly applicable in regards to a media campaign.
Diffusion of innovation describes how a behavior makes its way into a population and either is or is not accepted. The theory suggests a slow rate of adoption up to a “tipping point,” or the point at which the adoption rate increases in relation to time, followed by a rapid rate of adoption (21). If a media campaign is well crafted and is successful in reaching this tipping point it can have a chance at reducing the stigma surrounding mental illness.
Social marketing theory can help determine the information to communicate in a media campaign and how to package that information. A media campaign is most effective when research is conducted on the target population and the message is tailored accordingly. It may be beneficial to enlist a professional marketing team to assist in the development and implementation of a media campaign if the budget allows.
The “Truth” campaign is an example of how a media campaign can have great results. The “Truth” campaign was an anti-smoking media campaign funded by the State of Florida through its landmark victory against the tobacco industry. It included an earmarked budget of $200 million for a state-run pilot program to fight youth tobacco use. The “Truth” campaign is estimated to have been responsible for a twenty-two percent decline in youth smoking between 1999 and 2002 in the state. The Truth campaign utilized market research in designing their media plan, which resulted in unprecedented results and serves as a great example of an unorthodox yet effective public health strategy (22).
The major news media excludes people with mental illness speaking on their own behalf. The suggestion is to reach out to people that are in the public eye to speak out about their illness. The list of successful and famous people throughout history who are widely believed to have had manic depression or bipolar disorder (as documented by historians, biographers, private letters, etc.) is significant and includes Ludwig van Beethoven, Abraham Lincoln, Albert Einstein, Sigmund Freud and Isaac Newton. A more contemporary list includes Carrie Fisher, Richard Dreyfuss, Jean-Claude Van Damme, Margot Kidder and Linda Hamilton, all of who have spoken publicly about their struggles. "If well-known people in entertainment or politics talk about their experience, it provides people with a knowledge that they're not alone, and that it's an illness that's very treatable," says Mark D. Smaller, Ph.D., a Chicago-based psychotherapist and the director of the Neuro-Psychoanalysis Foundation in New York and London. "The more well known people speak out, the more it facilitates other people getting help (23)."
The final component of the media campaign is to boycott and protest programs and networks that foster the stigma of mental illness. Writing letters to and speaking out against offending programs and networks can be successful. The ABC program “Crumbs” that depicted mental illness in a derogatory light was cancelled after mental health advocates spoke out against it. Shows such as “Intervention” (24) on the A&E network present real life people, not actors, battling mental illness and shows how they can overcome their illness with treatment to lead productive lives. This is real progress we can point to as an example of another unorthodox yet powerful public health intervention that combats the stigma of mental illness.
The next step in the proposed intervention is to secure proper funding for mental health care. The ultimate goal is to pass legislation to make mental health care an entitlement program in the United States. An entitlement program is a government program that provides individuals with personal financial benefits, goods or services to which an indefinite number of potential beneficiaries have a legal right whenever they meet eligibility conditions that are specified by the standing law that authorizes the program (25).
Using our media campaign and social marketing, this goal could be realized. A conceivable way to pass this type of legislation would be to tack it onto Medicare, an existing entitlement program. The Americans with Disabilities Act defines mental illness as a disability (26). If the government can recognize the problem then it may choose to help fix it.
An integral part of the argument to have mental health care as an entitlement program is that it will save money. Most people with mental illness can be treated and live normal, productive lives. As mentioned above, the economic cost of untreated mental illness is more than $100 billion each year in the United States. (27). We would actually save money with an increase in economic productively and a reduction in acute care for untreated mental illness. In these tough economic times any new government program proposal needs to be budget neutral to have a chance of passing into law. This proposal would save the government money in the long term. For evidence of this we can look to the private sector and analyze the implementation of employee assistance programs (EAPs).
EAPs are programs that are typically outsourced or implemented through an organization’s human resources department. These programs offer confidential evaluation, treatment and referrals for a range of personal problems including family and marital issues, mental health, financial and legal problems and substance abuse (28). The results of these programs are noteworthy:
· More than 70% of all Fortune 500 companies have implemented EAPs
· Firestone Tire and Rubber estimated EAP savings of $1.7 million or $2,350 per person involved
· United Airlines reported a return of $16.35 for every dollar invested in EAP costs
· Scoville Manufacturing estimates an annual cost savings of $186,550 credited to their EAP
Undoubtedly a government mental health entitlement program will look very different than an EAP program but the government can use the example as a starting point for a ROI analysis. With a proactive mental health care plan we could potentially save the country millions of dollars. The suggestion is to conduct a comprehensive ROI analysis to support the proposed policy.
The final piece of the proposed intervention is to redesign how the medical establishment treats mental illness. I propose a system more in line with public health practices that focuses on prevention and early detection starting in elementary school. The model exists today in which elementary school children receive mental health evaluation and treatment at school.
Morgan Stanley Children's Hospital of New York conducts a program that serves children aged four to ten, and grades pre-K through five. The program consists of three parts. The first component is an in-school clinic program comprised of comprehensive clinics in five elementary schools. The second part is the Mobile Outreach, Referral and Education (MORE) program comprised of urgent evaluation, short-term treatment, and referral services in another six elementary schools. Finally, a school-based trauma services, prevention and outreach program in all eleven of the schools served. The program operates in collaboration with parents, teachers and school student support staff to give them tools to improve the behavioral and mental health status of their children (29).
This sort of early intervention makes it more likely that the person receiving care will have a positive first experience. This is critical to making the individual willing to reach out for care if he or she needs help in the future. Being exposed to mental health care at an early age will help remove the stigma of mental illness.
In summary, the multifaceted issues regarding mental health care require a multifaceted solution. The proposed approach deals with three major impediments of a coordinated mental health care system in the United States. The media influence on stigma, the policy implications on funding and the resulting approach of medicalized care deserves our utmost attention if we hope to make progress with mental heath care. The proposal of an alternate media campaign, a mental health care entitlement program and a public health approach to mental health care can serve our mentally ill, save money for everyone and enlighten our society.
REFERENCES
1. The National Institute of Mental Health. (n.d.). (National Institutes of Health) Retrieved November 15, 2008, from http://www.nimh.nih.gov/health/statistics/index.shtml
2. Public health. (n.d.). Retrieved November 15, 2008, from Wikipedia: http://en.wikipedia.org/wiki/Public_health
3. President's New Freedom Commission on Mental Health. (2002, December 2). Retrieved November 15, 2008, from Mental Health Commission: http://www.mentalhealthcommission.gov/
4. Stigma (sociological theory). (n.d.). Retrieved November 15th, 2008, from Wikipedia: http://en.wikipedia.org/wiki/Stigma_(sociological_theory)#References
5. Carter, M. (2005). Keep Quiet about It. Community Care , 38-39.
6. U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration , Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville, MD.
7. (Ibid)
8. (Ibid)
9. Corrigan, P. W., & Watson, A. C. (2003). Factors That Explain How Policy Makers Distribute Resources to Mental Health Services. Psychiatric Services , 54 (4), 501-507.
10. Skitka, L. J., & Tetlock, P. E. (1993). Providing Public Assistance: Cognitive and Motivational Processes Underlying Liberal and Conservative Policy Preferences. Journal of Personality and Social Psychology , 65 (6), 1205-1223.
11. Corrigan, P. W., & Watson, A. C. (2007). The Stigma of Psychiatric Disorders and the Gender, Ethnicity, and Education of the Perceiver. Community Mental Health Journal , 43 (5), 439-458.
12. (Ibid)
13. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from http://www.nimh.nih.gov/
14. DeFleur, M. L., & Ball-Rokeach, S. J. (1989). Theories of Mass Communication (Fifth ed.). White Plains, NY: Longman Inc.
15. Friedman, R. A. (2008, July/August). Media and Madness. The American Prospect , pp. 2-4.
16. (Ibid)
17. Chandra, A., & Minkovitz, C. S. (2007). Factors that Influence Mental Health Stigma Among 8th Grade Adolescents. J Youth Adolescence (36), 763-774.
18. (Ibid)
19. Hyde, M. M. (2008). National Evaluation of the Safe Start Demonstration Project: Implications for Mental Health Practice. Best Practices in Mental Health, 4 (1), 108-122.
20. Edberg, M. (2007). Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, Inc.
21. Wikipedia. (n.d.). Retrieved November 15th, 2008, from Diffusion of innovations: http://en.wikipedia.org/wiki/Diffusion_of_innovations
22. Social Marketing Institute. (n.d.). Retrieved December 10, 2008, from Success Stories: http://www.social-marketing.org/success/cs-floridatruth.html
23. Rustad, M. (2008, September 29th). Living with Bipolar Disorder. Retrieved Dec 7th, 2008, from Revolution Health: http://www.revolutionhealth.com/conditions/mental-behavioral-health/bipolar-disorder/living-with-bipolar-disorder/famous-people-with-mental-illness
24. A&E. (n.d.). Retrieved December 7th, 2008, from Intervention: http://www.aetv.com/intervention/
25. Auburn University. (n.d.). Retrieved December 10th, 2008, from A Glossary of Political Economy Terms: http://www.auburn.edu/~johnspm/gloss/entitlement_program
26. Americans with Disabilities Act. (n.d.). Americans with Disabilities Act. Retrieved December 7th, 2008, from http://www.ada.gov/
27. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from http://www.nimh.nih.gov/
28. Dictionary. (n.d.). Retrieved December 7th, 2008, from Case: http://www.case.edu/med/epidbio/mphp439/Dictionary.htm New York Presbyterian. (n.d.). Elementary School Children Receive Mental Health Evaluation and Treatment at School. Retrieved December 7th, 2008, from New York Presbyterian: http://www.nyp.org/news/hospital/814.html#

Prevention of Eating Disorders: Failing to Protect Young Women from the Thin-ideal. – Marissa L. Garofano

The prevalence of eating disorders is growing problem, and over the past 50 years the number of cases has steadily increased. Eating disorders; anorexia and bulimia, affect a small proportion of people in the United States, 0.5% - 1% and 1 – 2% respectively and possibly as much as 10% (1, 2) However, they are costly to treat and effective prevention methods are necessary. At least an additional 10% of women and girls in late adolescents have eating disorder symptoms at any given time (2). Health care professionals recognize the importance of primary prevention due to the difficult nature of treating eating disorders (3). In addition, only the small proportion of people who have a clinically diagnosable eating disorder will receive treatment, an unknown amount of others who have some symptoms receive no treatment.

There are a multitude of risk factors that may lead to the development of an eating disorder. The factors that receive the most attention in prior prevention efforts are individual factors which include: child abuse, having been teased, perfectionism, obsessive thoughts, and body dissatisfaction among others (1). In addition to individual risk factors, sociocultural influences including parents, peers and the media are being shown to have an effect on the development of eating disorder (1,4). There is a relationship between the two but there has been a greater emphasis on individual risk factors rather than social ones.

There has been an inverse relationship to the amount of available food and ideal body of certain groups of people; as there begins to be a surplus of food, the ideal body size tends to become smaller (1). The media norms, on television and in magazines, have helped to accelerate this process. American women depicted in the media have become steadily thinner in the past 50 years, and more than half meet the criteria for anorexia nervosa (5). The media sends constant messages to children and adolescents about what it means to be beautiful, successful, feminine, attractive and desirable: for women this comes with slenderness (6).

The Thin-Ideal and Drive for Thinness

The media is the greatest contributor to a culture’s thin ideal. The media creates a social norm that girls feel they need to live up to. Many young girls aspire to be actresses or models that are greatly admired by Western cultures and have a high status and a lot of money. Currently most every show on television and fashion magazines depicts thinness as the norm (4, 6). Slender, airbrushed women with very little fat, and no wrinkles or pimples are shown on television or fashion magazines. These images set the standards for women so high that failure is inevitable.

In addition to the glorification of slenderness in the media being fat is also looked down upon (6). Because of this and due to the amount of exposure to these ideals on the media, girls may begin to compare themselves to the slender actresses and develop a negative view of their own bodies (6). Today, children under the under the age of six spend around two hours a day watching television, or movies (7). Between the ages of eight and eighteen children spend around four hours watching television and an additional two in front of a computer (7). The amount of time older children and teens spend in front of a screen is nearly one fourth of their day. From this, it is evident how the media is able to instill these ideals in youth. It is the internalization of the thin-ideal that has been associated with weight concerns and disorder eating habits (8)

Current prevention methods have failed and this is demonstrated by the growing number of cases of eating disorders and increasing prevalence of dieting and unhealthy eating behaviors. The failure of current eating disorder prevention methods is due to the ineffectiveness of current education programs, the failure to alter social norms, and the media’s promotion of the thin ideal.

Current Education Methods are Ineffective

It has been shown that preventing eating disorders through changes in knowledge, attitude, and behavior via education is difficult and often unsuccessful (9). The majority of previous educational interventions have included information on the nature and consequences of eating disorders and dieting (10, 11). Many of these studies have shown an increase in knowledge but no change in eating behavior (11). Interventions of this nature use the health belief model (HBM) for behavior change. This model assumes that increasing the knowledge about the benefits of eating healthy and consequences of dieting and eating disorders will lead a person to weigh the risks and benefits of change against what they perceive to be the severity of eating disorders and how susceptible they feel they are to them. If the benefits of change are high along with the severity and susceptibility, this will lead to the intention to change, and then the adoption of a healthy behavior change (12). Prevention methods based upon the HBM address individual factors and does not account for outside social factors that influence a behavior. Also, the HBM is most effective when used for short term change or one time decision, as demonstrated by how soon after an intervention their was a greater change in attitudes but after time had passed the strength of theses attitudes decreased (10). Maybe the first night when these facts are still fresh in her memory, a girl may not eat a large tub of ice cream and then purge or fast afterwards. However, three months later, during a stressful time period, this may not be the case. The HBM suggests that teenage girls make rational decisions, and highly value their health over being accepted by their peers.

While education has very little effect on positive behavior change it may also have a negative effect on behavior and will lead to more unhealthy eating behaviors. It has been shown that providing detailed information about the symptoms of eating disorders to children and adolescents can increase the amount of disordered eating habits that occur (10, 13). While behavior and attitudes may change positively right after the implementation of an intervention, months later the girls may be back to their original views and behaviors, or they may have developed more negative views and have more disordered eating behaviors (10). The idea of providing teachers and faculty at schools with a detailed overview of the causes and symptoms of eating disorders has also been suggested (14). However this knowledge may create false accusations of students and stigmatization of them if not enough information is provided. If a stigma is created the student may fall into a self-fulfilling prophecy where she engages in disordered eating behaviors because others already accept it from her (15).

Current interventions for prevention are typically being implemented in adolescence or young adulthood. The time at which most educational interventions have been implemented are at or around the onset of puberty (11). By this time many disorders attitudes towards eating habits my have developed as by the time girls are 10, 81% are afraid of being fat (16). Also, by adolescence one’s views are already set and it is more difficult to alter these opinions. This suggests that intervention should be implemented at a younger age when children are more malleable and absorb the most information.

In addition current educational interventions fail to account for important influences on behavior; social and contextual factors (12). Education assumes that people want to be healthy rather than fit in with social norms. Also it fails to address the reasons for why these behaviors were adopted in the first place.

Failure to Alter Social Norms

The occurrence of dieting and the desire to be thin are extremely common among women and girls and begin at a very young age, as young as six. Forty-two percent of 1^st through 3^rd graders want to be thinner (16). It is common that when with a group of young women you will hear talk about current diets, being too fat, and needing to lose their excess weight. Trends in dieting are discussed as frequently as trends in fashion. Women will attempt to conform to the current definitions of what is beautiful and attractive in order to fit in with their social group (15). However, what women perceive as normal may not coincide with actual societal norms. They perceive that the most attractive figure to men is one that is very slender (18) when men actually prefer a more curvaceous woman with muscle tone to one who is super skinny and mostly bone. Women envision an ideal body shape that is smaller than their current one, feeling that they need to lose weight, to achieve that of what is perceived as attractive and what their peers hold as ideal (17). An attempt to achieve this ideal and fit in with their peer’s norm, may lead girls to begin methods of unhealthy methods to achieve the perceived ideal. The CDC found that, in 2000, 37.5% of girls trying to lose weight did so in an unhealthy manner (18). A study of high school girls showed that an increase in an individual’s unhealthy eating habits was correlated with perception of her friends dieting habits (19) which suggests that eating behaviors are not solely based on individual factors and the weighing of risks and benefits but group level factors as well.

Prevention methods that stress education do not account for perceived social norms or group level factors. Facts may be provided about the average size of a woman and comparing her to the average model but there is a lack of discussion regarding the perceived norms the girls have and how they feel about them. Marketing theory suggests that focus groups need to be created to determine what the girls think would be effective and what their current ideals are (20). After creating an intervention with the girls concerns in mind the outcomes will be more successful, as education does address these concerns and the programs are not created with the help of the girls who are affected by the norms.

The Social Networking theory gives insight as to how these ideals and practices have become normal. The theory relies on the relationships and interactions of the individuals within a group (21). If you have a group that consists of high school girls and analyze the relationships of them you will most likely see the thin girls who comply with society’s norm in the middle with the most friends and the heavier girls who are perceived as unattractive will be marginalized (21). Body shape will also dictate who will be in the subgroups or cliques in the network. The heavier girls will have less interpersonal contacts within the group. Social norms provided by the media suggest that people who are heavy are outsiders, and possess undesirable qualities and therefore it is acceptable to not interact with them and avoid contact (5). In order to change this social network one of two things would have to occur, either a change in norms to accept heavier people as attractive or, more likely, the heavier girls will adopt disordered eating behaviors to try to move to the center of the network and gain acceptance from peers.

Also in the social network would be parents and family members, neighbors, teachers and all other people the girls interact with (22). Parents and teachers play an important role in teaching the children to accept everyone for who they are and to help develop a positive self image (3, 21).

The Media’s promotion of the Thin Ideal

While there is a strong correlation between the idealization of thinness and occurrence of eating disorders, little has been done to protect children, especially girls, from this ideal. With nearly ¼ of a child’s or teen’s day spent in front of a computer or television, then combined with the amount of time spent reading fashion magazines, it is evident how the media can impact a person’s views on what it normal (7). Media awareness interventions that have been tested have not demonstrated much success at changing attitudes about eating and body image. Suggesting that the length of previous interventions were inadequate and long term programs may be more effective.

The social networking theory described above is dictated by societal norms, and these norms are greatly influenced by the media. The media depicts thin as being the right way and fat people, when shown in the media, are often shown as undesirable and lazy (5). The desire to be considered as beautiful and attractive is one that is highly sought out by girls and women young and old. With the influence of the media the attempt to achieve the ideal and avoid being considered lazy and undesirable may lead to an increase disordered methods of obtaining them. Becker, et al. (2002) conducted a study in Fiji where girls had not been exposed to the thin ideal media and where a larger figure was considered desirable and the norm (23). The study showed an increase in disordered eating habits and a shift in the ideal body over a three year period of time after the introduction and exposure to thin ideal media (23). These findings can be generalized to give insight as to how the United States and westernized cultures may have adopted this view.

The media may counteract any improvements made through education because it dictates what is perceived as both ideal and normal (2, 15, 23). As time passes there is less focus on being healthy and more on social ideals and now girls have the information on how to achieve this ideal because of an increased knowledge symptoms and unhealthy eating habits. The media has the ability to create a norm in which all sizes are accepted, and because of this there is a need to regulate what is shown on the media and diversify the images of women seen (6).

Most of the studies previously conducted on the relationship between the media and eating behaviors have been quantitative in nature and have not asked the how and why questions (23). Marketing theory would suggest that for an intervention to be successful one needs to determine the needs of the consumers (21). In this circumstance to discuss with adolescent girls how they are affected by the media, why they think this way, the changes they would like to see, etc. From the answers received by the girls a program can be developed that is specifically designed to influence the needs of this target population, something has not been considered when using educational methods.

However a reduction in the internalization of the thin ideal has been associated with positive outcomes suggesting that it is possible to significantly reduce these ideals if an effective method is discovered. (8).

There is a need to prevent eating disorders since they are costly to treat and have poor health outcomes. Also, as the prevalence of anorexia and bulimia increases there is an increased need for an effective public program. Current eating disorder prevention interventions have failed due to the overemphasis on education, lack of attention to the influence of social norms, and the influence of thin ideal media. The effects of education do not last over an extended period of time and may actually create more disordered eating habits than they prevent. Current social norms support these disordered behaviors in order to achieve the ideal body type valued by society. The media dictates these social norms and is a responsible for interacting with other risk factors to increase the prevalence of disordered eating behaviors.

These reasons for failure suggest that there is a need to reform the prevention methods that are used. New prevention methods should include the voice of girls to determine what they want and there opinions on these topics. New prevention measures should attempt to change the societal norm to one that does not focus on one ideal body but rather the acceptance of all healthy bodies.

Implications for future prevention methods

To improve upon the flaws of prior eating disorder prevention methods, new approaches must be implemented to improve upon the failures of past intervention because of their focus on education, lack of acknowledgment of social norms, and the media’s influence on the ideal. The new intervention would take place over a long time period and would use theories not typically used in the public health field, using mostly theories about marketing, social influence, and social networks. The basic structure of the new prevention program would consist of mapping a social network of teen girls in a representative area to determine the following: who is marginalized, who is heavy or thin, and who engages in disordered eating behaviors.

Next, girls who would fall into one or more of the above categories would be interviewed in focus groups with other girls similar to them to determine why they engage in certain behaviors, how other girls who are in their peer group influence them, and how the media influences them (24). Using the information collected, healthy eating behaviors can be marketed to this population in a way that shows this as the norm. The girls’ feedback on the media can be used to create media awareness campaigns, and regulations of the media that will create size acceptance and minimize the thin ideal.

Moving beyond education

New interventions would address education’s inability to produce long term change in the eating behaviors of teen girls. The use of marketing theory will take into consideration the needs and wants of the target population instead of coming from the point of view of health care professionals (24). As health professionals will focus more on the clinical aspects that are important to them rather than social ones which are more important to adolescent girls. The idea of gaining insight, through focus groups, as to why a consumer engages in a certain behavior is beneficial when determining the best way to “sell” healthful eating (24). Questions need to be asked to find out why the girls engage in a certain behavior at surface level and then continue to question them to discover the true motives for this behavior that are not at the surface level (24). Questions asked may include: how it makes them feel afterwards? How they usually feel before? Are there any external pressures they feel to engage in this behavior? Do the girls engage in healthy eating behaviors and if so why, what to they gain or lose through this action?

Conducting qualitative research instead of generating quantitative data is useful especially for studying a behavior and determining the reasons for a particular behavior. Quantitative research just discusses how common an event is (25). Discussing in small groups of girls who are either centralized or marginalized within a social network will provide a great deal of insight into the reasons for such behaviors prior quantitative research was unable to do this, however it is necessary to know the reasons for why one engages in behaviors to know how to intervene and prevent them. Education about the consequences of eating disorders, and their symptoms, as well as what foods are healthy and which ones are not should be discarded as it has not been proven effective in the past and may be causing more harm than good (10).

Additionally, another way marketing and social network theory improve upon education through the Health Belief Model, is how they do not assume that behaviors are made through a rational weighing of the risk and benefits (12). Unlike education methods based upon the Health Belief Model, they take into consideration the influence of outside forces through marketing theory and social networking theory in this new intervention would able to create effective programs to influence the healthy and unhealthy eating behaviors of teenage girls (19, 24).

Altering social norms

Currently society places normality on being thin and because of this there has been a marginalization of overweight and obese people (19). Social norms are extremely influential on adolescents, as they are still gaining a sense of self and have a strong desire to fit in with their peers. The current social network needs to be altered so that there is a mixture of thin and heavy people through out the group and there is not one group who is favored above the other. New prevention methods should focus on altering social norms by creating size acceptance and promoting the importance of healthy eating and how to do this. Decreasing the pressures to be thin will have a great impact on the amount of disordered eating behaviors in which a girl engages. If the social norms that influence whether or not a girl will engage in unhealthy eating behaviors are altered or reduced than the eating behaviors that follow will also be reduced through the role of social norms on how they depict what peer influences will impact other girls (19).

By changing the social influences on adolescent girls through the creation of size accepting norms there will be less marginalization of overweight individuals who would not fit in with the ideal body that is currently portrayed. If a second network was mapped of a similar group of teen girls after the alteration of social norms occurred, its structure would show a mixture of heavy and thin people centralized and those who are extremely obese or engage in disordered eating habits would be marginalized and seen on the outskirts of the social network. Social network analysis believes that actions are interdependent on others in an environment and not based upon an individual behaving in an independent manner (21). This analysis would demonstrate a norm for being healthy and not approving of unhealthy eating behaviors, such as dieting, purging, excessive exercise, fasting, and others. The media can be used to alter the social norms regarding ideal body.

Combating the media’s influence

The media is one of the most powerful tools in creating social norms and has the great impact on youth. Currently the media helps to create unrealistic and unhealthy standards for female physical appearance which American culture has come to accept, support, and strive for. Social norms about weight have fluctuated over time suggesting that it may be possible to shift the desired body to one of a healthier curvy figure. Americans need to become educated consumers about what is depicted on television and in fashion magazines, and how it is neither normal, healthy, or real (6). It is possible that media education can be integrated in to the classroom setting and be taught similar to that about alcohol use and violence (6, 16).

Through use of the focus groups used to collect data on the eating behaviors of teen girls can also be used to collect opinions about the media and the influence it has on the decision making of these girls (24). For instance what types of shows are currently watched and which ones were watched when the girls were younger. After learning what aspects of shows have had the greatest impact on the girls, it may be possible to implement some regulations in the media to alter this affect; such as the times when certain body types can be portrayed as ideal, the body types that are portrayed in children’s shows. Currently on television shows, overweight individuals are rarely portrayed and when they are it is usually in a negative manner where they are being depicted as clumsy, lazy, stupid, and unsuccessful (5, 6). If social networks of shows in the media do not marginalize heavier people than this will influence the setup of teen social networks. Becker, et.al (2002) demonstrated how the introduction of thin ideal media can change a society’s ideal from a heavier set on to an extremely thin one and how the pressures from the thin ideal lead to an increase in disordered eating behaviors (23). This also suggests that if the media were to introduce shows in which different sizes of people are shown, the thin ideal could be reduced and one regarding a healthy body can be created.

Using the media to alter social norms in a way that would suggest eating healthy and being of a healthier weight is seen in a positive manner and as more attractive to men. The qualitative data collected through use of marketing theory could also be used to create effective campaigns by addressing what is important to adolescent girls and portray these messages in a way that will actually impact them more than someone telling them what they should do.

Conclusions

In the past the ideal shape for a woman’s body has been curvy and heavier than the current societal ideal suggesting that it is possible to alter current norms (16). If it is possible to gain insight as to why girls begin to engage in disordered eating behaviors, then it will be more likely that they can be prevented. By focusing on external factors rather than individual ones eating disorder prevention is more likely to be successful. New prevention measures need to improve upon the failures in past approach in that they should not focus on education but rather the impact of social norms and the media on disordered eating behaviors.

References

1. Polivy, J., Herman, P. (2002). Cause of eating disorders. Annual review of psychology 53: 187 – 213.

2. Academy for Eating Disorders. (2005). Prevalence of eating disorders. Aedweb.org/eating_disorders/prevalence.cfm

3. NEDIC. Prevention of Eating Disorders

4. Smolak, L., Levine, M.P. (2001). Body image in children in Thompson and Smolak Body Image, Eating Disorders and Obesity in Youth.

5. Harrison, K. (2000) The Body Electric: Thin-Ideal Media and Eating Disorders in Adolescents. Journal of Communication: 119 – 143.

6. Levine, M.P., and Smolak, L. “The mass media and disordered eating: Implications for primary prevention” in The Prevention of eating disorders.

7. Gavin, M.L. (October 2008). How TV effects your child. http://kidshealth.org/parent/positive/family/tv_affects_child.html

8. Low, K., Charanasomboon, S., Brown, C., Hiltunen, G., Et al. (2003). Internalization of the thin ideal, weight and body image concerns.

9. Scime, M.S. and Cook-Cottone, C. (2008). Primary prevention of eating disorders: A Constructivist integration of mind and body strategies.

10. Carter J.C., Stewart, A., Dunn, V.J., Fairburn, C.G. (1996) Primary prevention of eating disorders: Might it do more harm than good.

11. Stewart, A. (1998). Experience with a school-based eating disorders prevention programme. In The Prevention of Eating Disorders

12. Becker, M.H. (1974). The health belief model and personal health behavior. Health Education Monogr (2).

13. Keca, J, and Cook-Cottone, C. (2005). Eating Disorders: Prevention is worth every ounce.

14. Bear, M. (2003). Prevention of Eating Disorders. NEDIC

15. Healthy Within. Statistics of Eating Disorders. http://www.healthywithin.com/stats.htm

16. Aronson, E., Wilson, T.D., and Akert R.M. (2007). Social Psychology (pp. 246 – 249).

17. Cohn, L.D., and Adler, N.E., Female and male perceptions of ideal body shape.

18. Centers for Disease Control and Prevention. (2000). CDC surveillance summaries. MMWR, 49, 1–5. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss4905a1.htm.

19. Eisenber, M., Neumark-Sztainer, D., Story, M., and Perry, C. (2004). The role of social norms and friends’ influences on unhealthy weight-control behaviors among adolescent girls. Social Science and Medicine 60: 1165 – 1173.

20. Kotler, P. (1989). Social Marketing: an approach to planned social change. Free Press: New York, NY.

21. Wasserman, S., Faust, K. (1994) Social Network Analysis. Cambridge University Press: Cambridge.

22. Story, M., Neumark-Stzainer, D., French, S. (2002). Individual and environmental influences on adolescent eating behaviors. The American Dietetic Association 102(3): s40 – s51.

23. Becker, A., Burwell, R., Gilman, S., Herzog, D., Hamburg, P. (2002). Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls. British Journal of Psychiatry 180: 509 – 514.

24. Wansink, B. (2005). Marketing Nutrition. University of Illinois Press: Chicago.

25. Marshall, Catherine & Rossman, Gretchen B. (1998). Designing Qualitative Research. Thousand Oaks, CA: Sage.

26. Irving, L.M. & Neumark-Stzainer, D. (2002). Integrating the Prevention of Eating Disorders and Obesity: Feasible or Futile? Preventative Medicine 34; 299 – 309.

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.

Setting

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.

Questions

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.

Interventions

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.

Setting

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.

Questions

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.

Interventions

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.

References

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