Shifting the Paradigm to No Where: How the American College Health Association Failed Primary Prevention – Erin Williston

United States college students are increasingly threatened with violence on campus. One of the most pervasive forms of violence happens in a place students rarely anticipate. National studies have consistently found approximately 32% of college students experience domestic/ relationship violence (1). The overwhelming prevalence of violence against women on college campuses is well documented nationally. Women ages 16-24 are at the highest risk for rape and other forms of intimate partner violence (2). While the statistics are omnipresent, higher education has neglected to set their sights higher than simply responding to incidents of violence, a form of public health called tertiary prevention.

In April 2007, the American College Health Association stepped out with their, “Position Statement on Preventing Sexual Violence on College and University Campuses”. What followed was a document with a mission to “provide facts, ideas, strategies, conversation starters and resources to everyone on campus who cares about prevention of sexual violence” – the ACHA toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence. Primary prevention is a public health approach using environmental and system-level strategies, policies, and actions that prevent sexual violence from initially occurring. The problem with Shifting the Paradigm surrounds not its idea to use primary prevention to address the issue – but in the theories and interventions it encourages its audience to use. The interventions presented are deficient, archaic, and fail to speak the language of higher education as an organization.

Promoting a Deficient Tool – Opening Pandora’s Box

Shifting the Paradigm authors encourage screening for sexual violence in college health and wellness services. This tool could help identify survivors of sexual assault, provide client centered services in the health care setting and encourage reporting. While screening is widely debated and mildly supported in medical-based literature, it is not primary prevention (11).

What is most interesting in this proposed intervention is the missing critical piece. There is no mention on training medical care providers to ask the questions proposed in this intervention! There isn’t even an analysis of student health centers and their ability to train and implement an effective screening tool. The classic study Opening Pandora’s Box helps explain why it is vital to deliver training to providers who will implement these screening tools.

An analysis of interviews with physicians found exploring domestic violence in the clinical setting analogous to "opening Pandora's box." Their issues included lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. This study revealed several barriers that physicians perceived as preventing them from comfortably intervening with domestic violence victims. These issues need to be addressed in training programs (3).

Student health centers are not equipped to respond to the answers these questions will bring. Questions such as:

• “Has someone ever touched you in a sexual manner against your will or without your consent?”
• “Have you ever recognized you had ‘unwanted’ sex while drunk or using drugs?”
• “Do you feel that you have control over your sexual relationships and your partner will respect your wishes if you say no to specific sexual activities?”

These questions don’t fit in to the 15 minute appointment providers have with students in a clinical setting; especially if the training or programs to support these questions doesn’t exist (3). Shifting the Paradigm misses the mark by calling this primary prevention and proposing it without mention of proper training for providers.

Revisiting Individual Models

Shifting the Paradigm makes several attempts to provide tangible primary prevention exercises for college health educators to use with their students. One of the first interventions is “[to] facilitate conversations about sex that focus on individual choices along the continuum of sexual activity… [to] identify and popularize healthy sexuality that respects gender, sexual orientation, and gender identity.” Another intervention encourages educators to distribute “10 ways young men can prevent sexual violence” to fraternities and other male dominated organizations on campus.

These are both classic examples of the Health Belief Model – an individualized public health model that assumes no social interaction, and demands rational behavior (4-5). This model and proposed intervention fails to understand one important issue in human behavior: people are not rational; they do not make decisions in silos and are easily influenced by unconscious factors.

Dan Ariely helps make this clear in his book Predictably Irrational: The Hidden Forces That Shape Our Decisions. Dr. Ariely conducted a study with Berkeley undergraduate students who underwent a variety of sessions in different orders answering questions about sexual and moral decisions. In one session students predicted their sexual and moral decisions while in a cold, dispassionate state. In another, they did the same but while in a hot, aroused state.

“In every case, our bright young participants answered the questions very differently when they were aroused from when they were in a ‘cold’ state….when participants were aroused they predicted that their desire to engage in a variety of somewhat odd sexual activities would be nearly twice as high as they had predicted when they were ‘cold’.” (6)

The results go on to demonstrate how in a cold, rational state, the men involved in this study respected women. They thought they understood themselves, their preferences and what actions they were capable of. These men, like many young college students, underestimated their reactions to arousal and the outside environment. It does not make these participants social deviants; it proves that human behavior is irrational.

This study is critical to understanding that college students do not make decisions in a vacuum; they are highly influenced in their vulnerable state of transition from high school to higher education. While Shifting the Paradigm encourages discussion about respecting gender and being aware of pop-cultures messages, the reality is college students are having good, bad and ugly sex without the influence of these conversations in the bedroom.

Could We Get a Little Buy In?

Contributing authors to Shifting the Paradigm express their hopes for primary prevention in the preface: “[primary prevention] must reach the same level of efficacy and adoptions as programs that respond to its consequences.”

Shifting the Paradigm authors makes 2 assumptions with this statement: 1. it assumes the reader is on a campus that is effectively responding to consequences of violence and 2. The reader understands the levels of public health prevention and the concept of moving upstream. These are erroneous assumptions considering many campuses are failing to make the basic responses to victimization work on campus. According to a 2005 National Institute of Justice report, of the nations institutions of higher education less than half listed a contact phone number for students who have been sexually assaulted that was accessible after “normal” business hours – when most assaults happen (7).

This demonstrates the lack of understanding Shifting the Paradigm authors have in regard to higher education organizations. If the authors had followed organizational development theory, they would have understood that one of the keys to mobilizing an organization is to know your community priorities. For example, by pairing a health issue with other priority issues you can maximize the potential for community action (8).

Shifting the Paradigm fails to speak the language of higher education and answer the questions critical to administrators in the organization. Administrators hold the keys to what college health professionals need – support from the institution: both financially and politically. Why should higher education administration care about sexual violence? How does it impact the organization and the students we serve? How much money will it save us if we invest in these programs? College health educators need to make the connection between health and academic success in order to speak the language of our stakeholders (9). Without this connection, administrators will fail to see the value in sexual violence prevention.

Moving Past Shifting the Paradigm

The authors and consultants for the ACHA toolkit neglected to produce a sound document for their intended audience. They sent out a grab bag of deficient, archaic and inconsistent tools for overburdened campus professionals to toss out at the end of the day. It is unfortunate that this opportunity to speak to higher education about primary prevention was wasted with the promotion of such tools as “discussion starters” and “screening interventions”. The lack of outcry from ACHA members isn’t surprising; many of them lost value in the document before reading it. In an effort to move forward and adopt a primary prevention approach to sexual violence, new theories must be brought to the table.

Smedley and Syme explain in their article Promoting Health: Intervention Strategies from Social and Behavioral Research, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.” Smedley and Syme, along with many others in this field support the need for a social and behavioral approach to violence prevention (6,12-18). Shifting the Paradigm could benefit from considering two specific social science theories: Organizational Development (OD) and Fostering Healthy Norms (Norming) (8, 16-18, 20-21,). The finale of this post will provide empirical data and examples in support of using OD and Norming to address primary prevention of sexual violence on a college campus. It is vital to know these methods lend themselves concurrently however; creating an environment open to change from the top down should be the first step.

Stimulating Change

Community mobilization around a specific issue can be challenging. It requires much from the agent of change in order to move an organization toward a new behavior (16). ACHA members fit into the role of ‘agent of change’ and learning to speak the same language is a gateway to common ground. ACHA members would benefit by cultivating relationships with professional leaders on campus; one great approach is to appeal to the individual’s self-interest, showing how their participation in your cause can aid in achieving their own goals and objectives (23). Utilizing OD theory to foster shared goals and motivation among members of the institution will aid in the change process (16-18). Organizational Development theory encourages community and organizational change while taking into account the culture, organizational climate and capacity (16). Systematizing an institutional change utilizing the culture, climate and capacity is critical to avoid simply replicating what other schools do without evidence of an effective intervention.

To mobilize an institution to address sexual violence through primary prevention, three key issues should be addressed (17).

1. Define the community: Develop an understanding of the chain of command within the institution. Set up individual interviews with key players and learn who the movers and shakers behind decisions made on campus might be.
2. Assess and work with the community’s capacity for mobilization: Are their experienced professionals on campus who are researching or addressing sexual violence currently? What is the history of task forces or committees to address sexual violence appointed by upper administration? Look for current action within the institution and work with those players to assess the ability to move upstream in addressing sexual violence.
3. Understand the community agenda and select the right issue: ACHA members should look at the mission of the institution and assess how sexual violence might impact that mission. This could be done by reviewing national and local data regarding sexual violence. Sources may include the ACHA National College Health Assessment, Jeanne Clery Act Reports, local police and prosecutor’s office data and qualitative data from local organizations that work in the area of sexual violence. The impact sexual violence has on matriculation, retention, and graduation could be a critical piece of information for upper administration. Successfully selling primary prevention of sexual violence can be achieved if you pair the institution’s goals and objectives with your topic area goals and objectives.

Fostering Healthy Norms

There are 5 damaging norms that impact attitudes and beliefs about sexual violence (12). These norms are:

1. Women: limited roles for and objectification and oppression of women

2. Power: value placed on claiming and maintaining power (manifested in power over)

3. Violence: tolerance of aggression and attribution of blame to victims

4. Masculinity: traditional constructs of manhood, including domination, control and risk-taking

5. Privacy: notions of individual and family privacy that foster secrecy and silence.

ACHA members can address these norms by strategically promoting normalizing messages about positive female roles, egalitarian relationships, men standing up to aggression, downplaying negative risk-taking, and engaging citizens. The social norms approach provides tools for increasing perceived support to take action to address health and violence behaviors (20). The key is to create and sustain healthy norms within the institution and surrounding community (12).

We know that one of the critical places students’ receive and trust messages is from health care providers (26). A mandatory training with continuing education credit for all health care professionals on campus (in the student health center and otherwise) could help foster norms at an individual level. This curriculum would consist of trust building, using positive sexuality language and sharing healthy relationship guidance in a clinical setting (12-13). Providers would be expected to use the tools learned in this curriculum with patients to build trust and promote the health center as a safe, positive place to receive information and services. In order to implement this type of care, health care providers will need more time with patients. A critical role for ACHA members will be advocating for longer visits with providers and promoting efficiency in scheduling visits (3, 12).

The second component to this ‘Fostering Healthy Norms’ approach is to develop a marketing campaign that is interactive and promotes positive environmental change. Studies suggest that the social norms approach to sexual assault prevention is a promising practice that is worthy of further attention and research to determine its effectiveness (20). For example, at James Madison University a campaign designed to change men’s intimate behavior towards women was implemented. Data demonstrated significant increase in the percentage of men who indicated “stop the first time a date says no to sexual activity” and a significant decrease in the percentage of men who said “when I want to touch someone sexually, I try and see how they react.” (20). Other campaigns have demonstrated similar findings, making social norms marketing campaigns a promising practice in prevention of sexual violence.

No Substitute for Planning

The American College Health Association’s toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence would be a greater resource if the role of health and its impact in higher education was all ready established. However, without this critical collaboration, no campus is ready to implement tools that have not been grounded in research. The interventions fail to speak the language of higher education as an organization or foster change in the current climate.

In an effort to design a replicable toolkit, ACHA would have done well to offer planning and evaluation tools for primary prevention of sexual violence on college campuses. Saltz and DeJong’s comment in ‘In Reducing Alcohol Problems on Campus: A Guide to Planning and Evaluation’, “Simply replicating what other schools are doing is not a substitute for sound planning.” Utilizing Organizational Development theory to stimulate change from the top down, followed by a comprehensive implementation of Fostering Healthy Norms allows flexibility to accommodate the institution’s individuality and take research to practice.

References

1. Feminist Majority Foundation. Violence Against Women on College Campuses. 2005

2. Gross A.M., Winslett A., Roberts M., and Gohm C.L. An Examination of Sexual Violence Against College Women. Violence Against Women 2006; 12(3): 288.
3. Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's Box. JAMA 1992; 267(23):3157-60.
4. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr 1974; 2: Entire issue.

5. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11(1): 1-47

6. Ariely, D. The Influence of Arousal (pp. 89-108). In: Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper Collins 2008

7. Kariane H.M., Fisher B. S., Cullen F. T. Sexual Assault on Campus: What Colleges and Universities Are Doing About It, U.S. Department of Justice Office of Justice Programs, December 2005, National Institute of Justice www.ojp.usdoj.gov/nij

8. Cummings, Worley. Organization Development and Change, 6^th ed. Boston, MA: South-Western; 1997

9. McNeil M., Grizzel J. Linking Student Health with Academic Success: American College Health Association Annual Meeting 2006.

10. American College Health Association. Shifting the Paradigm: Primary Prevention of Sexual Violence. www.acha.org/SexualViolence August 2008

11. PREVENT Program at University of North Carolina Injury Prevention Research Center. Prevent Provider Toolkit Module 1. January 2007

12. Davis R., Fujie-Parks L., Cohen L. Sexual Violence and the Spectrum of Prevention: Towards a Community Solution. National Sexual Violence Resource Center 2006.

13. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999; 5:203-207.

14. Smedley BD, Syme SL, A social environmental approach to health and health interventions. In: Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C. National Academy Press 2000:4.

15. Banyard, V.L.; Plante, E.; and Moynihan, M. M. Bystander Education: Bringing a Broader Community Perspective to Sexual Violence Prevention. Journal of Community Psychology 2004 32: 61-79.

16. Steckler A., Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3^rd ed. San Francisco, CA: Jossey-Bass; 2002.

17. Freire P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
18. Wendell L French; Cecil Bell (1973). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall. chapter 8.
19. 
    
20. Berkowitz, A. Fostering Healthy Norms to Prevent Violence and Abuse: The Social Norms Approach. Preventing Sexual Violence and Exploitation: A Sourcebook. Wood and Barnes Publishers, 2007.

21. Berkowitz, A.; Jaffe, P.; Peacock, D.; Rosenbluth, B.; and Sousa, C. Young Men as Allies in Preventing Violence and Abuse: Building Effective Partnerships with Schools. San Francisco: The Family Violence Prevention Fund, undated. http://new.vawnet.org/Assoc_Files_VAWnet/YoungMenAllies.pdf

22. Morrison, S.; Hardison, J.; Anita Mathew, A.; and O’Neil, J. An Evidence-Based Review of Sexual Assault Preventive Intervention Programs. Research Triangle Park, N.C.: RTI International, 2004. http://www.ncjrs.gov/pdffiles1/nij/grants/207262.pdf

23. Langford L., DeJong W., Strategic Planning for Prevention Professionals on Campus, U.S. Department of Education, Office of Safe and Drug-Free Schools, Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention, Washington, D.C., 2008.

24. Bachar, K.J., and Koss, M.P. From Prevalence to Prevention: Closing the Gap Between What We Know About Rape and What We Do. In: Renzetti, C. M.; Bergen R. K.; and Edelson, J. L. eds Sourcebook on Violence Against Women, Thousand Oaks, Calif.: Sage Publications 2000.

25. Bartholomew, L.K.; Parcel, G.S.; Kok, G; and Gottlieb, N.H. Planning Health Promotion Programs: An Intervention Mapping Approach. 2^nd ed. San Francisco: Jossey-Bass, 2006.

26. American College Health Association. Publications and Reports. Baltimore, MD: American College Health Association. http://www.acha-ncha.org/pubs_rpts.html

27. Population Council. Yaari Dosti: A Training Manual. New Delhi, India. Population Council. , 2006.

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

1. Family Violence Prevention Fund Get the Facts. Domestic Violence Is a Serious, Widespread Social Problem in America: The Facts. San Francisco, CA: Family Violence Prevention Fund, 2008. http://endabuse.org/resources/facts/.
2. Felson R, Pare, P-P. The Reporting of Domestic Violence and Sexual Assault by Nonstrangers to the Police. University Park, PA: Pennsylvania State University, 2005.
3. Chen P et al. Randomized Comparison of Three Methods to Screen for Domestic Violence in Family Practice. Annals of Family Medicine 2007; 5:430.

4. Chen 433.

5. Horsburgh B. Lifting the Veil of Secrecy: Domestic Violence in the Jewish Community (pp. 207, 220). In: Sokoloff NJ, ed. Domestic Violence at the Margins: Readings on Race, Class, Gender, and Culture. Piscataway, NJ: Rutgers University Press, 2005.

6. Zink T et al. Mothers’ Comfort with Screening Questions about Sensitive Issues, Including Domestic Violence. Journal of the American Board of Family Medicine 2006; 19:363-364.

7. Chen appendix.

8. Lewis MJ et al. Perceptions of Service Providers and Community Members on Intimate Partner Violence within a Latino Community. Health Education and Behavior 2005; 32:75.

9. Curse (p.661). In: Langenscheidt Editorial Staff, ed. Langenscheidt Compact Spanish Dictionary. New York, NY: Langenscheidt, 2004.

10. Grossman SF, Lundy M. Domestic Violence across Race and Ethnicity: Implications for Social Work Practice and Policy. Violence against Women 2007; 13:1032.

11. Farrer CR. Play and Inter-Ethnic Communication: A Practical Ethnography of the Mescalero Apache. New York: Garland Publishing, 1990.

12. Cole TB. Is Domestic Violence Screening Helpful? Journal of the American Medical Association 2000; 284: 552.
13. Gerbert B et al. Simplifying Physicians' Response to Domestic Violence. Western Journal of Medicine 2000; 172:329-330.

14. Horsburgh 207.

15. Susser M, Susser E. Choosing a Future for Epidemiology: I. Eras and Paradigms. American Journal of Public Health 1996; 86: 671.

16. Feldman MA. Introduction: What is Early Intervention? (pp. 1-2). In: Feldman MA, ed. Early Intervention: The Essential Readings. United Kingdom: Blackwell Publishing, 2004.

17. New York State Department of Health. The Early Intervention Program: A Parent's Guide for Children with Special Needs - Birth to Age Three. Albany, NY: New York State Department of Health. http://www.health.state.ny.us/community/infants_children/early_intervention/parents_guide/step4.htm.

18. Boston Head Start and Children’s Services. Head Start. Boston, MA: Action for Boston Community Development, Inc. http://www.bostonheadstart.org/our-services/head-start/.

19. Boston Head Start and Children’s Services. Head Start Families. Boston, MA: Action for Boston Community Development, Inc. http://www.bostonheadstart.org/families/.

20. Chen P 433.

21. Horsburgh 207.

22. Farrer C.

23. Zuckerman B, Zuckerman P, Siegel D. Promoting Self-Understanding in Parents - for the Great Good of Your Patients. Contemporary Pediatrics 2005; 22: 78.

24. Contemporary Pediatrics Guide for Parents. Ask Yourself About Your Childhood - and Make Yourself a Stronger Parent. Woodcliff Lake, NJ: Contemporary Pediatrics. http://contemporarypediatrics.modernmedicine.com/contpeds/data/articlestandard//contpeds/162005/156681/article.pdf.

25. Hegel MT et al. Training Residents in Problem-Solving Treatment of Depression: A Pilot Feasibility and Impact Study. Family Medicine 2004; 36: 204-208.
26. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR. Randomised Controlled Trial Comparing Problem Solving Treatment with Amitriptyline and Placebo for Major Depression in Primary Care. BMJ 1995; 310: 441-445.

A Critique and a Proposed Alternative Intervention to Boston’s Youth Violence Prevention Programs-Elizabeth Gonzalez Suarez

In the mid 1990’s Boston began a concerted multi-agency effort to address youth violence, which had increased by 230% from 22 victims in 1987 to 73 victims in 1990. ⁽¹⁾ This alarming rate of youth violence brought city officials, and violence prevention experts to create a menu of programs with the goal of reducing youth violence in the city.

One of the leading programs was the Boston Gun Project initiated by the Boston Police Department. The goal of this program was to analyze and determine best strategies to prevent and control the spread of youth violence in the city. To accomplish this goal, the Boston Gun Project formed a working group of law enforcement personnel, youth workers, and researchers to analyze the nature of Boston’s youth violence. The working group concluded that youth violence in Boston “was largely the result of patterned, largely vendetta-like hostility among a small population of highly active criminal offenders –particularly those involved in about 60 loose, informal, mostly neighborhood-based gangs.” ⁽²⁾

As a result of this analysis, the Boston Police Department’s Youth Violence Strike Force (YVSF) developed a strategy named Operation Ceasefire. Operation Ceasefire “is a problem-oriented policing intervention aimed at reducing youth homicide and youth firearms violence in Boston”.⁽³⁾

The YVSF, an elite unit of 40 officer and detectives, convened an interagency working group, comprised of law enforcement personnel, youth workers, and members of Boston’s Ten Point Coalition of black activist clergy to collaborate in the implementation of “Ceasefire”. The group developed a “pulling levers” strategy, which consisted in reaching out directly to gangs clearly stating that violence will no longer be tolerated. The anti-violence and deterrence message was communicated directly to gang members in formal meetings or indirectly through meetings with inmates or gang outreach workers. The message was backed up by “pulling every lever” legally available when violence occurred. ^{(2, 3)}

Another component of Ceasefire was to partner with social service agencies to provide services and opportunities to gang members who wanted to step away from violence.

One of the biggest accomplishments of the Boston Gun Project’s Operation Ceasefire has been to bring law enforcement agencies to work together in a coordinated fashion. Historically, Boston’s criminal justice agencies have worked independently, competing for scarce resources without much coordination amongst them. After Ceasefire, these agencies have worked in collaboration to fund, equip, and carry out complex strategies for controlling and preventing youth violence. ⁽²⁾

Furthermore, the Boston Gun Project’s Operation Ceasefire invited a Black community faith-based organization, Ten Point Coalition, to work in collaboration with the Boston Police. The process to engage the Ten Point Coalition in this initiative was not easy, since historically the Ten Point Coalition leadership was highly and publicly critical of police efforts to prevent youth violence^.(2)

Operation Ceasefire dramatically decreased youth homicides in Boston from 73 cases in 1990 to 15 to 18 cases per year from 1997 until 2000. This represents a decrease of 58 cases from 1990 to 2000. After 5 successful years, since the year 2000 youth violence in Boston has begun to escalate seriously and consistently from 15 cases in 2000 to 67 in 2007 (see Table 1- omitted from blog, contact author). The average youth homicide rate in Boston was about 44 per year between 1991 and 1995. From 2004 through September 2008, the average rate is 57 youth homicides per year. ^{(1, 5)}

What happened? Why the Boston Gun Project’s Operation Ceasefire did not keep youth homicide rate from escalating again. I believe that the short-term success of this well-intentioned initiative is due to several factors: (1) the top-down approach to design and planning; (2) the failure to develop a comprehensive intervention to reduce the flow of illegal guns; and (3) the failure to use an ecological model to design and implement the program.

Argument 1: Top-down approach

Operation Ceasefire was designed and implemented by the Boston Police Department’s Youth Violence Strike Force with support from academia. Once the program was developed, it engaged a community faith-based organization, the Ten Point Coalition, and other community-based agencies. The people most affected by the violence, Boston minority residents, were not involved in the planning or designing of the program. There were not focus groups, key informat interveiews or participant observation conducted with the affected community to inform the design and development of the Initiative.

Community input was sought after the program was implemented by the creation of the Safe Neighborhood Initiative (SNI), with one major limitation, -this network of governmental, private and nonprofit agencies was invited to problem-solve around crime-related issues in the Boston area, and not to inform or adapt the program to the culture of the community. ^{(4, 5)}

Basically, the Boston Police agency, an agency not trusted historically by minority communities, designed the youth violence prevention program to be implemented in Boston minority community. ⁽²⁾

As illustrated above, one of the failures of the Boston Gun Project’s Operation Ceasefire was its top-down approach to designing and implementing the program. Furthermore, many of the factors incorporated in the Boston’s Youth Violence programs are derived from research conducted predominatly in white American, middle-class populations, and none of the approaches where tested via formative research or adapated to work in the intended population.⁽⁶⁾

Operation Ceasefire should have conducted a thorough formative research, including a community assessment of needs and strength of the neighborhood, school or community which would have identified community culture, capacity, potential acceptance, as well as its willingness to participate in the program. Through the needs assessment it could have determined what keeps gangs going, the why and how many of our youth are carrying guns, how easy is to get a gun in Boston, and so on. This work would have allowed Ceasefire to understand contextual factors necessary to develop community capacity for the program to work beyond law enforcement, and work toward a more equitable community where crime it is less likely to proliferate.

Argument 2: Failed to develop a comprehensive intervention to reduce the flow of illegal guns

In 2006, the Harvard Youth Violence Prevention Survey found that 65% of the 1,244 students surveyed in schools across the city reported witnessing one or more acts of violence in the past year, 30% did not feel safe in their neighborhood, 31% carried a knife in the previous 12 months, and 6% carried a gun. Forty two percent believed it was easy to get a gun, and 28% reported not feeling safe on the bus or train. ⁽⁷⁾

Based on survey results, Maria Vriniotis, a research specialist from the HYVPC concludes that the “underlying cause of the shootings and student’s fear of them is the accessibility of guns”. ⁽⁸⁾

When comparing the U.S. to other developed nations, “the United States has, per capita, the most guns (particularly handguns), the most permissive gun control laws, and the most death by guns.⁽¹⁰⁾ Miller et al.(2006) found that in states with more guns, a greater percentage of the population living in urbanized areas, higher robbery and assault rates, and poverty have higher rates of gun-related homicides. The authors concluded that a strong predictor of high gun homicide is easy access to guns. ⁽¹¹⁾

One component of Operation Ceasefire was to prevent illegal firearms trafficking by systematically addressing the pattern of firearms trafficking, for example, interstate trafficking in Massachusetts. Unfortunately, the impact of these efforts was minimal and “did nothing to reduce the existing stockpile of illegally acquired and possessed firearms in Boston”. ^(3).

To have a greater, long-term impact, Ceasefire should have gone beyond addressing illegal firearms trafficking. It should have conducted focus groups and key informant interviews with gang members, community and law enforcement leaders to understand how youth gain access to fire arms, where the guns used in a crime come from, and what needs to be done to effectively affect the flow of illegal guns in Boston.

Ceasefire could have worked with law enforcement agencies to develop stricter policies to reduce the flow of illegal guns. For example, it could have worked with local gun dealers to enforce what Wal-Mart just announced as part of its policy for selling firearms. Wal-Mart will be videotaping all firearms purchases, conducting background checks of employees, and creating a record and alert system for guns sold that were later used in crime. In addition, it could have worked with police to develop better tracking systems, destroy guns that come into police possession, and report all lost and stolen guns. ⁽⁹⁾

In neighborhoods where 30% of our youth do not feel safe, and 42% believe that is very easy to get a gun, it is not surprising that a higher number of kids are carrying knife and guns around. As reported by Kim-Ju, et al (2008) “gang formation is not simply a product of greed and irrational deviant behavior, but rather of youth member seeking protection from harassment and discrimination.” ⁽¹¹⁾

Ceasefire recognized that youth violence is in part a self-protective behavior, especially for youth living in high-risk neighborhood. For this youth having a gun and using it, as well as being part of a gang has a functional meaning, -keeping them alive, and belonging to a group that can protect them. Although, Ceasefire acknowledged these contextual factors it failed to address them in the intervention. The intervention was focus in using deterrence to keep gangs from committing criminal acts, but there was very little done to increase safety level in high-risk neighborhoods, and decrease poverty. Spiegle (1995) outlines a comprehensive gang intervention model that “views the presence of gangs as largely related to a lack of socioeconomic opportunities, social disorganization, poverty, institutional racism, social policy deficiencies, and lack of misdirected social controls”. ⁽¹²⁾

Argument 3: Failed to address contextual issues

Youth Violence is a complex public health issue which requires an ecologic and interdisciplinary approach. Youth Violence programs must understand and address the social-ecological context where youth violence occurs. Part of this approach requieres developing partnership with leaders and agencies serving in the high crime neighborhoods. It will also requiere a significant amount of qualitative researh to understand the community’s perception, needs, and capacity to address the problem. ^(13,14)

Operation Ceasefire failed to address broader contextual factors that influence youth-violence behavior, like poverty, discrimination and people feeling unsafe in their neighborhood. It failed because it did not use an ecological approach to understand, design, and implement the program. It failed because it focus on gangs individual behaviors and not on social, environmental, and policy factors which influence youth violence behavior.

Feeling unsafe and high rates of youth homicides are real issue in Boston’s low-income minority communities. A recent Blue Cross/Blue Shield Survey found that Boston residents living in poorer neighborhood “were three times more likely to say they are worried about neighborhood violence, compared to those in more affluent towns.” ⁽¹⁵⁾ Yet, Boston Youth Violence Prevention Program still develops interventions to address youth individual behaviors, not changing the social environment where the homicides occur.

In Boston, there is very little being done to systematically address poverty, institutional racism, and social policy deficiencies as it relates to high rates of youth homicides.

Interventions have been developed to work with social services agencies to provide at-risk youth with job training, leadership skills, summer programs, and so on but no intervention has been developed to address social and environmental factors influencing youth violence behavior.

For a Youth Violence Prevention program to be effective long-term issues like lack of socioeconomic opportunities, poverty, institutional racism, and social policy deficiencies would need to be addressed systematically by a comprehensive, multilevel intervention designed based on ecological model principles.

Boston Youth Violence Prevention: An Alternative Approach.

Using an ecological model⁽¹³⁾ to develop a comprehensive, multi-component intervention will result in a more effective and sustainable Youth Violence Prevention program that will address the three flaws identified above.

In an ecological model youth violence is conceptualized as an outcome of a complex system of influences in several domains (e.g., policy and regulations, sociocultural factors, the physical environment, and individual factors). ⁽¹³⁾ In this framework, an intervention which works at different levels from the individual to the policy level needs to be developed for behavior change to occur.

The proposed intervention will use a grassroots approach ⁽¹²⁾ , in which leading community-based organizations recognized by their leadership and capacity in working with youth will coordinate the youth violence prevention initiative.

The leading community-based organizations (CBOs) will begin the Initiative by conducting a thorough assessment which will involve: (1) identifying and developing partnerships with coalitions, agencies and organizations located in Boston high crime neighborhoods; (2) working with these coalitions and organizations to conduct qualitative research to understand the community’s perception of the issue, needs, and capacity to address the problem; and (3) in close collaboration with partners, developing an intervention to address youth violence at several levels, home, school and public policy.

This Initiative will work at the neighborhood level, and its intended to reach out the youth and community systems beloging to the defined neighborhood. The idea behind developing an intervention for each community is to facilitate the development of a culturally appropriate and sensitive intervention.⁽¹²⁾ Boston is not one community, but it is a city with many neighborhoods with unique characteristics, which need to be taken into account if a successful youth violence prevention intervention is to be developed.

The intervention will be developed using the evidence presented in the CDC Community Guide ⁽¹⁷⁾ under Youth Violence Prevention. The interventions identified by the Task Force on Community Preventive Services as having sufficient or strong evidence will be used, after adapting them to our intended community by using findings from the qualitative research.

The evaluation impact will be measure through out the duration of the program using neighborhood data provided by the Boston Public Health Commission⁽¹⁸⁾, and reports from the Boston police.

I. Grassroot Aprroach

In this phase, the leading CBOs, in collaboration with other community coalitions, agencies and organizations located in the identified high crime rate neighborhood (e.g. Jamaica Plain or South End) will conduct the formative research.

In each identified neighborhood, leading CBOs will meet with neighborhood coalitions, tenants’ associations, school boards, faith-based organization, community youth agencies, and representative from the Boston Public Health Commission. During these meetings, partnership and collaboration will be sought through exploring how concern they are about youth violence and how they would like to work on addressing the violence.

Once community organizations are invested and committed to addressing the violence, a series of focus group, key informant interviews and participant observations will be conducted. Community leaders, residents, teachers, and youth (including gangs and non-gang members) will be involved in the qualitative research phase of the program. During this assessment, information such as what they think keeps a high rate of youth violence in their community, what they have done to try to address the issue, what they would like to do stop the violence, and what they think the community has or needs to reduce the violence, will be explored. The qualitative research will be conducted focusing on identifying what community thinks will work in the eighborhood, and who and how should be involved.

II. Intervention Development: Using an Ecological Framework.

Once the qualitative research has been completed, the findings will be presented to the CBOs involved in the Initiative. Intervention plans will be discussed and a menu of programs will be offered based on the formative research findings, the CDC Community Guide and the Harvard Violence Prevention Center recommendations.

Following an ecological framework the proposed intervention will be multi-component, and it will include: (1) an early childhood home visitation program; (2) a universal school-based violence prevention program; and (3) an advocacy group to work with city officials to change social policies that are perpetuating youth violence in Boston, such as easy access to gun in Boston’s neighborhoods. ⁽¹⁰⁾

1. Early Childhood Home Visitation Program: Children who grow up observing violence or being mistreated by parents or guardiansat home are more likely to engage in aggressive behavior and violence later in life.⁽¹⁹⁾ There are sufficient evidence demonstrating the effectiveness of using an early childhood home visitation program to prevent child maltreatment. As a result, the leading CBOs will partner with the MDPH Early Intervention Program to train the Early Intervention Workers (EIW) to address the following areas with parents during their home visits: infant care, parenting, child abuse and neglect prevention, developmental interaction with infants/toddlers, development of problem solving and life skills for parents, assistance with educational and work opportunities and linkage with community resources. ⁽²⁰⁾ Based on the Community Guide recommendations, the program will target high risk families and will be implemented for more than two years to produce lager effects. If the assessment identified other agencies in the community providing home visitation programs to family and children, these agencies will also be invited to attend the training, thus they can be involved in delivering the program.
2. Universal School-Based Violence Prevention Programs: Based on the evidence, the Task Force on Community Preventive Services recommends the implementation of universal, school-based program to prevent violence behavior. This will include working with elementary, middle and high-schools located in the neighborhood. School boards and teachers will identify resources and time to bring the universal curriculum to the classroom. This Universal program is intended to be brought to the classroom to all children not only to the kids with behavioral problems. The curriculum is adapted to each grade level and includes: emotional self-awareness, emotional control, self-esteem, positive social skills, social problem solving, conflict resolution and team work.

The curriculum will be enhanced by the findings from the formative research, particularly the findings coming from the focus groups conducted with youth (gangs and non-gangs members). The goal will be to tailor the universal program to respond to the community’s unique charateristics, consequetly creating more salient messages.

3. Advocacy: The advocacy group will be formed by members from the leading CBOs and community coalitions. The group will focus on the following: (1) advocating with city official to bring more resources to high risk neighborhood, like employment, high qulatiy daycare and aferschool programs that low-income people can afford: (2) advocating to develop a comprehensive plan to reduce poverty and increase safety in high risks areas, for example improving the quality of housing communities, increasing green areas, bringing more business and employment to the neighborhood; and (3) advocating to stop illegal guns by working with the Boston Police to enforce better tracking systems, destroy guns that come into police possession, report all lost and stolen guns, and effectively affect the flow of illegal guns in Boston.

This intervention works in many levels to address the contextual factors influencing youth violence prevention. It does not only focus in changing gangs individual behaviors but works towards changing the environment (home and school) and policy factors which influence youth violence behavior.

Ideally, this type of Initiative will be funded by private foundations and will be carried out by community-based organizations with a clear track record of serving youth. In addition, the community-based organization will need to have the organizational capacity to run a program that requires working in collaboration and partnership with many other community agencies. Lastly, using an ecological framework for program designed and a grassroots approach to mobilize community around this issue will result in sustainable changes in communities systems, as well as increase in social capital, and change in social norms resulting in long term changes. ^(12,13,15)

REFERENCES

1. Kennedy School of Government, Harvard University. Operation Ceasefire/Boston Gun Project. Cambridge, MA. Program in Criminal Justice Policy and Management. http://www.hks.harvard.edu/criminaljustice/research/bgp.htm

2. Kennedy School of Government, Harvard University. Creating an Effective Foundation to Prevent Youth Violence: Lessons Learned from Boston in the 1990s by A. Braga and C. Winship. Cambridge, MA. RAPPAPORT Institute for Greater Boston. http://www.hks.harvard.edu/rappaport/downloads/policybriefs/brief_tenpoint.pdf

3. Braga, A.A., Kennedy, D.M., et al. Problem-Oriented Policing, Deterrence, and Yoth Violence: An Evaluation of Boston’s Operation Ceasefire. Journal of Research in Crime and Delinquency 2001; 38 (3): 195-225.

4. NCJRS. Youth Violence: A Community-Based Response. One City’s Success Story. http://www.ncjrs.gov/txtfiles/boston.txt

5. NCJRS. Boston Strategy to Prevent Youth Violence. http://www.ojjdp.ncjrs.org/pubs/gun_violence/profile02.html

6. http://www.boston.com/news/local/articles/2008/09/18/ShootingvictimsinBostonbyagegroup/

7. Kerns, Suzanne E. U., Prinz, R.J. Critical Issues in the Prevention of Violence-Related Behavior in Youth. Clinical Child and Family Psychology Review, 2002; 5 (2):133-160

8. The Boston Data Project: Fact Sheet. What Kind of World Do You Want to Live in? Results on Weapon Carrying from the Boston Youth Survey. Boston, MA: Harvard Youth Violence Prevention Center. http://www.hsph.harvard.edu/hyvpc/research/boston-youth-survey/index.html

9. The Boston Globe. Youth no Longer a Refuge. http://www.boston.com/news/local/articles/2008/09/18/youth_no_longer_a_refuge/

10. Hemenway, D. Protecting Children from Firearm Violence. Big Ideas for Children: Investing in Our Nation’s Future http://www.firstfocus.net/Download/19-Hemenway.pdf

11. Miller, M., Hemenway, D., & Azrael, D. State-level Homicide Victimization Rates in the US in Relation to Survey Measures of Household Firearm Ownership, 2001-2003. Social Science and Medicine 2007; 64: 656-664

12. Kim-Ju, G. Mark, G.Y. Community Mobilization and Its Application to Youth Violence Prevention. American Journal of Preventive Medicine 2008; 34 (3S): S5-S12.

13. Spiegel, I. The Youth Gang Problem: A Community Approach. New York, NY: Oxford University Press, 1995.

14. Mark Edberg. Essentials of Health Behavior: Social and Behavioral theory in Public Health. Sudbury, MA: Jones and Barlett Publishers, 2007.

15. Watson-Thompson, J. Fawcett, S.B. et al. A Framework for Community Mobilization to Promote Healthy Youth Development. American Journal of Preventive Medicine 2008; 34 (3s): S72-S81.

16. The Boston Globe. Concern Over Safety oaring in HubArea: Study Finds Link Between Health, Fear of Violence. http://www.boston.com/news/local/massachusetts/articles/2008/11/13/concern_over_safety_soaring_in_hub_area/

17. Guide to Community Preventive Services: Systematic Reviews and Evidence Based Recommendations. Violence Prevention. http://www.thecommunityguide.org/

18. Boston Public Health Commission. Health Status of Youth 2007. http://www.bphc.org/news/report.asp?id=239

19. Guide to Community Preventive Services: Systematic Reviews and Evidence Based Recommendations. Violence Prevention. Chapter 9. Violence. http://www.thecommunityguide.org/violence/Violence.pdf

20. Guide to Community Preventive Services: Systematic Reviews and Evidence Based Recommendations. Violence Prevention. New Findings Demonstrate Early Childhood Visitation Prevent Child Maltreatment. http://www.thecommunityguide.org/violence/viol-int-homevisit.pdf