An Ecological Model for Family Violence Prevention Across the Life ...

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An Ecological Model for Family Violence Prevention Across the Life Cycle Jo Marie Reilly, MD; Judith A. Gravdal, MD

BACKGROUND AND OBJECTIVES: Family violence (FV) impacts individuals and their families, their communities, their physical health, and the economic health of society. The origins of FV are complex, and relationships among historical, cultural, interpersonal, and intrapersonal components are poorly understood. The morbidity, mortality, and cost of FV are enormous. This paper introduces an ecological model for FV prevention through the life cycle—from child abuse through interpersonal violence and to elder abuse. The model incorporates medical as well as social, justice, and educational literature about violence prevention efforts and programs. Health care professionals, particularly in family medicine, are on the front line of preventing family violence. The responsibilities and competencies related to preventing/addressing family violence include (1) identifying risk factors, (2) noting early signs and symptoms, (3) assessing for violence within families, (4) managing sequelae to minimize morbidity and mortality, (5) knowing/using referral and community resources, and (6) advocating for changes that promote a violence-free society. The model presented in this article provides a holistic approach to FV. This model can be applied to the Patient-centered Medical Home to promote educational initiatives, inter-professional collaborations, and community and population-based efforts to prevent and to decrease violence. (Fam Med 2012;44(5):332-5.)

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amily violence (FV) has broad impact and significant consequences to individuals, families, and communities. Only since the 1960s has FV been seen as a problem requiring a solution, rather than a “personal matter.” Violence arises from and is perpetuated by historical and cultural factors, interpersonal and intrapersonal stresses, and belief systems. Family violence and its sequelae threaten physical and emotional health, relationship integrity and function, and community stability. The costs of FV, economic and non-economic, are enormous.1 332

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The FV prevention tactics, programs, and scholarship needed to address the problems are rapidly evolving.2 The professional obligations and practice scope of family physicians and other health care workers place them in a central role for identifying and preventing family violence. Prevention efforts in clinical settings include (1) identifying risk factors (for both victims and perpetrators), (2) being aware of early signs and symptoms of FV, (3) assessing for violence in families, (4) managing sequelae to minimize morbidity and mortality, (5) knowing referrals and

community resources, and (6) advocating for societal change that promotes a violence-free environment. Strategies for violence prevention occur on four levels: primary, secondary, tertiary, and quaternary.2-4 At every stage of the life cycle and in every arena of human relations, each level needs to be understood and addressed. Failure to address violence that occurs across the life continuum and within micro and macro systems of human relations results in missed opportunities for violence detection, violence interventions, and violence prevention. Primary prevention addresses tactics that improve relationships, strengthens communities, and prevents abuse from occurring. Any human being can become a victim of FV, so the goal of primary prevention is to ensure that this possibility is reduced. The goal of primary prevention is to ensure that this possibility does not become a reality. Secondary prevention entails intervention with individuals and populations at high risk and/or soon after maltreatment occurs. Awareness of known risk factors also provides opportunities for education and early intervention. Alertness to early signs of FV allow for early secondary prevention resource deployment.

From the Keck School of Medicine at the University of Southern California (Dr Reilly); and Advocate Lutheran General Hospital, Park Ridge, IL (Dr Gravdal).

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Tertiary prevention efforts strive to ensure that although FV has occurred, recurrent abuse is avoided. These interventions can ensure that victims are neither caught up in a vicious cycle of abuse nor transformed into perpetrators. Tertiary prevention recognizes that FV is a chronic disease requiring ongoing surveillance, support, and intervention. Quaternary prevention educates caregivers and ensures that they possess the knowledge, skills, and resources to both provide compassionate, quality care and to help them cope with the stress of caring for abused victims and perpetrators.4 Quaternary prevention has two components. The first component is the avoidance of iatrogenic harm inflicted upon victims by well-meaning but poorly equipped professionals. The second component acknowledges the toll that working in the field of FV can exact on professionals. It is imperative that health care professionals practice self care. FV prevention optimally uses concerted, multi-pronged, multidisciplinary, and longitudinal efforts. Individuals, families, educational systems, health care entities, communities, cultures, and societies are impacted by FV, but, more importantly, they possess the ability to influence and prevent FV. Health care professionals must collaborate with community members and other professionals (eg, public health, education, social services, law enforcement, advocates, and politicians) to reduce FV. Development and assessment of an integrated response is complex. The traditional medical model alone is insufficient5,6 because it fails to address the psychological, family, society, community, and legal arenas in which human relationships interplay and, thus, misses opportunities for violence intervention. Additionally, it does not embrace the opportunities to address the FV that presents in multiple settings and across disciplines.

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Methods

The authors systematically reviewed the literature on preventing family violence. The following key search terms were used to identify relevant articles: family violence, domestic violence, child abuse, inter-partner violence (IPV), elder abuse, and primary, secondary, tertiary, and quaternary prevention. The authors also reviewed references cited in relevant articles on family violence. Medical, social science, education and justice literature was explored. Recurrent themes in the violence prevention literature included (1) the identification and modification of risk factors, (2) efforts to foster and strengthen healthy relationships and families, (3) strategies that ensure public safety, (4) the need to address cultural issues and biases, and (5) the reduction of barriers that limit access to education, social services, and health care. Unfortunately, the existing literature approaches violence in professional silos as well as age silos. The existing literature also fails to acknowledge the intersection of various forms of violence on victims and families. Violence does not happen de novo and is rarely a single event. Violence is usually recurrent, happening to the same person at multiple times over the lifespan and is often passed from one generation to another. The authors simultaneously identified ecological methods and models. Ecological models expand both perspective and responsibility into a holistic approach, allow for an integrated approach to prevent violence, and call for inter-professional initiatives.7-9 The interconnectedness of violence among individuals, within relationships and families, and across communities and society underscores the need for collaboration across disciplines. In particular, the work of Little in child and intimate partner abuse,10 Heise in intimate partner abuse,11 and Doty in elder abuse12 influenced the formation of a family violence model that spans

the life cycle. These models allow for a collective response to violence, noting the connection of violence within families and communities.

Results

The authors provide an ecological model to prevent FV through the life cycle (see Figure 1).13 This model examines violence across all stages of life and its interconnectedness to family, community, and society. Additionally, it demonstrates FV in multiple arenas of human activity. The variety of studied prevention strategies include educational, health care, community-based and societal and legal interventions, and the range of their impact are depicted. Primary, secondary, tertiary, and quaternary preventions apply to each ring and to every strategy.

Discussion

Family violence prevention begins prior to birth within the personal and family realms. Interventions require an understanding of the unique risks and vulnerabilities that predispose to FV. Factors that lead to a victimized child becoming a victim of inter-partner violence and, later, an abused elder, or to becoming a perpetrator continue to be clarified. Unless FV is understood and addressed, the cycle of violence may be perpetuated. A responsive, educated health care provider has a unique opportunity to address violence within the family unit and to empower individuals by providing resources on stress management, counseling, firearm safety and substance abuse education, and referrals to appropriate agencies. A specific example of how the model addresses the silos of concern and care is how violence is portrayed in various media. A comprehensive FV prevention strategy must understand and address how violence is portrayed in television, movies, music, radio, video games, and via Internet, texting, and tweeting. Media violence is pervasive, insidious

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Figure 1: Ecological Model for Family Violence Prevention Across the Life Cycle

Gravdal and Reilly 2011.13 Reprinted with permission.

and underestimated as it perpetuates a significant degree of violence among individuals and in our society. Health care providers, educators, and legislators must work together to promote images and messages that are violence free and promote and model respectful, safe, healthy relationships. This work can never begin too early in the life of an individual or the lifecycle of a family.14 The ecological model presented in this paper invites the health care team, educational system, community, society, and legal system to empower individuals and families to use proven and available resources and to work together in doing so. Health care providers and those charged with the social welfare and safety of others must become educated about FV risk assessment tools and contribute to developing and evaluating more effective tools.

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Health care providers need to be familiar with and utilize violence prevention resources. These include parenting classes, religious organization support, school-based education, community centers and programs for all ages, elderly respite care centers, abuse hotlines and safe living environments, victims assistance programs, job training, and advocacy and legal resources. The use of these resources and referral options must be recognized as basic competencies in medical education. Those who regularly identify and intervene in FV face a tremendous challenge to remain compassionate and empathic. This model reminds health care providers that their work is neither solitary nor rests solely on any one person. Programs that educate health care providers, promote caregiver wellness, and/or prevent caregiver burnout must contain

well-designed and evaluated content on FV prevention/identification in their curricula.15

Weaknesses/Limitations

The ecological model presented represents a theoretical picture of FV prevention. Dissemination of this model invites theoretical critique to confirm or challenge the face validity of the model. Studies are needed to validate this ecological model for FV. Practical investigation requires implementing and evaluating the model in educational programs. The model should be tested in multiple arenas, including medical education (at all levels), patient education, community education, and education of other professionals who collaborate on FV prevention efforts. One approach to validation of such models has been described by Rykiel.16 A clear understanding of the model’s

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purpose, how it performs, and what its intended context is must be stated. Four components include conceptual validation (face validity and event validity), qualitative validation (comparison to other models and other qualitative evaluations), quantitative evaluation (research providing data), and statistical validation. Evaluation and research are needed to drive educational efforts, training practices, community resources, and legal reforms to proven strategies for preventing FV. Studies investigating the acceptance, utility, and various applications of this model are needed.

Conclusions

Health care providers must both advocate for and develop tools for concerted and effective efforts in violence prevention. A holistic approach to FV is relevant to the Patientcentered Medical Homes currently being constructed and evaluated. It is also critical to the Accountable Care Organizations and newer models of care delivery currently being developed. Educational initiatives are needed at many levels, for all disciplines and in many venues. Health care professional violence prevention education must be both interdisciplinary and inter-professional. This ecological model underscores the imperative to develop creative, collaborative educational programs. These include programs for and by health care professionals, preschool through graduate school educators, community workers, the legal system, public safety officials, and governmental agencies and officials. Education must engage individuals, communities, and professionals. Each initiative requires careful design and critical evaluation methods. This model illustrates the central role of community and populationbased efforts for the prevention of family violence. Measurement will allow the identification of problems not yet solved, new problems, and

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successful interventions. Clearly defined terms and standardized metrics are prerequisites to furthering this work. The development of a comprehensive and shared family violence database would further the innovation and evaluation of prevention strategies. Further study of this ecological model is needed. Both research needs and opportunities are great in the area of FV prevention.17 The literature is beginning to shed light on causes and prevention. A standardized, integrated, and multidisciplinary approach to violence prevention will lead to healthier individuals and safer communities. Adequate local, state, and national funding would encourage collaborative, inter-disciplinary research across education, legal, and health care fields. The ecological model of family violence prevention presented in this paper illustrates the complex interplay of individuals, family units, educational settings, health care, community, and society across the life cycle. The model gives health care providers and educators a useful tool to prevent and ameliorate FV. It offers integrated strategies that incorporate the perspectives, language, and tools of other disciplines. This model offers a holistic approach and depicts both the challenges and opportunities in developing comprehensive FV intervention programs. As stated in the World Report on Violence and Health, “Recognizing violence and its effects may require a great deal of courage and fortitude as many faces of violence go deep into the roots of families, societies and cultures.”1

2. Doll LS, Saul JR, Elder RW. Injury and violence prevention interventions: an overview. In: Doll LS, Bonzo S, Sleet D, Mercy J, Haas EN, eds. Handbook of injury and violence prevention. New York: Springer, 2007:21-30.

CORRESPONDING AUTHOR: Address correspondence to Dr Reilly, Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, KAM B-29, Los Angeles, CA 90033-9039. 323-442-2439. Fax: 323-442-3051. [email protected].

15. Spickard A, Gabbe S, Christensen J. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288(12):1447-50.

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16. Rykiel EJ. Testing ecological models: the meaning of validation. Ecological Modeling 1996;90:229-44. 17. Dahlberg LL, Butchart A. State of the science: violence prevention efforts in developing and developed countries. Int J Inj Contr Saf Promot 2005;12(2):93-104.

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