State Violence and Injury Prevention Programs - OPP OD Comments (10.11.12)

Preventing Intimate Partner Violence, Teen Dating Violence and Sexual Violence Saves Lives

Unhealthy relationships can start early and last a lifetime. Dating violence often starts with teasing and name-calling. These behaviors may be thought of as a “normal” part of a relationship, but can set the stage for more serious violence like physical assault and rape. The Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control (CDC’s Injury Center) is providing leadership in understanding and preventing intimate partner violence (IPV), teen dating violence (TDV) and sexual violence (SV) before it begins. Evidence indicates strategies promoting healthy behaviors in relationships are important, though there is still more to learn about preventing these types of violence.

Public Health Problem

IPV, TDV and SV are serious public health problems in the United States. SV refers to sexual activity where consent is not obtained or freely given. Survivors often experience long-term health problems and emotional impacts and often engage in negative health behaviors. Although there is overlap between IPV, TDV and SV, they are distinct forms of violence with some unique risk factors, patterns and consequences. The term “IPV” describes physical, sexual or psychological harm by a current or former partner or spouse. TDV is defined as physical, sexual,or psychological/emotional violence within a dating relationship.

Youth who perpetrate TDV (both physical and SV) are at increased risk for perpetrating violence against an intimate partner as adults. Prevention offers an important opportunity to reduce levels of intimate partner and SV across the life course.

•  On average, 24 people per minute are victims of rape, physical violence,or stalking by an intimate partner in the United States. Over the course of a year, that equals more than 12 million women and men.

•  More than one million women report being raped each year and 1 in 5 women reported being raped in their lifetime (1 in 71 men reported having been raped in their lifetime).

•  Of the 1336 homicides due to IPV in 2010, 82% of the victims were women.

•  IPV disproportionately affects young people. The majority of victims first experienced some form of IPV prior to age 25.

•  One in 11 high school students report being a victim of physical abuse (hit, slapped, or physically hurt) by a dating partner each year.

•  In 2010, the medical care, mental health services and lost productivity (e.g., time away from work) cost of IPV exceeded $8 billion.

Promising Strategies

While CDC’s Injury Center has identified promising TDV prevention strategies, less is known about how to prevent intimate partner and SV. In order to make significant progress in reducing and preventing all types of violence more research and evaluation is needed to develop and evaluate promising and effective strategies. CDC has played an important role in developing and evaluating promising strategies promoting healthy relationships and building social contexts preventing TDV, IPV, and SV perpetration.

TDV Prevention

Two examples of evidence-based school-based TDV prevention programs include Safe Dates (a proven, interactive curriculum for 8th grade students) and Fourth R (an interactive curriculum with core lessons about healthy relationships, sexual health and substance use prevention for 8th and 9th grade students). Both programs have been rigorously evaluated and have sufficient evidence to be considered promising for preventing violent teen dating relationships.

IPV Prevention

While TDV prevention programs such as Safe Dates and Fourth R may also be effective at preventing IPV, most studies have not followed participants into adulthood to examine whether these programs have lasting effects on participants. This type of research would greatly assist in understanding the evidence around what works to prevent IPV.

SV Prevention

The high incidence and terrible consequences of SV highlight the urgent need to develop effective prevention programs. Brief, one-session programs intended to raise awareness about SV are not sufficient to produce change in sexually violent behavior. Promising emerging strategies are more comprehensive, include multiple sessions and address key risk factors for SV in adolescence. These promising programs focus on addressing SV prevention within the context of building healthy teen dating relationships, and often involve building bystanders’ skills to intervene and change expectations about the acceptability of SV.

Unique Role of the CDC Injury Center and Federal Partnerships

CDC’s Injury Center works to understand the effectiveness of strategies that address risk factors for teen dating, intimate partner and SV perpetration (such as hostile attitudes towards women or abuse of alcohol or drugs); modify social norms and values condoning or tolerating violence; and promote a social context intolerant of violence. CDC Injury Center’s evaluation and research activities are designed to inform programmatic activities by identifying and developing evidence-based and evidence-informed prevention strategies for implementation in the field by state and local grantees.

CDC ‘s Injury Center works to understand the problem; develop an evidence base for primary prevention through the identification of risk/protective factors and promising prevention strategies, and disseminate evidence-based strategies promoting respectful, nonviolent intimate partner relationships through individual, community and societal level change. CDC’s unique prevention focus complements the efforts of other federal agencies. Other federal agencies focus on responding to TDV, IPV and SV after the violence occurs, typically stopping repeat perpetration or victimization.

TDV, IVP, SV Prevention in Action

CDC’s Injury Center prevention efforts are focused on defining the problem and evaluating program effectiveness and scalability.

Understanding the Problem

Preventing TDV, IPV and SV begins with understanding the nature of the public health problem, its scale, where it is, and whom it affects. CDC’s Injury Center is actively involved in developing surveillance and data systems to capture this information. Surveillance data are critical as they help raise awareness about the magnitude of the problem and the characteristics of individuals and communities most at risk for TDV, IPV and SV. These data are also used to inform and target primary prevention strategies by states and communities to address TDV, IPV and SV. Examples of current activities include:

National Intimate Partner and Sexual Violence Survey (NISVS)

CDC’s Injury Center has developed NISVS, an ongoing, nationally-representative telephone survey collecting detailed information on SV, stalking and IPV victimization of adult women and men in the United States. The survey collects data on past-year and lifetime experiences of violence. CDC launched NISVS in 2010 and published the first summary report in December 2011. The survey provides baseline data in order to track trends in SV, stalking and IPV. CDC developed NISVS to better describe and monitor the magnitude of these forms of violence in the United States.

Understanding the Relationship between Bullying and SV Perpetration

CDC’s Injury Center has supported the first study to examine the association between bullying experiences and co-occurring and subsequent SV (including sexual harassment and unwanted sexual activities) among middle school students. Preliminary data provide evidence that bullying perpetration is associated with SV perpetration. Other analyses are focusing on the effects of homophobic teasing and masculinity on the relationship between bullying and later SV perpetration, and CDC is developing user-friendly summaries of study findings to be shared with Rape Prevention Education (RPE) grantees and other SV partners to inform prevention efforts nationwide.

Evaluating Program Effectiveness and Scalability

In order to direct limited prevention resources most effectively, it is critical to understand the programs and strategies with the highest likelihood of being effective in preventing TDV, IPV and SV. CDC’s Injury Center is identifying what works for whom, and under what conditions. CDC’s Injury Center is developing and evaluating promising programs and strategies to prevent violence with a focus on those that are both replicable and scalable.

Implementing and Evaluating Dating Matters

Dating Matters is a comprehensive community-wide TDV prevention initiative to promote respectful, nonviolent dating relationships among youth in high-risk urban communities, with a focus on 11-14 year olds. It is engaging the local health department and uses evidence-based programs for students and their parents, and supports the skills learned through educator training, local policy development and a communication campaign using social media and text messages. This prevention initiative is being delivered in 45 middle schools across four cities (Baltimore, MD; Chicago, IL; Ft. Lauderdale; FL and Oakland, CA) and includes a rigorous evaluation as well as cost analysis.

Conducting a Rigorous Evaluation of Green Dot SV Prevention Program

CDC’s Injury Center is funding a rigorous, large-scale evaluation trial of the Green Dot program (a prevention strategy designed to motivate individuals to take action in situations where others are at risk for violence) for the prevention of SV and TDV among high school students. This evaluation will result in critically important data on the impact of Green Dot on SV behaviors among high school-aged youth.

Evaluating Second Step: Student Success Through Prevention

Second Step: Student Success Through Prevention is a middle school prevention program targeting the shared risk and protective factors for bullying, SV and dating aggression. Currently, the program is being evaluated in 32 sixth grade classrooms in Illinois and Kansas. The evaluation of Second Step will provide valuable information about whether this program is effective at preventing the onset of SV and TDV behaviors. Results of the evaluation will be available in 2013. Findings from the study will be used to inform evidence-based prevention strategies used in Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) and Rape Prevention and Education (RPE).

Evaluating Nurse Family Partnership and IPV Prevention

CDC’s Injury Center is evaluating the effectiveness of incorporating IPV components in the Nurse Family Partnership (NFP) home visitation program. The new components include training and a standardized assessment to help nurses better detect and respond to IPV, a secondary prevention component for mothers who disclose IPV to their nurse and a primary prevention component for all NFP participants. This project, which involves a rigorous trial of NFP with the IPV components, has the potential to impact the effectiveness of the most widely used evidence-based home visitation program on child and maternal health and to reduce IPV among teen mothers and adults.

Successes

CDC’s Injury Center has had a number of successes including:

Research and Evaluation

Results from two (2) CDC Injury Center funded research trials were published in 2012. The research team in one study developed and tested the first family-based TDV prevention program, Families for Safe Dates. The program was effective in promoting changes in the family context to provide a foundation for preventing teen dating abuse over time, decreasing teen acceptance of dating abuse and preventing dating abuse victimization. The second trial evaluated the Coaching Boys to Men Program developed by Futures without Violence. The study was conducted in five large urban school districts in Sacramento County, California. The evaluation of this athletic coach-delivered violence prevention program showed increases in high school male athletes’ intentions to intervene and bystander intervention behaviors.

National Intimate Partner and Sexual Violence Survey (NISVS)

NISVS is a public health surveillance system designed to describe the magnitude of SV, stalking and IPV victimization in the United States. CDC’s Injury Center has released a national report and a new special report including findings on victimization by sexual orientation. Several additional in-depth reports are in the process of being developed. Future reports will continue to provide updated estimates of the prevalence of victimization among various subgroups and improve our understanding of the impacts of these experiences.

IPV Screening Trial

CDC’s Injury Center conducted a randomized control trial to examine whether screening women for IPV and giving them information on partner violence resources improved their health. The study, published in 2012, was conducted with 2700 women seeking services in primary health care clinics. It compared three groups of women – women who were screened and provided a list of partner violence resources; women who were not screened but given a list of partner violence resources, and a control group of women who were not screened and did not receive a list of partner violence resources. No significant differences were found between the three groups of women studied in their physical or mental health, days lost from work or household activities, use of health services or partner violence-related services, or the recurrence of partner violence. These findings suggest passive referral to services and other resources is not enough. CDC’s Injury Center hopes this study will be considered together with others to inform decisions about the kinds of interventions of benefit to women who disclose partner violence in primary care settings.

Future Goals

CDC’s Injury Center will strengthen its efforts to prevent SV, TDV and IPV by:

•  Developing a sustainable microfinance intervention to address the dual challenges of IPV and HIV/STD transmission to bolster men’s and women’s health in low-income, urban, African-American communities. Recent international evidence suggests microfinance programs (MFPs) can be adapted for health threats such as IPV and HIV/AIDS contraction. Although promising, this work must be adapted to implement within the sociocultural and economic context of the US. MFPs increase family income and a community’s economy through the provision of financial services and economic opportunities to people who cannot access traditional financial resources. Additionally, MFPs may be a fundamental lever for reducing health disparities, and consequently, improving health outcomes. Such a transformative, economic innovation has the potential to reduce health risk behaviors with the ultimate goal of improving the health of individuals and the communities.

•  Continuing to implement NISVS results and to use data to address gaps in knowledge about IPV, TDV and SV, and to understand the impacts and latest trends.

•  Working to identify risk and protective factors for the perpetration of IPV, TDV and SV. This will advance our understanding of the key factors placing individuals at risk for engaging in these forms of violence, and identify those factors presenting promising avenues for prevention. This research will open the way for the development and evaluation of prevention strategies that reduce risk, promote healthy relationships and prevent violence, including strategies for addressing individual, relationship, and community level factors .

•  Continuing to support efforts to develop, disseminate and implement comprehensive evidence-informed and evidence-based SV, IPV, and TDV strategies, through programs such as DELTA and RPE, including the addition of an evaluation component in the RPE program.

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