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Many efforts to reduce family violence are documented in the published literature. We conducted a systematic review of interventions intended to prevent family violence in Aboriginal communities. We retrieved studies published up to October 2009; 506 papers included one systematic review, two randomized controlled trials, and fourteen nonrandomized studies or reviews. Two reviews discussed interventions relevant to primary prevention (reducing the risk factors for family violence), including parenting, role modelling, and active participation. More studies addressed secondary prevention (where risk factors exist, reducing outbreaks of violence) such as restriction on the trading hours for take away alcohol and home visiting programs for high risk families. Examples of tertiary prevention (preventing recurrence) include traditional healing circles and group counselling. Most studies contributed a low level of evidence.
The United Nations Population Fund (UNPA) lists sixteen forms of violence directed against women. The most common are repeated assaults, physical and psychological, within families (UNPA, 2010). Family violence can include action that “endangers the survival, security or well-being of another person (College and Association of Registered Nurses of Alberta, the College of Licensed Practical Nurses of Alberta, and the College of Registered Psychiatric Nurses of Alberta, 2008). The Royal Commission on Aboriginal Peoples (RCAP) considered the infrastructure of family violence as “the serious abuse of power within family, trust or dependency relationship” (RCAP, 1996).
It is not only women who suffer. Infants in violent families experience adverse effects along with their mothers, and abuse of boys is common (Boy and Salihu, 2004). The term “family violence” reflects this suffering of all members of the family (including the perpetrators), and the children of these families are at increased risk of developing personality disorders, mental health problems, poor self esteem, and low educational achievement (Bair-Merritt et al., 2006).
Several interrelated factors contribute to high levels of family violence experienced in Aboriginal communities. These include poor socioeconomic conditions, high rates of alcohol and substance abuse, systemic discrimination and racism against Aboriginal Peoples, as well as the trauma and inter-generational cycle of violence resulting from the residential school legacy, and the impact of colonialism on traditional values and cultures (RCAP, 1996).
The Aboriginal-specific literature on family violence is sparse; a brief review summarizes what is known about the effectiveness of interventions in nonindigenous communities, and comment on the applicability of successful interventions in Aboriginal communities. The primary focus of this review is the relevance of initiatives to reduce family violence in Aboriginal communities in Canada.
The term “systematic review” refers to exhaustive searching, selecting, collating, appraising, interpreting, and summarizing data from original studies (Cook et al., 1997). These studies may be observational or randomized trials, qualitative or quantitative. Limited to published material, a well known difficulty of systematic reviews is that component studies are simply too different in the way they approach a problem for the information each offers to add up. When the quality of primary studies is poor, a systematic review can at best note the flaws; it cannot improve the data.
There is currently no agreed classification for interventions addressing family violence. Table 1 offers a standard prevention framework (primary, secondary, and tertiary prevention) including examples from the Human Rights and Equal Opportunity Commission in Australia (HREOC, 2006). Tertiary prevention of family violence receives most attention and research investment; it focuses on the protection and care of victims, and punishment and rehabilitation of perpetrators with the intention of reducing recurrence. Secondary prevention identifies those with risk factors and prevents their progress to overt violence through screening, counselling, or removal of the risk factor. Primary prevention receives less research interest and public funding; this seeks to avoid the genesis of risk factors for family violence.
In the characterization of interventions intended to reduce family violence, holistic refers to the fullness of interventions at any one of these levels, as they include spiritual, cultural, and other dimensions of indigenous ways of life.
We developed a protocol to summarize and evaluate the intervention studies in indigenous communities. Initial literature scans identified published systematic reviews as a means of summarizing several hundred studies. We extracted relevant reviews of intervention studies conducted in Aboriginal and non-Aboriginal communities at this stage. Beverley Shea and Amy Nahwegahbow assessed all publications to identify relevant studies and included these in the review. We searched for primary studies published up to and including October Week 3 2009 using MEDLINE, PsycINFO, HealthSTAR, North American Indian Biographical Database, Violence and Abuse Abstracts 2001–2004, EMBASE, Global Health, and the Cochrane Library. Search terms varied by database.2
We did not limit the searches by study type. Beverley Shea and Amy Nahwegahbow read the full text of these studies. We confined our literature retrieval to studies that provided qualitative and quantitative estimates of prevention. Formal assessment of randomized trials used the SIGN 50 instrument (SIGN, 2010) and non-randomized studies relied on the Effective Practice and Organization of Care instrument (EPOC 2010). However, the broad range of the other study types required an informal approach to quality assessment and precluded any attempt at data pooling.
The search yielded 506 citations up to October 2009. Combinations of search terms identified a smaller number of potentially relevant titles from each database: MEDLINE (93), EMBASE (26), and CENTRAL (28), psychINFO (96), Global Health (16), North American Indian Biographical Database (70) Violence and Abuse Abstracts (6). There was considerable overlap between the retrieval lists for these databases. Beverley Shea and Amy Nahwegahbow examined all titles and identified 27 articles describing school and community-based interventions aimed at decreasing family violence (see Figure 1). We excluded 12 studies that did not describe or test interventions to prevent family violence in Aboriginal communities (Appendix 1). A key inclusion criterion was that studies involve an indigenous population, whether the intervention was at individual or community level. One of eleven studies in the single systematic review (Whitaker et al., 2006) included Aboriginal participants (Table 2).
We identified two randomized controlled trials (RCT) of interventions in indigenous communities (Duggan et al., 2004; Duggan et al., 2007) and fourteen nonrandomized studies (Tables 3 and and4).4). These interventions include: community injury prevention (role modelling, life span focus, accessibility, acceptability and active participation), restriction on the trading hours for take away alcohol, home visiting, parenting, traditional healing circle and group counselling provided in an Aboriginal health setting. The methodological quality of the two RCTs was 60% (Duggan et al., 2004) and 66% (Duggan et al., 2007) while that of the other studies ranged from 29%–45%.
Table 2 lists nine systematic reviews that together summarize much of the large literature on the prevention and reduction of family violence in non-indigenous communities. Despite the international importance of the subject, few high quality intervention studies appear in the literature. Every systematic review and task force report concludes with a call for more and better studies on family violence.
Two RCTs in the review by Andersson and colleagues (2008) point to promising ways to reduce interpartner violence in Africa: a randomized controlled trial of income enhancement and gender training resulted in reduced gender violence and HIV risk behaviours (primary prevention), and a trial of a participatory learning program reported a reduction of male risk behaviours.
Other interventions that one might expect to help in practice have not done so in well conducted studies. Screening female patients by health professionals, for instance, increased referral for counselling but did not reduce subsequent episodes of abuse. The creation of temporary sanctuaries for women does not have a lasting effect on occurrence of family violence unless combined with postshelter advocacy and counselling. There is no evidence that early childhood visits, though beneficial in other ways, reduce the rates of subsequent assaults on mothers and children. Abuse is well established by the time detection occurs and interventions at this stage are probably insufficiently powerful to change the behaviour of perpetrators (Table 2).
Eight studies described interventions relevant to the prevention of family violence in Aboriginal and indigenous communities (Table 3). We found no published reports of these interventions tested in a controlled setting. We also identified six quantitative studies (Table 4) that examined prevention including role modelling, life span focus, accessibility, acceptability and active participation; secondary prevention such as restriction on the trading hours for take away alcohol, home visiting programs (healthy start program) and parenting; and tertiary prevention including traditional healing circles and group counselling.
Relevant to primary prevention, Kiyoshk (2003) discussed interventions that integrated spiritual practices and ceremonies into psycho-educational group counselling models. Their “Change of Seasons model” included a 28 session psycho-educational group counselling approach that sought to integrate cultural healing methods for Aboriginal men. Spiritual practices and ceremonies included smudging, the talking circle, and the sweat lodge. The author claimed their model was accepted by Aboriginal clients “because it fits with their community’s spiritual beliefs and worldviews” and proposed that “Systems Thinking” could be applicable to Aboriginal communities. The description offers no evidence of impact on family violence.
Oetzel and Duran (2004) summarized several studies on the determinants of and interventions for intimate partner violence (IPV) in American Indian and/or Alaska Native (AI/AN) communities. Using a social ecological framework that identified proximal and distal risk factors, they described multilevel interventions that addressed a variety of determinants including age, gender, socioeconomic status, alcohol, European colonization, and infrastructure. “While the social ecological framework makes intuitive sense, there are few multilevel interventions to address IPV and none in AI/AN communities.” They offered no quantitative evidence of impact.
Holkup et al. (2007) described the Family Care Conference (FCC), an elder-focused, family-centred, community-based intervention for the prevention and reduction of elder abuse. The intervention involved inviting family members, family-nominated supportive community members, a spiritual leader, and relevant health and social service providers to attend a meeting in which individuals bring forward their concerns about the welfare of the elder. The authors claimed that families accepted and appreciated their intervention, and attributed its success to the community’s long history of respect for elders and preference for mediation over confrontation:
Drawing on the values of interdependence and reciprocity among Native American kin, the FCC provided a culturally anchored and individualized way to identify a frail elder’s care needs and to find solutions for meeting those needs from among family members and available community resources.
The report did not provide quantitative measures of impact in reducing elder violence.
Norton and Manson (1997) described a family violence program in an urban US Indian health centre that provided a range of services for American Indians including counselling, crisis housing, and transportation to appointments. To increase participation, the program used home visits and a weekly family violence group that incorporated traditions and values (talking circles, sharing of meals). The home visits tended to build an emotional connection with the counsellor. A weekly domestic group provided an informal atmosphere for sharing problems and concerns over a potluck dinner. Though not supported by numeric data, the authors reported that
Many of these women were able to build a relationship with the counsellor, and benefit from active participation in a family violence program. Home visits significantly enhance care and the effectiveness of counselling.
Willmon-Haque and Bigfoot (2008) reviewed the published literature on poverty and historical trauma, including a discussion on oppression and hegemony (authority and power). They described research on violence and the resulting trauma, suicide, family violence, and post-traumatic stress disorder. Since very young children can also be affected by traumatic events, the authors called for early intervention and awareness of family violence. Recent efforts to influence mental health care provided to AI/AN children and families included: training in advocacy and community mobilization, increasing community capacity, promoting culturally relevant services, enhancing knowledge and awareness on the issue, and involving communities in research.
Brewin and Coggan (2004) evaluated the Ngati Porou Community Injury Prevention Project (CIPP) in a predominantly Maori rural community on the east coast of the North Island of New Zealand. Participants included Maori selected at a forum (tribal gatherings, language nests, and sports venues). The CIPP used the World Health Organization (WHO) Safe Community Model for injury prevention, which acknowledges that community injury problems are best addressed by those who live in that community. Two activities addressed family violence: 1) identify and affirm traditional Ngati Porou care and protection practices for whanau (families) through 22 education sessions, information packs, and ongoing training to resource people; 2) coordinate and implement regional programs to address family violence and child abuse to tie in with national campaigns. The initiative included a gathering on emotional and physical violence, and a family violence-free concert to raise awareness. Community surveys indicated that the proportion who encountered threatening situations outside the home decreased (pre 73%, post 66%) and there was a small increase in those who always/mostly walk away from a threatening situation at home (pre 27%, post 31%). There was a significant increase in awareness of injury prevention among Ngati Porou whanau (pre 17% and post 25%).
Douglas (1998) considered an intervention to restrict availability of alcohol in a small town in Western Australia (population 1,200); 63% were Aboriginal. Other programs implemented along with the intervention included a school education program. Overall, the incidence of crime declined. Alcohol-related presentations to the hospital and presentations resulting in family violence decreased relative to the period prior to the intervention (odds ratio 0.43, 95% CI 0.31–0.60). The authors reported no change in domestic violence.
An RCT by Duggan and colleagues (2004) assessed the impact of home visits in the prevention of child abuse and neglect in the first three years of life in families identified as at-risk of child abuse through population-based screening at the child’s birth. The study focused on Hawaii Healthy Start Program (HSP) sites operated by three community-based agencies. The intervention had two parts: (1) screening of medical records by paraprofessionals to identify indicators of families at risk of child abuse and neglect; and (2) home visiting of these identified at-risk families. The home visiting aimed to prevent child abuse and neglect by improving family functioning in general and parenting in particular. Home visitors were paraprofessionals working under professional supervision. Home visits included both direct services and linkage with community resources. Direct service included providing emotional support to parents, encouraging them to seek needed professional help, teaching about child development and role-modelling parenting skills and problem-solving techniques. Intervention group mothers were less likely to use common corporal/verbal punishment but this was attributable to one agency’s reduction in threatening to spank the child. Intervention group mothers also reported less neglectful behaviour, related to a trend toward decreased maternal preoccupation with problems and to improved access to medical care for intervention families at one agency. The intervention and control groups were similar on most measures of maltreatment. The program did not prevent child abuse or promote nonviolent discipline. From the reader’s viewpoint, it seems the intervention could be tightened up considerably; HSP records rarely noted home visitor concern about possible abuse.
A second RCT by Duggan et al. (2007) assessed the impact of a para-professional home visiting program in preventing child maltreatment and reducing parental risks for maltreatment. This focused on six Healthy Families Alaska (HFAK) programs aimed at preventing child maltreatment by promoting positive parenting and child health and development. There was no overall program effect on parental risks for child maltreatment or on outcomes for families with high dose home visiting. Home visited mothers did report using mild forms of physical discipline less often than did control mothers, although the groups were similar in their use of more severe forms of physical discipline. Mild physical assault of the child was less common in the HFAK group only in the subgroups of multiparous mothers and for those not in a violent relationship at baseline. These positive findings must be balanced against deficiencies of the study: home visitors discussed parental risks for maltreatment in less than one half of active, risk-positive families; most risk-positive families were not referred to community services raising an issue of viability of the intervention.
The systematic review by Whitaker et al. (2006) included one study involving First Nations youth (Wolfe et al. 2003). This dating violence prevention program included middle or high school students with behavioural outcomes including conflict in adolescent dating relationship inventory (perpetration and victimization), healthy relationships skills, adolescent interpersonal competence questionnaire (emotional support, negative assertion, self-disclosure, conflict management, conflict resolution, trauma symptoms (trauma symptom checklist) and hostility. Interventions consisted of education about healthy and abusive relationships, conflict resolution and communication skills, and social action activities. Only 8% of participants were First Nations youth; the positive results declared by the study may also apply to them, but this is not presented in subgroup analysis.
Heilbron and Guttman (2000) report interviews with five women exposed to traditional Aboriginal healing practices and the sharing of beliefs in the therapy process for First Nations and non-Aboriginal women survivors of child sexual abuse. A counselling group combined a traditional “healing circle” with conventional cognitive therapy. The intervention involved weekly group meetings over a ten-week period for approximately two hours per session. The healing circle provided a spiritual framework for addressing problems in the group, and may have influenced participants in several ways: spiritual focus heightened participant motivation for confronting issues; participants felt empowered to speak; they felt comfortable and supported; the ceremony was conducive to encouraging a warm, caring, and relaxed environment; and a safe, supportive and spiritually nurturing environment was encouraged. The sharing of Aboriginal teachings and stories in the group may have provided personal meaning for the First Nations women and enabled them to develop a stronger devotion to Aboriginal healing methods:
At first she blamed herself for the abuse that occurred. It was through aboriginal teachings that this woman learned she was not to blame.
Mokuau (2002) examined culturally based interventions for Native Hawaiians that incorporate cultural values and practices, and involve Native Hawaiian participants in the design and delivery of the interventions. This study described two culturally based interventions: The first, ho’oponopono (“to set right”), was a family-focused holistic approach for maintaining and restoring relationships with family members and others in a spiritual realm. It was facilitated by a respected elder, family member, or community leaders, and included a spiritual component. The second intervention, aloha ’aina (“caring for the land”) involved activities that reflect the Native Hawaiian connection to the land. For example, working in the taro field entailed physical discipline, cognitive attention, emotional reflection, and spiritual openness. While working, participants learned about the cultural past through storytelling by elders and other caregivers. Participants learned values such as cooperation and reciprocity, engaged in self-reflection on cultural identity and cultural pride, and explored their spirituality:
Native ancestors have left the United States a legacy of cultural values and traditions that can have a powerful impact on resolving some of the issues of child abuse.
Luna-Firebaugh (2006) reported the evaluation of the Services-Training-Officers-Prosecutors Violence Against Indian Women (STOP VAIW) Program, a partnership between the tribal justice system and the nonprofit, nongovernmental service programs. Indian tribal governments received financial assistance to implement strategies to address violence against Indian women, and to develop and enhance services provided to Indian women who are victims of violent crimes. Tribal approaches include coordination of services to ensure better response to violence against women; enhancement of law enforcement response; innovative approaches to tribal prosecution; new approaches to shelter; and implementation of the full faith and credit provision of the Violence Against Women Act (with reference to protection and restraining orders). The authors claimed that STOP VAIW programs had a significant impact in Aboriginal communities. The program helped raise awareness among tribal leadership and the community, as well as promote various approaches to confronting the problem of violence against women. Most tribal communities felt that it was essential to combine “culturally compatible law enforcement and prosecution components with victim’s assistance and outreach.” Tribes and tribal officials, program personnel, and women were reportedly empowered by involvement in the development and enhancement of tribal programs that address the safety of Indian women. This supported tribal sovereignty. Across all programs, the authors claimed that the development of coordinated community-wide responses to the problem of family violence was successful in addressing family violence, sexual assault, and stalking. Other results they claimed included:
Becker and colleagues (2008) reported a methodologically constrained trial; only one half of the participants completed the baseline questionnaire and the authors only analyzed those who completed the treatment. They examined outcomes of a 12-week “culturally influenced” group intervention for children and adults exposed to family violence. The intervention involved 90 minutes of support through a psycho-education children’s group provided — Haupoa meaning “make the ground soft for planting.” A simultaneous weekly support and education group exposed parents to what their children were learning and addressed parenting in the aftermath of family violence. Notwithstanding the methodological flaws, the authors claimed statistically and clinically significant improvements in children and parent violence-related skills. Children receiving the intervention showed improvements in internalizing and externalizing difficulties despite the lack of direct symptom-focused intervention in these domains. More than one-half (53.2%) of children exhibited clinically significant internalizing difficulties at pre-intervention, compared to 21.3% at postintervention. Participants were of diverse ethnic backgrounds, most reporting Asian or Pacific Island heritage; this cultural diversity raises questions about how culturally appropriate the intervention could have been.
Few studies relate to Aboriginal and indigenous communities and those that do exist contribute only weak empirical evidence. We could not identify quantitative evidence of primary prevention (reduction of risk factors for family violence). Most authors equate tertiary prevention (recovery and reduction of the worst consequences) with prevention of family violence. Our extensive search retrieved a very small number of published reports of controlled studies.
In considering protective factors against suicide of Aboriginal youth, Chandler and Lalonde (1998) considered that restoring and rebuilding community culture could be protective. The concern for “cultural continuity” resonates with almost all the interventions described in this review, which took into account Aboriginal beliefs and values, holistic concepts of health, spirituality, traditional ceremonies, and healing practices. Many authors on interventions to reduce family violence recognize that strong social support networks should underwrite prevention efforts and change community perception about the issue of family violence. Authors also recognized that community involvement in the development, design, and implementation of family violence interventions should empower the community, make the interventions better received by its members, and contribute to the overall success of the intervention.
Despite this almost uniform recognition of the importance of cultural relevance and participation, there is not much hard evidence of impact in reducing family violence in Aboriginal communities. We see at least two reasons for this. First, the current literature rests on qualitative approaches that generate insights into cultural dynamics and participant perspectives. These studies can be pivotal to understanding what might work and how it might work (Carriere, 2007; Olesen, 1994). With this now in hand, we look forward to a next generation of research that start from these qualitative studies, going on to quantify the impact of interventions that reduce family violence.
Second, mirroring the investment in nonindigenous communities in Canada and internationally, most family violence research focuses on tertiary prevention (prevention of recurrence). There is a growing body of work on secondary prevention (reduction of violence outbreaks where the risk factors exist). We found only two narrative reviews relevant to if not actually directed at primary prevention, the prevention of emergence of risk factors that could lead to family violence. Yet this is exactly the upstream prevention where indigenous strengths are mostly likely to play out. Two programs in Africa emphasized the importance of participatory learning and structural interventions that change the position of women — and therefore, their risks to family violence.
The causes of family violence are complex and deeply rooted. Once established, the cycle is difficult to break. Interventions most likely to be effective are those designed to prevent family violence rather than, once established, to reduce its frequency and severity.
This review highlights the need for high quality research to inform interventions that reduce family violence in Aboriginal communities. Barriers to prevention in this context include the instability of programs, funding, and lack of capacity. Even with a potentially effective intervention, these implementation factors will need consideration. Future research priorities include the development and implementation of evidence-based interventions tested in pragmatic randomized controlled trials.
Bev Shea has a PhD in epidemiology and is a researcher at Community Information Epidemiological Technologies (CIET) and co-director of the Anisnabe Kekendazone (AK) Network Environments for Aboriginal Health Research (NEAHR), administered by CIETcanada. Over the past few years she has been working in Aboriginal health and international research leading to the production of systematic reviews and in the areas of HIV/AIDS and childhood immunization. She has contributed to the creation of new knowledge in the field of quality assessment and qualitative data analysis. During the past ten years she has worked in improving the field of systematic review methodology. She also mentors in systematic review courses through CIET and the University of Ottawa.
Amy J. Nahwegahbow is a research coordinator with Community Information and Epidemiological Technologies (CIET). Amy is a member of the Whitefish River First Nation and a graduate of Trent University in the Honours Bachelor of Arts Program with a major in Native Studies. Since 1999, she has worked for National Aboriginal Organizations such as the National Association of Friendship Centres, the National Aboriginal Health Organization and the Assembly of First Nations on a variety of First Nations health issues such as youth at risk, suicide prevention, injury prevention, research ethics, environmental health and public health issues of concern to First Nations. She has developed several toolkits for First Nations communities on ethical research practices, the principles of OCAP, and Aboriginal health indicators. Amy brings a broad knowledge of First Nations health and wellness issues, as well as experience in conducting on the ground research with communities. She is pursuing her education and a life long career in epidemiology to help improve the health, social, and personal prospects of indigenous communities.
Dr Neil Andersson is the executive director of CIET and adjunct professor in the Faculty of Medicine at the University of Ottawa. He has three decades of experience designing, implementing and managing evidence-based health planning initiatives. A medical epidemiologist, for the last 15 years he has supported training of researchers in more than 200 Canadian First Nations, Métis and Inuit communities.
1Acknowledgements: We thank Jessie McGowan who designed the search strategy and conducted the literature search. This systematic review was entirely supported by the Canadian Institute of Health Research (CIHR) Grant “Rebuilding from Resilience” Project number 84489.
2KW=(domestic violence) or (family violence) or (elder abuse) or KW=(child abuse) or (spous* abuse)and KW=(therap* or treatment* or prevent*) and KW=(native or aborigin* or eskimo or inuit or indigenous or indian); Global health: TX (Domestic violence or family violence or elder abuse or child abuse or spous* abuse) and TX (therap* or treatment* or prevent*) and (aborigine* or indigenous or Inuit* or Eskimo* or Indian or Indians or First Nation*); Native Health Database: (Domestic violence or family violence or elder abuse or child abuse or spous* abuse) and (therap* or treatment* or prevent*)