Samia Addis* and Lara Snowdon†
ABSTRACT
This review identifies effective practice for the prevention of violence against women, domestic abuse and sexual violence (VAWDASV). The review is underpinned by public health principles which provide a useful framework to understand the causes and consequences of violence as well as prevention. This systematic evidence assessment had two stages: a database search identified reviews of interventions designed to prevent VAWDASV, published since 2014; a supplementary search identified primary studies published since 2018. Reviews (n=35) and primary studies (n=16) focus on a range of types of violence and interventions. At the individual and relationship level, interventions work to transform harmful gender norms, promote healthy relationships, and promote empowerment. In the community, effective interventions were identified in schools, the workplace, and health settings. Finally, at the societal level, interventions relate to legislation and alcohol policy. The findings reveal a wealth of literature relating to the prevention of VAWDASV. However, gaps in research were identified in relation to the prevention of trafficking, violence against women, domestic abuse, sexual violence among older age groups, and so-called honour-based abuse other than female genital mutilation. Also, while many interventions focus on change at the individual and relationship level and within community settings, there is less evidence for societal-level prevention. The prevention of VAWDASV is both feasible and effective and there is an imperative to invest both in prevention programming and high-quality research to continue to guide efforts to prevent VAWDASV.
Key Words: Gender-based violence, Prevention and early intervention, Adolescent dating violence, Intimate partner violence
Violence against women, domestic abuse and sexual violence (VAWDASV) is a major public health problem, a criminal justice issue, and a violation of human rights that impacts individuals and families and harms the health of communities, societies, and economies (World Health Organisation, 2021).
Within the term VAWDASV, a range of forms of violence are recognised. These include gender-based violence (GBV); intimate partner violence (IPV); domestic violence and abuse (DVA); sexual violence and abuse (SVA); coercive control; forced marriage; child marriage; so-called honour-based abuse (HBA); female genital mutilation (FGM); human trafficking; sexual harassment; cyber harassment, and adolescent dating violence (ADV). Many of these terms are used as umbrella terms and are not mutually exclusive but are reflected here as they are used in the literature.
While boys and men can be victims of certain forms of VAWDASV and abuse occurs within same-sex relationships, family relationships, and against transgender men and women, in terms of the scale of the problem being addressed by VAWDASV programs, overwhelmingly, perpetrators tend to be male while the victims are mainly female. As a result, understanding VAWDASV requires an appreciation that it is part of a social pattern of predominantly male violence towards women (Hester & Lilley, 2014). This means recognizing the gendered nature of violence against women as rooted in power imbalances and inequality between women and men (Council of Europe, 2011).
At the same time, sexuality, age, class, race, and disability intersect with gender and create differences in lived experience of VAWDASV, access to services, as well as unequal outcomes. This means that while VAWDASV can happen to anyone, anywhere, some women and girls are particularly vulnerable—for example, young women and girls, women who identify as lesbian, bisexual, transgender, or intersex, migrants and refugees, indigenous women and ethnic minorities, women and girls living with HIV and disabilities, and those living through humanitarian crises (United Nations, 2021).
The short- and long-term health consequences of VAWDASV for women’s health are many and significant. Sexual violence can lead to a multitude of health consequences for women, including physical, reproductive and psychological consequences (Jina & Thomas, 2013). Female genital mutilation can lead to both immediate health risks and a variety of long-term complications which can affect women’s physical, mental, and sexual health and well-being throughout the life-course (World Health Organisation, 2023). Women who experience violence are at higher risk of injuries, with 42% of women who experience IPV reporting an injury as a consequence of this violence. Women who suffer IPV are twice as likely as women without experience of IPV to experience depression and 1.5 times more likely to acquire a sexually transmitted infection (World Health Organisation, 2018).
Additionally, such violence can have fatal outcomes. Every day, 137 women are killed by a family member, and it is estimated that, of the 87,000 women who were intentionally killed globally in 2017, more than half (50,000) were killed by intimate partners or family members. More than a third (30,000) of the women intentionally killed in 2017 were killed by their current or former intimate partner (United Nations Office on Drugs and Crime, 2019).
VAWDASV places a heavy burden on health, economic, and social prospects, with the adverse psychological, sexual, and reproductive health consequences affecting survivors at all stages of life. In addition, VAWDASV has health consequences for children and socio-economic impacts on families, communities, and societies (World Health Organisation, 2021). In the United Kingdom, a Home Office report estimates the economic and social costs of domestic abuse at £66 billion annually (Oliver et al., 2019), suggesting that if all forms of VAWDASV were included, the costs would be considerably higher.
The “ecological framework” for violence prevention presents a model which represents the complex interplay between individual, relationship, community, and societal factors, which interact to determine the risk and experience of violence. Such models, a key feature of a public health approach, are based on the idea that influence and determinants are interrelated, reinforcing the importance of a comprehensive approach in which actions at each level of the social ecology work to support other levels.
The principles of public health, including a focus on inequalities, partnership working, and evidence-based practice, also provide a useful framework to understand the causes and consequences of violence and for preventing violence from occurring through primary prevention programs, policy interventions and advocacy (Violence Prevention Alliance, 2021). Three tiers of intervention are identified by public health prevention science. Primary prevention aims to prevent violence before it occurs; secondary prevention focuses on the immediate response to violence; tertiary prevention focuses on long-term care after violence has occurred.
Applying this framework to VAWDASV has demonstrated its effectiveness as a tool for supporting change across the spectrum of time that violence occurs (Walden & Wall, 2014). However, it is acknowledged that the division between primary, secondary, and tertiary violence prevention is not always clear cut, and that levels of prevention are not mutually exclusive (Heard et al., 2020).
In Wales, the National Strategy identifies the primary prevention of VAWDASV as a key commitment (Welsh Government, 2016). In 2020, the Welsh Government commissioned an evidence review to address the research question “What works to prevent VAWDASV?.” The purpose of the review was to identify effective practice for the prevention of VAWDASV, with the findings intended to inform the adoption of evidence-based practice through a national VAWDASV strategy refresh in Wales in 2021.
Initial mapping of the research area was undertaken to ensure that the review included:
The following databases were searched: Cochrane Database of Systematic Reviews, PubMed, DARE, Medline, and Google Scholar. Using a defined search strategy, the searches were undertaken in two stages between November 2020 and February 2021. Stage one identified systematic reviews of interventions related to the primary or secondary prevention of VAWDASV (published 2014–2020). Stage two was a supplementary search which identified primary studies published more recently (2018–current) that, as such, may not be included in the systematic reviews identified and studies that encompass topics where the evidence base may be too limited to be the subject of a systematic review.
The study used a PICO format. See Table I for search terms included.
TABLE I Search terms: Search 1
See Table II for additional terms for the supplementary search.
TABLE II Search terms: Search 2
Child sexual abuse (CSA) was not included in the search because, while there are significant links between CSA and VAWDASV, it is deemed a safeguarding issue and outside the remit of the Welsh Government definition of VAWDASV.
To be included for Search 1, papers had to be a systematic review of interventions designed to prevent VAWDASV and published since 2014. For Search 2, papers had to be published since 2018 and focus on interventions designed to prevent VAWDASV. Across both searches, papers had to focus on primary and secondary prevention strategies, be written in English, and review interventions implemented within high-income countries with a similar social and cultural context to Wales (reviews which considered low- and middle-income countries in addition to high-income countries were also included).
Selected records were imported into an excel spread-sheet, duplicates were removed, and each record was screened against the inclusion/exclusion criteria by one author. Where there was a query about inclusion, records were assessed by the second author and any differences were resolved through discussion (Figure 1). This resulted in the inclusion of 35 reviews and 16 primary studies (Appendix A).
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FIGURE 1 PRISMA diagram | ||
For each paper, extracted data included violence type, intervention type, intervention setting, age range, and the number and type of studies included (systematic reviews) or type of study (primary study). Due to the diversity of approaches and studies included, this review uses a narrative synthesis, sorting studies into common themes and providing a descriptive summary of each.
The reviews and primary studies were categorized and are presented according to intervention type; each intervention type is placed within the socio-ecological framework which highlights four levels where prevention can occur (Table III).
TABLE III Findings by socio-ecological level
Where reviews include a range of intervention levels but focus on a specific violence type (e.g., IPV), these have been summarized separately.
Violence prevention practice has evolved to include approaches that seek to transform the relations, norms, and systems that sustain gender inequality and violence, in recognition that masculinity and gender-related norms are implicated in violence (Casey et al., 2018; Jewkes et al., 2014). While findings overall for these interventions were mixed, some studies found promising evidence of change; “Real Consent” showed statistically significant increases in terms of gender equitable attitudes as well as documenting a significant decrease in reported IPV over time. Additionally, it was the only program delivered online and to individual participants (Casey et al., 2018). Another program, “Changing Boys into Men” (CBIM) was found to significantly decrease overall domestic violence perpetration among male high school athletes (Casey et al., 2018; Graham et al., 2019).
Focusing on empowerment, one large-scale evaluation of self-defence and empowerment programs for girls found improvements in awareness raising, recognizing inappropriate behaviour and learning ways to keep yourself and friends safe (Jordan & Mossman, 2018). In another primary study, survivor empowerment training, advocacy, and prevention solutions to combat child sexual exploitation resulted in the incidence of self-reported sexually explicit behaviour reduced by half over time; dating abuse victimization also decreased (Rothman et al., 2019).
Successful approaches for the prevention of FGM included recognition of FGM as gender-based violence, providing clear preventive roles for frontline professionals, clear protection and prosecution approaches, and participation of affected communities (Baillot et al., 2018). One intervention which aimed to improve healthcare providers’ capacity in the prevention and treatment of FGM found that midwives in the United States reported feeling more confident in the management of women with FGM (Balfour et al., 2016). However, no survivor-victim or population health outcomes were reported.
Two reviews focussed on a range of interventions aimed at tackling VAWDASV in the adolescent age range. Three interventions, “Safe Dates,” “Fourth R,” and “Shifting Boundaries” were found to have positive intervention effects on preventing IPV perpetration (De Koker et al., 2014). These findings are echoed in a further review which found that students in the intervention group of the “Safe Dates” study were less likely to be victims or perpetrators of self-reported sexual violence and “Shifting Boundaries” was effective in reducing self-reported perpetration and victimization (DeGue et al., 2014).
Applied theatre projects use a wide range of techniques and approaches that are generally participatory in nature and share the goal of creating social awareness and behavioural change with the audience. Such interventions can involve role-plays, playmaking with audiences, interactive workshops, and talk-back sessions. Theatre interventions reported positive outcomes in relation to creating awareness of IPV, reducing gender stereotyping, and encouraging engagement in nonviolent conflict resolution (Heard et al., 2020). A primary study also found that participants gained new awareness and understanding in relation to child sexual exploitation and abuse (CSEA) as a result of a school-based theatre program (May et al., 2020).
In the school setting, program theories generally seek to encourage behaviour change through building skills and knowledge for healthy relationships and as active bystanders, and/or developing prosocial attitudes towards specific social norms (such as positive gender norms). The assumption is that this would change behavioural intention and, eventually, actual behaviour, with a resulting effect on the incidence of perpetration and/or victimization (Stanley et al., 2015). Four reviews focused on school-based interventions and found evidence of a positive effect of some programs. The “Fourth R” program resulted in a decrease in the perpetration of physical dating violence (Woolfe et al., 2009, cited in Stanley et al., 2015), and the “Healthy Relationships” program resulted in significant reductions in both perpetration and victimization of dating violence (Ellsberg et al., 2015).
Two other interventions, “Shifting Boundaries” and “Safe Dates,” reported a reduction in adolescent dating violence (Ellsberg et al., 2015). These findings are supported by a further review which found that “Safe Dates,” the “Fourth R” program, and “Stepping Stones” were studied in trials with the strongest evidence of effect in that they have the longest follow-up periods (2–3 years). “Safe Dates” was also strong in that it measured the widest range of forms of dating violence and was able to show the effects of several forms of violence which persisted over time (Lester et al., 2017).
Gender transformative approaches in the community suggest that education for middle school boys can be successful at changing violence-related beliefs that are risk factors for the perpetration of harassment and sexual and dating violence. The “Reducing Sexism and Violence Programme – Middle School” was successful at changing violence-related beliefs that are risk factors for the perpetration of harassment and sexual and dating violence at the community level (Banyard et al., 2019).
Bystander programs focus on equipping people with the skills to safely intervene when they witness behaviours that can result in VAWDASV. In the educational setting (schools, colleges, and universities), bystander programs were over-whelmingly found to be promising, with evidence of a positive impact on changing attitudes and beliefs. However, the impact on behaviour was less clear cut. Seven primary studies evaluated interventions including the “Red Flag Campaign” (Borsky et al., 2018; Carlyle et al., 2020), “Green Dot” (Coker et al., 2019), “Bringing in the Bystander” (Edwards et al., 2019) and “The Intervention Initiative” (Fenton & Mott, 2019). While studies were predominantly undertaken in university settings, one study indicates that the bystander approach (“Active Bystander Communities”) can be transferred from student population to general communities and from sexual violence to DVA in the United Kingdom (Gainsbury et al., 2020).
Also, within a university setting, one primary study evaluated the effectiveness of a 5-year marketing campaign, the “Social Norms Sexual Violence Prevention Marketing Campaign.” The campaign focused on four overarching themes: consent, bystander, rape myths, and sexual activity. Results suggest the campaign was successful, resulting in reporting of less sexually aggressive behaviour and increased frequency of engaging in bystander interventions (Mennicke et al., 2018).
It is recognized that health professionals are ideally placed to identify VAWDASV through screening, to provide advice and support, and to signpost patients to further resources. For interventions undertaken in healthcare settings, evidence was mixed. In the primary care setting, most studies demonstrated patient-level benefit, with community referrals for IPV the most common, positively affected outcome (Bair-Merritt et al., 2014). In the Emergency Department, it was found that one-off training in isolation may improve staff awareness but has limited impact on clinical practice (Ansari & Boyle, 2017). Where interventions were implemented across a range of healthcare settings, findings were mixed, with one review finding no evidence that screening increases referrals or reduction in IPV (O’Doherty et al., 2014) and another that women did not show a reduction in IPV or improvement in quality of life (Feltner et al., 2018). In a further study, educational interventions were associated with improvements in knowledge and behaviours of healthcare workers despite inconsistent results (Sawyer et al., 2016). In one primary study based in the United States, no benefits were found for a home visiting program (Jack et al., 2019).
It is recognized that a barrier to IPV prevention can be related to the mode of delivery, and common barriers for victims wishing to initiate services include a lack of knowledge of community resources and fears about privacy (Anderson et al., 2019). In the healthcare setting, web-based approaches were found to demonstrate effective access to telehealth services such as online support groups for victims and changing behaviour expectations through educational programming (Anderson et al., 2019). Another review suggests that information and communication technologies (ICT)-based interventions had the potential to be effective in spreading awareness and in terms of IPV prevention (El Morr & Layal, 2020) and that participants were less likely to report experiencing physical IPV at follow-up (El Morr & Layal, 2019).
One review outlined interventions to prevent IPV within the workplace setting by focusing on recognizing signs of abuse, responding to victims, and providing referrals to community-based resources. Findings indicate that there may be benefits in terms of increased knowledge and provision of information and resources, but strong evidence of effective interventions is limited at this time and further research is required (Adhia et al., 2019).
In the night-time environment, studies focused on bystander interventions, awareness raising campaigns, and the role of alcohol legislation. It was concluded that to prevent sexual violence in the night-time environment, a broad suite of programs is necessary, including reducing excessive alcohol consumption, making the drinking environment safer, and having laws in place to ensure that inappropriate sexual behaviour specific to sexual violence is both discouraged and addressed (Quigg et al., 2020). A primary study evaluated “The Good Night Out Campaign,” which provided training and guidance to workers on preventing and responding to sexual violence and found that awareness-raising was associated with greater readiness and confidence to intervene (Quigg & Bigland, 2020).
Multiple partnerships were shown to be effective in building a coordinated community response to VAWDASV, the most significant element of which was the comprehensive early intervention outreach/advocacy service. This service incorporated a wide range of community-based and women-centred interventions, as did other advocacy interventions that tended to adopt a more holistic approach. Overall, interventions that adopt an advocacy approach appear to have more impact and are more sustainable, and, when co-located with statutory or voluntary services, multi-agency working is enhanced (Cleaver et al., 2019).
Overall, the evidence supports a consistent link between policies which increase the price of alcohol (or prevent low prices) and relevant health outcomes, including sexual violence perpetration (Lippy & DeGue, 2016). Several policy areas demonstrate initial evidence of a direct association with sexual violence, including those affecting price, outlet density, bar management, sexist alcohol marketing content, and alcohol bans on college campuses and in substance-free dorms. This evidence points to the potential utility of these approaches as part of a comprehensive sexual violence prevention strategy targeting individual and community-level risk factors for perpetration. However, more research is needed to better understand the nature of the association between those factors and sexual violence perpetration risk as well as the effects of specific policies on VAWDASV and sexual violence outcomes (Lippy & DeGue, 2016).
Two studies reference the impact of legislation on IPV, specifically the Violence against Women Act (VAWA) introduced in the United States in 1994. Findings indicate that areas which had received VAWA grants had significant reductions in the numbers of sexual and aggravated assaults compared with areas that did not (DeGue et al., 2014; Ellsberg, 2015).
Arango et al. (2014) present a review of reviews of evidence on reducing the victimization or perpetration of a range of types of violence against women and girls (VAWG). This review includes primary prevention of IPV in high-income countries, home visiting programs, and screening programs. It finds evidence of positive results in respect of primary prevention interventions, and that home visiting programs have the potential to reduce IPV, although this evidence is mixed. Also, while evaluations of screening programs found positive results for identifying survivors of IPV, there is no evidence that screening alone increased referral to support agencies.
The focus of this systematic evidence review was to address the research question, what works to prevent VAWDASV? The review was undertaken in two stages, a systematic evidence assessment of reviews of interventions designed to prevent VAWDASV and a supplementary search to identify primary studies published more recently and to encompass topics where the evidence base may be too limited to be the subject of a systematic review. Reviews (n=35) and primary studies (n=16) focussing on a range of types of violence and types of intervention were identified.
These findings indicate that there is a wealth of literature in terms of the prevention of VAWDASV, including several high-quality studies undertaken recently suggesting that the prevention of VAWDASV is feasible and can be effective. In addition to the prevention of the perpetration and victimization of VAWDASV, the included studies incorporate a range of outcomes in recognition that measuring changes in violence is challenging, especially over the short time periods of most projects. As a result, many studies assess attitudinal and behaviour change as outcomes, as part of a broader preventive theory of a change.
The studies highlight a number of factors which contribute to the success of interventions. These include intervention duration, socio-cultural relevance and mode of implementation. For interventions seeking to transform gender norms, the evidence indicates that more successful programs have a relatively long participant engagement time (Jewkes et al., 2014). In relation to bystander programs, results suggest that low-resource interventions have a modest effect on increasing bystander behaviour and higher resources were needed for a bigger impact (Borsky et al., 2018). The most effective strategy was found to be a multidose, multimode approach, tapping into various ecological levels as greater exposure to information and education yields better outcomes (Banyard, 2014; McMahon & Seabrook, 2019).
For interventions in school settings, it was also found that longer interventions delivered by appropriately trained staff, using multiple delivery methods, appeared more likely to be effective. With appropriate training and support, teachers are well placed to embed interventions in schools, with young people involved in the design and delivery of programs as part of a whole school approach (Cleaver et al., 2019; Stanley et al., 2015). It was also found to be important that interventions address the requirements of participants from a range of backgrounds, with one study highlighting a lack of materials designed for LGBT (lesbian, gay, bisexual, trans) young people (Stanley et al., 2015).
The use of online and social media platforms in violence prevention might resonate with younger audiences in countries with high internet usage (Graham et al., 2019). In the healthcare setting, the use of ICT-based interventions seems to be an attractive option for disseminating awareness and prevention information due to the wide availability of ICT (including mobile phones) globally. A major strength of mHealth IPV prevention programming is the ability to tailor interventions to individual needs without extensive human resource expenditure by providers (Anderson et al., 2019). Additionally, ICT presents an opportunity to deliver culturally sensitive multilingual interventions using consumer health informatics. However, there is a clear need to develop women-centred ICT design when programming for IPV (El Morr & Layal, 2020).
International bodies suggest the need for a comprehensive multi-sectoral long-term collaboration between governments and civil society at all levels of the ecological framework to secure a public health approach to VAWDASV prevention. In order to generate population-scale impact, an integrated, systematic model should be used in which there are multiple theory and evidence-based interventions implemented across the socio-ecology. All elements of the model must interact to develop a system which encourages safe, healthy, and prosocial behaviours and discourages and holds violent behaviour to account (DeGue et al., 2012, cited in DeGue et al., 2014).
This systematic evidence review demonstrates that there is a range of evidence for effective interventions to prevent VAWDASV across this multi-level approach. However, there are still gaps in the research which need further exploration, in addition to research into the ways in which these interventions may interact to reinforce behavioural change across the socio-ecology.
A strength of undertaking a systematic review of reviews is that it allows the creation of a summary of reviews within a single document (Smith et al., 2011). This review identified a substantial number of reviews, encompassing a range of types of VAWDASV and intervention types, and provides a comprehensive overview of key evidence in relation to what works to prevent VAWDASV. Additionally, using a two-stage search process enabled the identification of primary studies which had not been included in the systematic reviews, resulting in a broader range of studies being included.
However, the broad review question and relatively short time scale in which the review was conducted means that the search for evidence cannot be exhaustive and, consequently, certain topic areas may be missed. Further, all review methods risk generating inconclusive findings that provide a weak answer to the original question. Finally, the diverse methodological frameworks of the reviews and primary studies present challenges in terms of synthesizing data, presenting findings and drawing conclusions.
Research While the literature is rapidly progressing in this field, there are still significant gaps. In this review, there are no interventions in relation to the prevention of trafficking, VAWDASV among older age groups, or so-called honour-based abuse other than FGM. Additionally, concern was raised with respect to the quality of studies under consideration by a number of reviews, including a paucity of studies with impact evaluations over a long follow-up period, and a lack of trials conducted in UK settings, as opposed to the United States (Fenton et al., 2016; Kovalenko et al., 2020; O’Doherty et al., 2014).
While many interventions focus on change at the individual and relationship level and within community settings, there is less evidence for societal-level prevention, considered a critical gap in the field (DeGue et al., 2014). Further research is also needed in terms of specific forms of VAWDASV mentioned above, as well as how prevention programs intersect with the needs of individuals and communities who are LGBT+, Black, Asian and minority ethnic (BAME), older age groups, and those with disabilities.
While the bigger picture of how the pandemic has impacted VAWDASV is yet to fully emerge, it appears likely that both the scale and nature of VAWDASV has worsened, with rising helpline contacts for all forms of VAWDASV and increased reports to emergency services (Hohl & Johnson, 2020). The rapidly emerging literature suggests that public health restrictions, including lockdown, shielding, and social distancing regulations have impacted rates of VAWDASV (Snowdon et al. 2020).
While traditional avenues of prevention, such as face-to-face interactions, are limited, new opportunities have emerged: multiple forms of media, online communications, and many community mobilization programs involve delivering activities virtually (UN General Assembly, 2020). A number of interventions use online platforms (“Real Consent” and “mHealth” screening tools), and these interventions may have particular relevance where face-to-face interactions may be limited.
The prevention of VAWDASV is both feasible and effective, with intervention literature pointing to numerous examples of effective and promising practice. Prevention programming should be undertaken using a multi-layered approach to create an “ecosystem” of interventions which prevent VAWDASV in different settings and contexts. Further evidence suggests the efficacy of program features include multi-agency and multi-dose approaches, well-trained staff, and long program length. There is an imperative to invest both in prevention programming and high-quality coordinated research to continue to guide efforts to prevent VAWDASV.
The authors declare that there are no conflicts of interest.
*ACE Hub Wales, Policy and International Health, WHO Collaborating Centre on Investment for Health & Well-being, Public Health Wales, Cardiff, UK.
†Violence Prevention Unit, Policy and International Health, WHO Collaborating Centre on Investment for Health & Well-being, Public Health Wales, Cardiff, UK.
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Journal of CSWB, VOLUME 8, NUMBER 2, June 2023
