Abstract
We used a community-based participatory research approach to develop, implement, and evaluate one of the first health curricula for female intimate partner violence (IPV) survivors residing at a transitional housing program. The curriculum comprised 12 workshops that were developed based on the survivors’ experiences, needs, and interests. Evaluation participants included 20 of the 37 women who attended at least one workshop, 12 workshop facilitators, and two housing center staff. Participants found the curriculum to be engaging, interactive, and helpful in building a supportive community. Suggestions for curricular improvement as well as opportunities for further research and curricular development are discussed.
Keywords
Background
Intimate partner violence (IPV) is recognized as a serious medical and public health epidemic (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). IPV is defined as physical violence, sexual violence, stalking, or psychological aggression by a current or former intimate partner. For women in the United States, lifetime rates of psychological, physical, and sexual IPV are 48%, 33%, and 26% respectively (Breiding, Chen, & Black, 2014). 1 Studies reveal that IPV is associated with a myriad of physical health morbidities, including injuries, chronic pain, high blood pressure, obesity, and elevated markers of inflammation (Bosch, Weaver, Arnold, & Clark, 2015; Centers for Disease Control and Prevention, 2008; Newton et al., 2011). IPV survivors are at an increased risk for psychological concerns such as decreased feelings of self-worth, depression, posttraumatic stress disorder, and substance use (Bosch et al., 2015; Campbell, 2002; Centers for Disease Control and Prevention, 2008). Associations between IPV and reproductive health morbidities also exist, including sexually transmitted infections, preterm labor, and adverse obstetric outcomes (Campbell, 2002; Chambliss, 2008). Furthermore, IPV survivors face challenges accessing health care services and developing trusting relationships with their health care providers (Bair-Merritt et al., 2008; Battaglia, Finley, & Liebschutz, 2003; Robinson & Spilsbury, 2008).
IPV is also a risk factor for homelessness, financial insecurity, unemployment, and poverty. The intersection between IPV and poverty was clearly articulated by Goodman, Smyth, Borges, and Singer (2009) who wrote, “When poverty and IPV occur together, their negative effects—including stress, powerlessness, and social isolation—magnify each other” (pp. 310-311). The authors go on to conclude that identifying and empowering IPV survivors at risk for poverty is critical to reducing adverse health effects, as well as helping survivors gain independence and recover from past trauma.
Survivors of IPV residing in community-based temporary housing are particularly vulnerable to the negative effects of abuse and poverty and are more likely to be younger, of lower-socioeconomic status, and facing housing insecurity (Galano, Hunter, Howell, Miller, & Graham-Bermann, 2013; Grossman & Lundy, 2011). The two most common types of community-based housing for IPV survivors are emergency shelters that offer temporary residence for 1-2 months and transitional housing programs (THPs) that provide subsidized accommodations for 1 or more years as a bridge to permanent housing. Both emergency shelters and THPs offer a variety of services such as case management, job training, and childcare; however, programming at THPs often also emphasizes rebuilding self-sufficiency and independence (Baker, Niolon, & Oliphant, 2009; Grossman & Lundy, 2011). Despite increased access to services and support, women at both emergency shelters and THPs describe multiple health needs and difficulty utilizing health care services (Ragavan et al., 2016; Wilson, Silberberg, Brown, & Yaggy, 2007).
There are only a few published programs designed to improve the health of IPV survivors residing in community-based temporary housing, all of which have been developed for emergency shelters. For example, Johnson, Zlotnick, and Perez (2011) showed that participating in a 12-session cognitive behavioral therapy curriculum decreased emotional numbing symptoms, reabuse rates, and depression. Hernández-Ruiz (2005) reported that attending five, 30-min music therapy sessions improved both anxiety levels and sleep quality. Finally, Constantino, Kim, and Crane (2005) found that attending an 8-week curriculum that emphasized referrals to local resources, opportunities to connect with a counselor, and strategies to promote self-esteem, decreased participants’ psychological distress and improved their perceived availability of social support.
Despite these studies, two important gaps are evident in the literature. First, to our knowledge, there are no published health programs for IPV survivors residing at THPs. Given the prolonged length of stay and focus on providing supportive life skills, there may be opportunities to design health curricula tailored for this setting. Second, there are few reported health programs for IPV survivors that have been developed, implemented, and evaluated using a community-based participatory research (CBPR) approach. CBPR emphasizes collaboration between community partners and researchers. Key principles include choosing research interests of importance to the community, building on community resources, involving an iterative evaluation process, balancing research and action, and disseminating findings to all partners (Israel et al., 2008; Minkler, 2005). Using this approach may be particularly important when designing programs for IPV survivors, as abuse often leads to feelings of isolation, stress, and disempowerment (Goodman et al., 2009; Jewkes, 2002). In fact, in a recent commentary, Yuan et al. (2016), noted both the benefits of using CBPR in the violence-prevention field to develop strengths-based interventions, as well as a dearth of such programs.
Therefore, as a partnership between a community-based organization and an academic center, we developed a pilot health curriculum for female IPV survivors residing at a THP. This article is unique as it describes one of the first health curricula developed for IPV survivors using a CBPR approach, explores lessons learned from a comprehensive qualitative curricular evaluation, and outlines potential next steps and implications from this pilot curriculum. The goals of the health curriculum were defined and refined throughout the research process, to ensure continuous alignment with the needs of the IPV survivors.
Method
Study Setting
This study occurred at a not-for-profit THP in northern California (referred to as the “Center” in this article), which serves female IPV survivors and their families. All women residing at the Center were in abusive relationships and now are living separately from the abusive partners. The Center consists of staff offices, community meeting rooms, and multiple apartment buildings with private living quarters and shared common areas. There are two full-time employees at the Center: the manager and the women’s case manager. The majority of the women residing at the Center self-identify as Hispanic/Latina; however, there are families of multiple racial and ethnic backgrounds, including Asian, Caucasian, and African American. Forty-six women live at the Center, approximately 40-50% of whom speak Spanish as a first language. Families most often enter the Center from emergency shelters and often have incomes that are below poverty level. Along with subsidized housing, the Center offers programs to promote self-sufficiency and independence, including case management, job training, and financial literacy educational workshops. There is also a children’s program comprising case management, academic tutoring, and art therapy, which is run by a part-time employee and volunteers.
Community–Academic Partnership
The partnership between the Center and Stanford University’s School of Medicine began in January 2014 when the primary author (M.R.) approached the Center’s manager (coauthor S.L.) to determine opportunities for collaboration. Through years of experience supporting women at the Center, the Center’s manager identified health as a pressing need. The manager expressed an interest in developing a community-engaged health curriculum sensitive to the experiences of women residing at the Center. The overall goals for the health curriculum were kept broad at this time, as we aimed to frame the workshops around the needs identified by the survivors themselves. This collaborative study took place over an 18-month period, in four phases: (a) needs assessment; (b) curricular development; (c) curricular implementation; and (d) qualitative curricular evaluation (see Figure 1). CBPR principles were integrated into all phases of the study. Study materials were approved by Stanford University’s Institutional Review Board.
Timeline of complete study.
Needs Assessment
Results from a comprehensive needs assessment, comprising focus groups with 25 women residing at the Center and individual interviews with the two full-time staff employed by the Center, formed the foundation from which the curriculum was built. The needs assessment was part of a larger qualitative study exploring the health of IPV survivors and their children. Full description of needs assessment methodology and results have been previously provided and are summarized below as background information to help contextualize curricular development and evaluation (Ragavan et al., 2016). Briefly, during focus groups and interviews, we began with an open-ended question and then targeted our conversation from the subsequent discussion (If you could design an ideal health program that best meets the needs of the women living here, what would you do?). We kept the goals of the curriculum as well as the word “health” broad to allow women and staff the opportunity to conceptualize this initiative in a way that was meaningful to them.
Women and staff requested interactive and practical workshops on a variety of topics including obesity prevention, parenting, child development, and information regarding community health resources such as enrolling in health insurance. They thought the workshops should be informative, provide opportunities for discussion, and relay practical and tangible tips. Improving children’s health was a commonly described need, as women were worried about the effects IPV had on their children. Both women and staff requested that volunteers with health backgrounds and topic-specific expertise facilitate the workshops and that workshops be conducted once to twice a month, so women could participate in other nonhealth focused programs offered by the Center. Finally, they preferred group-based learning and opportunities to build their social networks. In fact, a commonly discussed goal was to use the health curriculum as a way to collaborate, socialize, and share stories and advice.
Curricular Development
Based on women’s and staff’s interests and input, we created a pilot curriculum consisting of 12 workshops on a variety of topics including nutrition, physical activity, parent–child communication, developing partnerships with health care providers, accessing community resources, and self-compassion. The goals of the curriculum were developed to mirror the results garnered from the needs assessment. Primarily, we hoped to relay health education, build skills, and provide a forum for group-based learning and the development of social networks. The majority of the workshops were developed by a topic-specific expert recruited from the academic center (physicians, psychologists, and dieticians), although four workshops were designed in collaboration with other not-for-profit organizations in the community (see Table 1 for an overview of workshop topics and facilitators). We also included three workshops specifically focused on children and incorporated children’s needs into almost every other workshop (e.g., family friendly meals during the healthy cooking class).
An Overview of Specific Workshops Including Topics and Facilitators.
We created a facilitator’s manual for each workshop so individuals without topic-specific expertise could teach the lessons in the future. Each facilitator’s manual was reviewed by M.R., the topic expert, and the Center’s manager to ensure the lesson material was sensitive to the needs of IPV survivors and aligned with the Center’s mission of promoting self-sufficiency. The Center’s manager and women’s case manager requested that we not ask the women to review the detailed content of the manuals, to not add to their multiple responsibilities. This was the only component of program development where the women did not provide direct feedback.
Curricular Implementation
The curriculum was implemented from September 2014-May 2015. A topic-specific expert facilitated each workshop, with the women’s case manager in attendance to provide assistance. Prior to leading the workshops, the facilitators received a 30-min training about the health effects of IPV and services provided by the Center. Women were recruited to the workshops by the women’s case manager via email, text messages, flyers, information sessions, and word of mouth. Participation was voluntary, as the Center does not require that women partake in services. Each workshop was 90 min in length, contained both didactic and interactive components, and was focused on practical knowledge that could be applied to the women’s daily lives. Examples of workshop activities included preparing a healthy meal as a group, signing up for library cards, and practicing breathing exercises. Additionally, each woman completed a short demographic survey once.
Facilitating the workshops for the Center’s community was linguistically challenging as women at the Center identify as English-speaking only, Spanish-speaking only, and bilingual. The research team and community partner decided to have a trained interpreter sit by the Spanish-speaking women and interpret while the facilitator was speaking in English, thus allowing women to attend the workshops together rather than splitting into two language-specific groups.
Curricular Evaluation
To evaluate the curriculum, we conducted focus groups with 20 women who attended at least one workshop as well as interviews with the 12 workshop facilitators and the two full-time staff employed by the Center. We conducted focus groups with women to facilitate conversation between individuals with shared experiences and individual interviews with workshop facilitators and the Center’s staff to accommodate their differing schedules (Krueger & Casey, 2015). We chose to include three key groups (women, staff, and facilitators) in the evaluation, in keeping with the CBPR principle of shared and collaborative decision making between all partners involved in an initiative (Minkler, 2005).
The aims of the evaluation were to uncover areas of programmatic success, challenges which kept women from fully engaging in the workshops, and ideas for curricular improvement. We asked women, workshop facilitators, and staff identical questions focused on each of the above-mentioned aims. Examples of questions included (a) Please describe what you liked about the workshops; (b) Please describe ways to improve the workshops; (c) Please explain how we can make the workshops more engaging and interesting to women living at the Center; and (d) If you could change the workshops so they better serve the needs of the women and children living at the Center, what would you do? The questions were translated into Spanish by a trained interpreter.
M.R. and coauthor (J.M.S.) conducted all focus groups with women at the completion of the curriculum. A maximum variation purposeful sampling strategy was used to ensure that all women who lived at the Center and attended at least one workshop were invited to participate (Patton, 2015). The women’s case manager conducted recruitment via text messages, flyers, and word of mouth. Women signed up for English or Spanish language focus groups and bilingual participants chose whichever group was more convenient for their schedules. Informed consent was obtained from all participants. We continued to conduct focus groups with women until all women who wished to participate were able and when theoretical saturation was reached, determined when we heard no new themes or content during groups (Guest, Bunce, & Johnson, 2006).
M.R. conducted individual interviews with the workshop facilitators and staff at times convenient for them. Due to the low total sample size of these two groups, we conducted interviews with all facilitators and staff rather than using the principle of theoretical saturation. All interviews occurred in English and informed consent was obtained from each participant.
An inductive, thematic-analysis approach was used for data transcription, coding, and analysis (Braun & Clarke, 2006). By inductive, we mean that we analyzed the data based on the participants’ perspectives rather than using a predetermined structure or set of themes (Elo & Kyngas, 2007). This participant-centered approach is more in line with CBPR methodologies (Israel et al., 2008). All audio recordings were transcribed by a bilingual transcription service; transcripts were then read alongside the original recordings by M.R. and J.M.S. (both fluent Spanish speakers) to assess accuracy. Spanish transcripts were also professionally translated into English. M.R. and coauthor (E.S.) coded each transcript line by line, with the assistance of the Dedoose software package (Dedoose 6.2.21, 2015). The two coders met after coding half of the transcripts to discuss emerging codes, develop a shared codebook, and establish intercoder agreement through discussion to reach consensus (Braun & Clarke, 2006; Patton, 2015). The coders then completed the same process for the remainder of the transcripts, iteratively refining the codebook as needed. After creating a final codebook, the primary coders met with the full study team to resolve any coding discrepancies and identify principle themes. At this time, we also compared and contrasted the perspectives of the women, facilitators, and staff. The manuscript was prepared as a collective effort between all authors. The Center’s manager (who was also an interview participant) was not directly involved in the coding process to minimize bias, but provided feedback on the list of principle themes and edited the manuscript. The decision was made to include her in the data analysis and writing process to stay true to the mission and principles of CBPR (Minkler, 2005).
Results
Curriculum and Evaluation Participants
The curriculum consisted of 12 workshops facilitated by topic-specific experts from the community and academic center (see Table 1). Of the 46 women residing at the Center, 37 (80%) attended at least one workshop and each workshop had 3-12 attendees. See Table 2 for demographic characteristics of the curriculum participants.
Demographic Characteristics of the Women Who Participated in the Curriculum and Evaluation. a
Due to rounding, percentages for ages in the curriculum group add up to 99.
Due to rounding, percentages for education in the curriculum group add up to 99.
N = 46 as nine women living at the Center did not attend any workshops.
Due to rounding, percentages for workshops attended in the curriculum group add up to 101.
Twenty women, all of whom participated in at least one workshop, took part in one of four evaluation focus groups (two groups in English and two in Spanish, with four to six women per group). The characteristics of the women who participated in the focus groups were similar to those who attended the workshops (Table 2). The 12 workshop facilitators (see Table 1), Center’s manager, and women’s case manager also participated in the evaluation. At the time of the interview, the manger had been working at the Center for 4 years. Her primary roles include supervising staff and volunteers, developing new initiatives that advance the mission of the Center, and meeting individually with families living at the Center. The women’s case manager had been working at the Center for 5 years. Her primary roles include serving as a case manager for women at the Center, helping families find employment and regain independence, and coordinating workshops and other educational initiatives. Both have years of experience working with IPV survivors and a deep knowledge of the needs and backgrounds of the women residing at the Center.
Evaluation Themes
Seven themes emerged from the inductive data analysis process including (a) satisfaction with workshop topics; (b) importance of building a supportive community; (c) challenges in developing strong survivor–facilitator relationships; (d) barriers to attendance; (e) linguistic sensitivity; (f) incorporating children; and (g) identification of sustainable workshop facilitators. We found that similar themes traversed the three participant groups (women, workshop facilitators, and the Center’s staff), so have presented quotations concurrently to facilitate comparison. 2 Additionally, apart from the discussion about optimizing learning for Spanish-speaking participants (Theme (e)), women in English-speaking and Spanish-speaking groups held similar opinions.
Satisfaction with workshop topics
Women, facilitators, and staff enjoyed the workshops and felt they conveyed novel and interesting skills in an interactive and practical manner. Many women also appreciated having the programming at their place of residence. One woman stated,
My health improved and it got me and my son back into walking. I think that every class that was brought here was just unbelievably rich. They were also easy to attend since they were at our home. (English group)
The women’s case manager agreed: “The women were very engaged. They enjoyed it. I could see them giggling during the classes.” A woman added that she found the workshops practical: “I liked the yoga exercises. I felt relaxed because before my body was tense. And the best part was that it is practical and you can do it from home” (Spanish group). Women and staff suggested ideas for future workshops to complement the current curriculum, including more exercise classes, strategies to combat insomnia, opportunities to play with their children, and information about contraception and sexual health.
Participants thought the lesson materials were sensitive to the experiences and backgrounds of IPV survivors. The women’s case manager stated, “I thought all the topics were great for our community and for women who have been abused.” Facilitators expressed putting time and thought into making the programming appropriate for IPV survivors. One facilitator said, “I was very careful to remember that the women were all victims of abuse. I adjusted the talk to avoid addressing fathers and coparenting.”
Importance of building a supportive community
Participants explained that the workshops helped foster a sense of community for women residing at the Center. One woman stated, “I have my depression, I bring my pain of the violence, of what has happened to me to the workshops and join with others who have the same pain. And we can motivate each other” (Spanish group). Another stated,
I think for us to be together in this group helps. Because I felt like I was a failure, that my health was so bad and it was my fault, but when we all share our worries I see I’m no different. So I think just the freedom to be with you guys [other women at the Center] helped me a lot. (English group)
A facilitator shared a similar perspective: “I thought it was empowering for them to listen to each other and share tips.”
Building supportive relationships was deemed so critical that women wanted more group-based activities in the future. Some women requested community-led groups to share health successes and discuss how to apply newly gained skills into their lives. One woman explained, “[The workshops] should be twice a month. The first can be the actual workshop and the second talking as a group about achieving health goals” (Spanish group). A few women also wanted to extend group-learning to electronic platforms, such as social media. One stated,
I think it would be good, so cool, if we had a website where we could write what our health goals are. And maybe [the Center] can look at the website to see our progress. Or we can have a Facebook page to share our individual successes and celebrate together. (English group)
Challenges in developing strong survivor–facilitator relationships
Despite enjoying the curriculum, women and workshop facilitators described barriers to developing a therapeutic relationship between the two groups. Women stated they appreciated having topic-specific experts, but thought it was challenging to fully trust the facilitators. One woman stated,
Everyone [the facilitators] was very nice and taught me a lot but I guess I have issues with trust as an [IPV] survivor. You know a lot of people are extremely judgmental of women who are victims of it. I wanted to know more about their [the facilitators] background and motivations. (English group)
Some women added that having the same facilitator teach multiple workshops would be more appropriate for IPV survivors. One woman expressed, “Maybe having the same person every time. You need to establish trust if you want people to come and be invested” (Spanish group). The Center’s manager agreed, stating, “It needs to be the same people teaching the workshops so women don’t have to get use to different personalities. That is important for survivors.”
When asked how their experience teaching the workshops could be improved, facilitators recalled that women would sometimes speak tangentially. One facilitator explained, “There was a group of women that started off in a side conversation about their life experiences. I was glad they were enthusiastic, but I felt it was a little hard to make sure everyone was paying attention.” The women’s case manager empathized with the facilitators’ frustrations, but reflected that the workshops were empowering for participants:
I get it, if someone is there to teach nutrition and suddenly it turns into an IPV support group with people talking loudly that is really hard. The other perspective is it doesn’t matter, as long as the women walk away thinking that [the workshop] was great. They communicated together and had a voice.
Barriers to attendance
Participants also discussed the barriers that prevented women from attending the workshops. Women described that IPV survivors have busy lives with multiple responsibilities. A woman recalled, “The two I missed were because I had to go to school. Even though the classes were at our house, it was still hard to go to them all” (English group). Some women also felt the depression and anxiety associated with IPV limited women’s ability to participate. One woman noted, “Some women do not attend because of the depression and trauma. They do not see that it [a workshop] is for one’s own benefit. It is because of what they have experienced” (Spanish group).
Women provided several solutions to improve participation including repeating workshops at different times, creating a library of video-recorded lessons, providing incentives for women to participate, and having women motivate each other to attend workshops. During one focus group, two participants had the following conversation:
Woman One: Those of us who attend, we can help others by motivating them to come. We can say “There’s a workshop, would you like to attend? Let’s go, I’m inviting you.” Woman Two: Yes, and also the classes should repeat at different times. Maybe in the afternoon or different days, because our schedules are hard. (Spanish group)
Linguistic sensitivity
Women, staff, and facilitators thought the approach of including both English and Spanish speakers in the same workshop was important. They felt that having separate groups would be isolating and detract from the supportive community the curriculum created. One woman explained, “The classes need to be both us and women who speak English. We need to be together. We learn from each other” (Spanish group). Another agreed, adding that during the workshops there should be equal distribution of English- and Spanish-speaking women throughout the room: “Sometimes we [Spanish-speaking women] sat together in the class and put ourselves in a corner. And then we would talk amongst ourselves. But we should all be together and listen to each other” (Spanish group).
Although Spanish-speaking women appreciated having bilingual workshops, they suggested ways to optimize the interpretation to better serve their needs. They requested workshop facilitators receive a brief tutorial on how to work with an interpreter, as they felt the facilitators spoke too quickly. A woman explained,
Sometimes the person who is teaching the class would speak very fast. They forget that the other person is interpreting. And then the person who is interpreting wasn’t able to tell us everything, just the last thing she heard. (Spanish group)
Incorporating children
Multiple participants discussed whether children should be invited to attend workshops with their mothers. Some felt that including children would improve mother–child bonding, but the majority enjoyed having workshops as protected time for learning and self-care. During one focus group, women had the following discussion:
Woman One: Maybe we can try to do little hands-on activities with them, like cooking. Woman Two: I agree, but it is nice to have time alone to relax and learn. (English group)
Both staff and facilitators agreed that children could be included in components of the curriculum, but should also have their own concurrent activities. The women’s case manager explained, “I think it is really important that they [women] have their own space. [But] for some of the workshops it would work to have kids. Like the class on parent–child communication. I think we have to pick and choose.”
Identification of sustainable workshop facilitators
Most participants recognized the importance of identifying future facilitators to ensuring curricular sustainability. Facilitators thought workshops should be replicated, although they felt it was not practical to have topic experts volunteer on a yearly basis. Instead, they suggested that committed volunteers with more availability, the Center’s staff, or women facilitate the workshops. One facilitator said, “A volunteer could teach the classes or we can train the staff or a woman here so they feel comfortable with the topics. I think that’s probably the best way to carry it on year after year.”
Staff and women agreed the curriculum should be sustainable, but did not think having women facilitate the workshops was an effective model. They stated that IPV survivors have multiple priorities and an obligation to facilitate workshops may add to women’s trauma and stress. Instead they preferred having a volunteer from outside the Center’s community teach the workshops. One woman noted,
When you are trying to raise your own personal bar and trying to get out of whatever situation you are in, it is nice to have volunteers come in. About us teaching, it is intimidating. I have never taught anything so I don’t know. (English group)
The Center’s manager concurred, explaining her reasoning for having volunteers rather than women facilitate workshops:
In theory I think having women teach is an amazing idea. But, remember, we are working with women who are recovering from trauma. We don’t want to add something to their plates or make them feel obligated. I think a volunteer who cares about this topic will relate well with the women and convey the material in an approachable manner.
She went on to state her preference of continuing the community–academic partnership: “I love the idea of maintaining a partnership with [the academic center]. It is great to have the help of health experts and to work together on these issues.”
Discussion
In this article, we describe use of a CBPR approach to develop one of the first health curricula for female IPV survivors residing at a THP. We also outline key strengths and challenges of such an initiative. Women, workshop facilitators, and staff considered the curriculum both engaging and helpful in advancing a sense of community at the Center. These strengths mirror the original programmatic goals described during the needs assessment. Participants also relayed areas for improvement, including aligning the expectations of facilitators with those of IPV survivors, increasing attendance, optimizing learning for Spanish-speaking women, and incorporating children into workshops.
This study was conducted as a community–academic partnership, with shared and equal contributions between the Center and Stanford University’s School of Medicine, as well as assistance from other community experts. Previous literature has indicated that more teamwork is needed between the various sectors working with IPV survivors. For example, Goodman et al. (2009) encouraged individuals to “reach across silos and systems . . . to respond to the survivor and her needs as she frames them” (p. 320) and Yuan et al. (2016) described the importance of community–academic partnerships when addressing violence prevention. This study details how multiple sectors can work together to build a survivor-defined initiative, as well as ways of overcoming obstacles inherent in creating such a relationship.
Although women and staff appreciated the partnership with the academic center and the expertise that the professionals brought to the workshops, they were concerned about a lack of continuity and felt it was difficult to fully trust the facilitators. Previous studies have reported that while IPV survivors face similar obstacles building therapeutic relationships with members of the health care system, support from a trusted health care provider can help IPV survivors seek assistance when they feel ready (Bair-Merritt et al., 2008; Chang et al., 2005; McCloskey et al., 2006; Robinson & Spilsbury, 2008). These findings may be applicable in the context of a community–academic partnership. If collaborators from the academic center can become trusted members of survivors’ support systems, they may be able to play a larger role in empowering IPV survivors to improve their health and begin the process of recovering from past trauma. More work is needed to determine how to best utilize the assets of the academic center in ways that are most helpful for IPV survivors and community partners.
A key curricular strength that emerged from the evaluation was development of supportive and shared collaboration between women. The workshops were seen not just as an opportunity to learn about a specific health topic, but also a chance to share experiences and establish social connections. This may have been possible because the workshops took place at a THP where survivors are provided long-term residence and community-building is encouraged (Baker et al., 2009). Social support is described in the literature as positively influencing IPV survivors, including improving their health, empowering them to leave abusive partners, and assisting their recovery from past trauma (Anderson, Renner, & Danis, 2012; Kamimura, Parekh, & Olson, 2013; Zapor, Wolford-Clevenger, & Johnson, 2015). The results of this study indicate that when designing health curricula for IPV survivors, emphasizing opportunities to enhance social networks should be held paramount.
Optimizing the workshops for a bilingual community was an important consideration during curricular development and evaluation. Previous work has emphasized the use of a trained interpreter for non-English-speaking IPV survivors; however, there are few studies describing IPV survivors’ preferences regarding monolingual versus bilingual programming (Bauer, Rodriguez, Quiroga, & Flores-Ortiz, 2000). We found that women appreciated the approach of teaching in two languages simultaneously, to avoid feelings of isolation which may arise if split into language-specific groups. This may relate to the overall emphasis placed on using the workshops to foster group-based, collaborative learning. Researchers should continue to explore the best ways to conduct health workshops with a community of IPV survivors who speak multiple languages.
Participants also shared their opinions about whether future workshops should go beyond simply discussing children’s health to actually including dyadic mother–child activities. Parent–child therapy for IPV survivors has been shown to be effective; however, there is a dearth of initiatives focused on improving the health of families residing at either IPV-specific emergency shelters or THPs (Graham-Bermann & Miller, 2013; Timmer, Ware, Urquiza, & Zebell, 2010). The creation and rigorous testing of integrated mother–child health programs for IPV survivors is warranted. The results suggest that such curricula should incorporate familial bonding while also offering IPV survivors opportunities for self-care and relaxation.
We recognize limitations with curricular development and implementation. The total number of participants was small and the majority were of Hispanic/Latina descent, likely due to the study location. Therefore, it may be difficult to generalize these results to other THPs. Another notable limitation is that women chose to attend as many workshops as they liked, which may have caused a selection bias. This could not be avoided as mandatory programming contradicts the Center’s mission. Finally, although 80% of women residing at the Center attended at least one workshop, only about 30% attended six or more. Barriers to attendance were discussed during the evaluation and will be important to address in future iterations of the curriculum.
There are also a few important methodological limitations of the evaluation. Three key study personnel were involved with both curricular development and components of the evaluation. There are benefits and limitations of using internal evaluators in CBPR; although they know the program well, it may be harder for them to be objective (Springett & Wallerstein, 2008). For that reason, a coauthor (E.S.), who played no role in developing or implementing the curriculum, co-coded the evaluation data. To elicit women’s perspectives, we used a focus group rather than interview approach, making it difficult to link specific demographic characteristics or number of workshops attended with individual participant’s perceptions. Finally, we only included perspectives of women who attended the workshops. Opinions of nonparticipants, if possible to obtain in the future, would prove valuable especially to further our understanding of attendance barriers.
Despite its limitations, the results of this pilot study present opportunities for further scholarly inquiry and program development. We recommend that this curriculum be implemented with larger groups of IPV survivors at other THPs using the framework we created, to determine how to adapt the workshops to meet the needs of diverse communities of IPV survivors. Studies should also explore how certain sociodemographic characteristics, such as racial background or cultural heritage, may impact participants’ perceptions about curricular development or evaluation. This program was designed for women and there may be opportunities to create similar curricula focused on the needs of children, adolescents, or male survivors. It may also be helpful to further explore community partners’ perspectives on the CBPR process and the way the curriculum may affect their workflow. Finally, now that we have described the development and qualitative evaluation of a survivor-defined health curriculum, it will be important to assess short- and long-term health-related outcomes. These include whether participating in this curriculum can improve health knowledge and attitudes, reduce risky health behaviors, and decrease the prevalence of disease morbidity among IPV survivors. To ensure that IPV survivors stay fully engaged with the research process, we recommend that they work closely with the research team to identify which specific outcomes are most important when evaluating the long-term efficacy of this curriculum.
Conclusion
In this article, we describe a unique collaborative effort between a THP and an academic center to design, implement, and evaluate a pilot health curriculum for female IPV survivors using a CBPR approach. We found that due to their complex health needs, IPV survivors are willing and interested in being fully engaged in the development and evaluation of health-related initiatives. Health curricula for this population should not only be informative, but also cultivate a sense of community and develop IPV survivors’ social networks. Additionally, we found that using a community–academic partnership provided a well-liked and feasible framework for curricular design and implementation. However, the role of the academic center must be balanced with the importance of continuity of instructors to foster a collaborative and trusting relationship between the two groups. This study demonstrates the utility of a CBPR approach when addressing the health of IPV survivors, and provides a foundation for further research and curricular development with this population.
Footnotes
Acknowledgements
We thank the women residing at the transitional housing program and the workshop facilitators for their insight, assistance, and participation. We thank Wanda Nallan, Samantha Cedillo, and Next Door Solutions to Domestic Violence for their continued support. Finally, we thank Alyssa Bogetz for reviewing the manuscript, Nicole Capdarest-Arest for her help with literature searches, and Harise Stein for her mentorship.
Authors’ Note
Portions of the data reported in this manuscript were presented at the National Conference on Health and Domestic Violence in March 2015, at the American Public Health Association’s Annual Meeting and Exposition in October 2015, and at Pediatric Academic Societies in April 2016. Maya Ragavan was a pediatric resident at Stanford University when the study was conducted. Sarah Lucha was the manager of Self-Sufficiency Services at Next Door Solutions to Domestic Violence when the study was conducted.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We received funding for this study from a Community Access to Child Health (CATCH) grant through the American Academy of Pediatrics and a Community-Based Research Fellowship grant through the Stanford University Haas Center.