Measuring the Effects of the Shape Your Life Project on the Mental and Physical Health Outcomes of Survivors of Gender-Based Violence

Abstract

Little is known regarding the types of physical activity interventions most effective in supporting the mental and physical health of woman-identified survivors of gender-based violence. This study measured the experiences of 56 participants who participated in a 14-week trauma-informed, noncontact boxing program once per week for 90 min. Participants completed measures of health-related outcomes including physical and mental health, quality of life, mastery, resilience, self-esteem, physical self-efficacy, social conflict, and financial strain at baseline, program midpoint, and program end. Analyses of variance showed significant improvements for all indicators measured except financial strain, demonstrating viability and effectiveness of this program.

Keywords

trauma informed boxing physical activity domestic abuse health outcomes

Gender-based violence (GBV) is one of the most common forms of violence reported worldwide. The United Nations and the World Health Organization (WHO) have identified GBV as a global health issue and a violation of women's human rights (Garcia-Moreno et al., 2005; WHO, 2017). GBV is defined as physical, psychological, or sexual harm against women and girls because of their gender, gender expression, gender identity, or perceived gender (Status of Women Canada, 2020; United Nations General Assembly, 1993). Worldwide, one in three women are physically and/or sexually victimized in their lifetime (Garcia-Moreno et al., 2013). In Canada, a woman or girl is killed every 2.5 days. In addition, more women than men experience domestic violence, sexual assault, harassment, and sex trafficking. While all women can experience GBV, some are at an increased risk because of various forms of oppression, including racism, homophobia, transphobia, and ableism. As a result, women living with a disability, queer, nonbinary, lesbian and bisexual people, Black, Indigenous and people of color, and women living in remote and rural regions are at a greater risk of violence (Status of Women Canada, 2020).

There is extensive research documenting that the effects of trauma resulting from GBV have serious, long-lasting negative consequences on women's overall well-being. Trauma results from experiences that overwhelm a person's capacity to cope, including when someone is unable to take action to protect themselves (Poole & Greaves, 2012). Psychiatrist and trauma expert, van der Kolk (2014, p. 1) explains, “Trauma, by definition, is unbearable and intolerable” and leaves one stuck in a state of helplessness and terror. Even after the traumatic event has ended, the whole body has been affected, resulting in a fundamental reorganization of the way the mind and body manage experiences. As a result, there are ongoing impacts on mental and physical health. While trauma responses are unique to each person, physical pain is often an ongoing consequence, causing poor physical health including gastrointestinal disorders, somatic symptom disorder, and poor reproductive health, among other responses (Coker et al., 2002; Heise et al., 2002; Rees et al., 2011; van der Kolk, 2014). Trauma is also associated with psychological outcomes, such as depression, anxiety, posttraumatic stress disorder (PTSD), low self-esteem, substance abuse, and addiction (Cascardi & O’Leary, 1992; Golding, 1999; Pico-Alfonso et al., 2006; Poole & Greaves, 2012; Rees et al., 2011; Woods, 2000).

Advances in neuroscience have provided researchers with a better understanding of the ways in which trauma leaves an imprint on the brain and the body, as well as new possibilities to address and even reverse the damage. While there is no single “treatment of choice” for trauma (van der Kolk, 2014, p. 21), women are often directed towards talk-based therapy or pharmaceutical interventions, where they are medicated to address a range of physical and psychological symptoms (insomnia, anxiety, hyperarousal, depression; van Ingen, 2020a). As physical activity and sport researchers, we were struck by the knowledge that trauma is held in people's bodies (van der Kolk, 2014). As van der Kolk (2014, p. 27) outlines, healing from trauma “depends on experiential knowledge” that requires that people feel fully in charge of their body, in all its visceral dimensions. Traumatized people chronically feel unsafe in their bodies, and there are few opportunities for woman to access trauma-informed physical activity where they can experience being in charge of their own bodies.

A recent scoping review investigated the peer-reviewed literature on trauma-informed physical activity (Darroch et al., 2020). They found a total of only 29 articles, of which 26 used yoga as their trauma-informed physical activity, highlighting a need to understand the impact of more diverse forms of trauma-informed physical activity. These authors found varied outcomes reported, including symptoms of PTSD, mental health (e.g., anxiety and depression), and physical activity levels. However, many of these studies did not measure outcomes of the trauma-informed physical activity itself, but rather perceptions of the program, barriers, or the feasibility of integrating physical activity into existing programs. These studies also used varied populations, including adults with PTSD symptoms, adolescents, as well as yoga instructors and health care providers. In general, these studies provided support for the potential for trauma-informed physical activity (i.e., yoga) to reduce symptoms of PTSD (Gallegos et al., 2017) and anxiety (Mitchell et al., 2014) in women with PTSD. As noted by Darroch et al. (2020) and Pebole et al. (2020) in their commentary on physical activity for female survivors of violence, researchers must look at more diverse outcomes, such as quality of life, resilience, and physical health. As little is known about other types of physical activity interventions (beyond yoga) that are effective in supporting the mental and physical health of woman-identified survivors of GBV, this study measured the experiences of participants in a trauma-informed, noncontact boxing intervention in Toronto, Canada.

Shape Your Life: A Trauma-Informed Physical Activity Program

There has been growing recognition of the importance of trauma-informed approaches rooted in an understanding of the potential effects of trauma on participants. It is important to note that trauma-informed services and programs are not created to treat trauma-related symptoms. Rather, they are designed to be responsive to the effects of trauma such that they provide women with services that are framed and delivered with understanding of the impact of violence, including abuse, neglect, witnessing violence, and disrupted attachment, on individuals and work to support recovery (Elliott et al., 2005; Wilson et al., 2015). There are a wide range of perspectives and practices reflecting different understandings of trauma-informed practice. However, core principles include an understanding of trauma in all aspects of programing and service delivery and prioritizing the safety, choice, and control of the participant (Poole & Greaves, 2012). Creating a safe, positive environment, establishing trust and collaborations between staff and participants, facilitating empowering relationships among participants, addressing the relationship between trauma, mental well-being, and substance abuse, and understanding the long-term consequences of trauma (Elliott et al., 2005; Huntington et al., 2005; Wilson et al., 2015) have shown significant improvements in anxiety (Fallot et al., 2011; Karatzias et al., 2016), PTSD symptoms (Amaro et al., 2007; Cocozza et al., 2005), mental health severity (Amaro et al., 2007), and mental health and trauma symptoms (Morrissey et al., 2005).

Although trauma-informed programs have shown to be effective in improving mental health, they often overlook the need for physical, body-based experiences. Herman’s (2015) groundbreaking work in Trauma and Recovery outlined that recovery from trauma and violence always begins with safety, and that safety always begins in the body. Writing about the recovery process, she argued that the first stage is the establishment of safety which “begins by focusing on control of the body and gradually moves outward toward control of the environment” (Herman, 1998, p. 99). A key recognition is that survivors often feel unsafe in their bodies and that “having physical experiences that directly contradict the helplessness, rage, and collapse that are part of trauma” are important for regaining self-mastery (van der Kolk, 2014, p. 3). Some body-oriented therapies, in particular trauma-informed yoga, have been shown to reduce anxiety, depression, and PTSD symptoms for survivors of interpersonal violence (Clark et al., 2014; van der Kolk, 2014).

Trauma-informed physical activity programs provide opportunities for participants to become familiar with the sensations of their body, which is a key component of recovery (van der Kolk, 2014). The overall purpose of this study was to expand the understanding of the mental and physical health outcomes for woman-identifying survivors of violence in the Shape Your Life Project (SYL), post 14-week intervention. SYL is a free, trauma-informed program that reconfigures the sport of boxing into a noncontact form—which means there is no sparring or punches directed at the participant as they learn footwork, punch combinations, and hit heavy bags and punch mitts. SYL was founded in 2007 in Toronto, Canada, and is informed by an anti-oppression framework and feminist trauma work (van Ingen, 2011b). Over 2,300 people have participated in the program and there is an active waiting list to join the program. van Ingen (2011a, 2011b, 2016, 2020a, 2020b) has published several qualitative articles exploring the impact of SYL in the lives of survivors, but to date there has been no study quantitatively documenting changes. The SYL project received funding from the Public Health Agency of Canada for three years (2016–2019) to measure physical and mental health outcomes. This study used a mixed methods approach to assess the effectiveness of a 14-week trauma-informed, noncontact boxing program designed to improve the mental and physical health of woman-identified survivors of violence. This article details the quantitative data collected across six 14-week sessions over 3 years (see van Ingen, 2020a, 2020b for qualitative findings). Two specific research questions were assessed: (a) Does the 14-week SYL program lead to improvements in physical and mental health and quality of life, and (b) Does the SYL program lead to improvements in social support, self-esteem, resilience, perceived physical ability (PPA), personal and interpersonal agency, and perceptions of financial strain? Based on previous qualitative research with SYL participants showing physical and psychological benefits, it was hypothesized that all variables would show improvements across the 14 weeks. Specifically, we hypothesized significant increases in physical and mental health and quality of life after 14 weeks of participation in the SYL program. With respect to secondary outcomes, we expected increases in social support, self-esteem, resilience, physical ability, personal and interpersonal agency, and decreases in perceptions of financial strain. However, given that it was unclear when these improvements might occur, we did not make any hypotheses regarding changes at program midpoint.

Method

The study followed a feminist, trauma-informed research design (van Ingen, 2011b, 2020b) in its conceptualization and design led by faculty at Brock University and staff at Opportunity For Advancement, a Toronto-based community agency providing advocacy and support for under-resourced women. The study was conducted over three years, through six 14-week sessions. The main outcomes measured were physical and mental health and quality of life, with secondary measures including interpersonal relationships, self-esteem, resilience, PPA, personal and interpersonal agency, and financial strain.

Study Participants

Eligible participants included woman-identified (cis or trans) survivors of violence aged 18 years or older. Participants were recruited from the SYL participant waiting list database and through advertisements posted at agencies and community groups working with survivors of violence in Toronto. As SYL has been operating since 2007, there were several ongoing relationships with community agencies including the Centre for Addiction and Mental Health, Parkdale Community Health Centre, Women's Health in Women's Hands, and Children's Aid Society, among others. Women who expressed interest in joining SYL were contacted by the project coordinator, a registered social worker, who provided further information about the program. In line with trauma-informed approaches, individuals were not asked to disclose their trauma to gain access to the SYL program. The safety of participants was considered at every interaction. Interested participants were invited to a more detailed information session at which time informed consent was obtained and the baseline questionnaire was administered. Participants were not compensated for their participation; however, they were provided with transit tokens to cover their return trip to the gym for each session. Healthy food/snacks were provided, as well as running shoes and clothing, if needed. A stipend to cover the cost of childcare was also provided to participants.

One hundred and twenty-nine women participated in the study. Of this number, 73 women did not complete the questionnaire package, thus were excluded from the analysis, leaving a sample size of 56 women (N = 56) whose data are reported in this article. Participants were on average 35 years old (range = 18–66 years old) and were primarily White/Caucasian (41.2%); 21.1% were Black/African Canadian, 9.6% were Latinx, 7% identified as Middle Eastern/Arab, 5.3% were Asian/South Asian, and the remaining identified as Other or declined to respond to that question. It should be noted that 78.4% of the sample who completed the questionnaire package reported completing some level of postsecondary education. There were numerous reasons why participants chose not to complete the questionnaire package. The questionnaires were emotionally difficult for some women in the sample, and though respondents reported that the questionnaires and participating in the study was personally meaningful, and that the results would be useful to others, some chose not to complete them. In addition, although assistance was available at all times during completion of questionnaires, issues related to language and reading comprehension also played a role.

Intervention Protocol

The trauma-informed, noncontact boxing protocol was designed to acknowledge and be responsive to the lived experiences of trauma survivors who were often unable to participate in physical activity programs for reasons which may include a lack of financial resources, experiences with structural racism, as well as flashbacks, anxiety, disassociation, and other trauma responses. To ensure consistency in our approach, all SYL coaching and project staff participated in a trauma-informed workshop led by two of SYL's cofounders (Cathy van Ingen and Joanne Green) to ensure that all aspects of the program were rooted in trauma-informed practices and policies.

Trauma-informed boxing adapts the environment in which the boxing is delivered to fit the needs of the participants. This included using invitational rather than directive language when giving coaching cues; emphasizing choice in all activities including warm-up, all boxing activities, and cool-down; and eliminating hands-on contact from the coaches without first asking permission from the participant. Coaches were also aware that participants might exhibit trauma-related behaviors during class given that physical activity programs are not experienced as “one size fits all” by participants who showed up with a range of experiences with violence and trauma. At times when a participant did struggle with anxiety or another trauma response, they were given space and supports without being forced into a diagnostic or treatment mold. To this end, clear boundaries were established among SYL staff. Coaches programed and delivered trauma-informed boxing but were not to take on the role of a social worker, as coaches did not have the same training, supports, and supervision as a social worker. A registered social worker was always on site to oversee sessions and offer support to individuals who chose to talk or wanted to access additional supports and resources. In addition, all the coaches and program staff met 30 min before the arrival of participants and the start of the weekly SYL program to review the coaching plan for the day, discuss any issues that the project coordinator/social worker felt the coaches needed to be aware of, and to socialize and support one another while doing emotionally demanding, direct service work with survivors of violence.

In addition, careful attention was paid to the physical space of the boxing studio, including physical layout. This included cleaning the space each week prior to participants arriving to ensure the boxing studio was well organized and clean. As the experience of violence is chaotic and often unpredictable, it was important that the gym stand in stark contrast to this so that participants had a bright, clean, clutter-free, well-organized space to enter each week. We also made sure the boxing studio did not have street-level windows to ensure privacy from onlookers. As the boxing studio was located in the upper level of a commercial, mixed-use fitness facility, we hired a “door person” to prevent non-SYL individuals from entering the boxing studio, ensuring that the space was only inhabited by SYL participants and staff while sessions were underway. The door person also greeted SYL participants as they came into the mixed-use gym space and was there as they exited the boxing studio, which several participants reported was grounding.

To accommodate as many participants as possible, a total of six 14-week interventions were offered. Once participants had completed the 14-week intervention, many wanted to continue to access the free, noncontact, trauma-informed boxing. To address this need, an additional SYL Grad Class was created to ensure that participants could continue to access the SYL program and supports, post the 14-week intervention. The Grad Class offered a 1-hr boxing session, followed by the addition of a 1-hr trauma-informed yoga session. The same staff (coaches, researchers, and social workers) were present and the same resources (food, transit tokens, childcare funding) were offered.

The research study was cleared by the Research Ethics Board at Brock University. The first SYL class was conducted at the boxing gym where participants were introduced to the primary and coinvestigator, research assistants, and coaches, and were given a gym tour as well as access to a variety of healthy foods. No physical activity was completed during this session. Once participants had met with the coaches, the coaches left the session and participants engaged in a Q&A session with the researchers about the research. Interested participants signed the consent form and completed a set of questionnaires either online using a tablet or with paper and pen (preintervention; time point one). A research assistant was on hand to answer any questions and to assist those who needed help for language or literacy reasons. Participants were encouraged to take their time in completing the questionnaires and to skip any item that were triggering or sensitive to them. It took participants approximately 30–40 min to complete the questionnaire package. The same set of questionnaires was administered in weeks 7–8 (midintervention; time point two) and in week 14 (postintervention; time point three). The questionnaire package was administered prior to the activity portion of the session and the identities of those who completed the survey were not known to the coaches.

Measures

Measures were chosen to assess health and quality of life, as well as strengths or capacities of women. Where possible, measures that had previously been used in studies examining the effects of interventions with female survivors of violence (Wuest et al., 2015) were selected.

Physical and Mental Health

Physical and mental health were assessed using the Short-Form General Health Survey (SF-12; Ware et al., 2002). The SF-12 is a 12-item scale that was developed from the original Short Form-36 Survey (Bullinger, 1995; Ware et al., 1993) and assesses eight different health concepts including physical functioning, mental health, role limitations due to physical and emotional health problems, general health perceptions, freedom from bodily pain, vitality, and social functioning. From these eight concepts, physical and mental summary health scores are calculated following a scoring chart of standardized values, ranging from 0 to 100 with higher scores indicating better physical and mental health. While widely used as indicators of physical and mental health, it is important to note that they are self-report measures and as such represent individuals' perceptions of their health. However, evidence suggests that the SF-12 can differentiate between people of different health statuses (Ware et al., 1996). In the present study, internal consistency was adequate for physical health (Cronbach's α = .84) and mental health (Cronbach's α = .80).

Quality of Life

Quality of life was measured using the World Health Organization Quality of Life measure (WHOQOL-BREF; WHOQOL Group, 1998). The WHOQOL is a 24-item measure that gauges overall quality of life and health. The 24 items are divided into four different domains: physical (seven items), psychological (six items), social relationships (three items), and environment (eight items). Items are rated on a 5-point scale, with the mean score multiplied by four. A higher score indicates greater quality of life. In the current study, internal consistency was acceptable for all domains: physical (Cronbach's α = .88), psychological (Cronbach's α = .80), social relationships (Cronbach's α = .89), and environment (Cronbach's α = .87).

Social Support

Social support was assessed using the Interpersonal Relationship Index (IPRI-SS; Tilden et al., 1990). The IPRI is a 39-item scale consisting of three subscales: social support (13 items), reciprocity (13 items), and conflict (13 items), that assess social relationships. For this study, the 13-item social support subscale, which measures perceived availability or enactment of helping behaviors by members of the social network, was used. Items are rated on a 5-point scale (1 = strongly disagree to 5 = strongly agree). A total score ranging from 13 to 65 is calculated with higher scores indicating greater perceived social support. In the present study, internal consistency was acceptable (Cronbach's α = .87).

Self-Esteem

The Rosenberg Self-Esteem Scale (Rosenberg, 1965) was used to measure self-esteem. The 10 items are rated on a 4-point scale (3 = strongly agree, 2 = agree, 1 = disagree, and 0 = strongly disagree) with a total score calculated ranging from 0 to 30 with higher scores indicating higher self-esteem. In the current study, internal consistency was acceptable (Cronbach's α = .83).

Resilience

Resilience was assessed using the Resilience Scale (Wagnild & Young, 1993). The 25-item measure reflects five characteristics of resilience which include perseverance, equanimity, meaningful life or purpose, self-reliance, and existential aloneness. Items are rated on a 7-point scale (1 = disagree to 7 = agree) with a total score calculated. In the present study, internal consistency was adequate (Cronbach's α = .84).

Perceived Physical Ability

PPA was measured using the Physical Self-Efficacy Scale (Ryckman et al., 1982). This 22-item scale consists of two subscales: PPA and physical self-presentation confidence. For this study, the 10-item PPA subscale, which measures physical ability, was used. Items are rated on a 6-point scale (1 = strongly agree to 6 = strongly disagree) with a total score calculated ranging from 10 to 60. A higher score indicates higher PPA. In the current study, internal consistency was adequate (Cronbach's α = .86).

Personal Agency

The Personal Agency Scale (Smith et al., 2000) was used to assess personal agency, which reflects an individual's sense of control over their actions to achieve outcomes. This eight-item scale measures the use of one's own efforts and abilities to achieve the desired consequences. Items are rated on a 4-point scale (1 = never to 4 = often). A mean score is calculated with higher scores indicating greater perceived personal agency. In the current study, internal consistency was adequate (Cronbach's α = .81).

Interpersonal Agency

Interpersonal agency, sense of control over action in interactions with others, was measured using the five-item Interpersonal Agency Scale (Smith et al., 2000). It measures the use of one's own efforts while interacting with others to achieve a desired consequence. Items are rated on a 4-point scale (1 = never to 4 = often). A mean score is calculated with higher scores indicating greater perceived interpersonal agency. In the present study, internal consistency was acceptable (Cronbach's α = .77).

Financial Strain

Financial strain was assessed using the Financial Strain Index (Ali & Avison, 1997). The 10-item scale measures the extent to which individuals have experienced difficulties in meeting financial commitments in 13 areas, including transportation, housing, and dental, and are rated on a 5-point scale (1 = very difficult to 5 = not at all difficult) with a total score ranging from 10 to 50 with higher scores indicating less financial strain. In the present study, internal consistency reliability was adequate (Cronbach's α = .87).

Data Analysis

A single group repeated measures study design was implemented, with quantitative data collected at three time points during the SYL intervention: baseline (time one), at weeks 7–8 (program midpoint; time two), and at the end of the program (postintervention; time three) to examine changes in health outcomes including physical and mental health, quality of life, mastery, resilience, self-esteem, physical self-efficacy, social conflict, and financial strain. A series of repeated measures analysis of variance (RMANOVA) were conducted for each variable. Post hoc analyses with Bonferonni adjustment to control for type 1 error were conducted to specifically examine changes from baseline to program midpoint, from baseline to postintervention, and from program midpoint to postintervention. Data were screened for missing variables, outliers, and assumptions prior to all analyses.

Results

Missing data were random and replaced by series mean. No outliers were identified; data were normally distributed and all assumptions were upheld.

Reported in Table 1 are the means and standard deviations for each study variable (i.e., physical and mental health; quality of life physical, psychological, social, and environmental; interpersonal relationships: social support, personal and interpersonal agency, resilience, self-esteem, financial strain, and PPA) for each time point. Generally, an improvement was seen in physical and mental health, quality of life (all domains), social support, personal and interpersonal agency, resilience, self-esteem, financial strain, and PPA from pre- to postintervention.

Table 1.

Means and Standard Deviations for the Primary and Secondary Outcomes by Time Point.

Variable	Time 1M (SD)	Time 2M (SD)	Time 3M (SD)
Interpersonal relationships—support*	44.92 (12.13)	48.19 (10.58)	49.85 (9.92)
Financial strain*	30.07 (7.72)	33.14 (5.17)	33.00 (5.65)
Personal agency*	2.98 (0.44)	3.17 (0.41)	3.29 (0.43)
Interpersonal agency	2.76 (0.62)	2.96 (0.63)	2.99 (0.59)
PPA*	34.07 (8.93)	38.11 (7.87)	40.74 (6.63)
Self-esteem*	10.55 (4.90)	14.85 (5.72)	15.78 (4.56)
Resilience*	103.44 (21.12)	119.22 (23.61)	124.26 (19.33)
SF12—physical health*	44.28 (10.51)	48.30 (8.47)	50.26 (9.97)
SF12—mental health*	28.49 (9.21)	36.91 (13.05)	36.08 (11.02)
QoL—physical health*	11.59 (2.83)	13.14 (2.43)	13.35 (2.55)
QoL—psychological health*	9.68 (2.50)	12.02 (2.87)	11.92 (2.45)
QoL—social relationships*	9.53 (4.29)	11.60 (4.10)	11.43 (3.78)
QoL—environmental*	11.50 (3.24)	13.15 (3.29)	13.22 (2.90)

Notes: Interpersonal relationships—support scores are in the range of 13–65 with higher scores indicating greater perceived social support. Financial strain scores are in the range of 10–50 with higher scores indicating less financial strain. Personal agency and interpersonal agency scores are in the range of 1–4 with higher scores indicating greater personal and interpersonal agency. PPA scores are in the range of 10–60 with higher scores indicating greater efficacy in physical ability. Self-esteem scores range from 0 to 30 with higher scores indicating greater self-esteem. Resilience scores are in the range of 17–175 with higher scores indicating greater resilience. Physical and mental health scores are in the range of 0–100 with higher scores indicating better physical and mental health. All four quality of life subscales scores range from 4 to 20 with higher scores indicating greater quality of life. N = 56 participants, M = mean, SD = standard deviation.

*p < .001.

Physical and Mental Health

A RMANOVA showed a significant improvement in physical health: F(2,110) = 5.57, p = .005, η² = .09, observed power = 0.85, and mental health: F(2,110) = 21.35, p < .001, η² = .28, observed power = 1.00. Post hoc analysis with Bonferroni adjustment revealed participants experienced greater physical health at time three compared to time one, 95% confidence intervals (CIs) [1.03, 6.96], p < .001. Furthermore, they also reported greater mental health at time two compared to time one, 95% CIs [4.14, 11.36], p < .001, and time three compared to time one, 95% CIs [5.18, 11.76], p < .001.

Quality of Life

Four RMANOVA (physical, psychological, social, and environmental) showed significant improvements in all four dimensions of quality of life—physical: F(2,110) = 18.79, p < .001, η² = .26, observed power = 1.00; psychological: F(2,110) = 22.15, p < .001, η² = .29, observed power = 1.00; social: F(2,110) = 14.78, p < .001, η² = .21, observed power = 1.00; and environmental: F(2,110) = 17.98, p < .001, η² = .25, observed power = 1.00.

Post hoc analysis revealed that participants experienced greater quality of life—physical at time two compared to time one, 95% CIs [0.54, 1.02], p < .001 and greater quality of life—physical at time three compared to time one, 95% CIs [0.94, 2.29], p < .001. Similarly, improvements in quality of life—psychological were seen at both time two compared to time one, 95% CIs [0.90, 2.7], p < .001 and time three compared to time one, 95% CIs [1.31, 3.02], p < .001. Quality of life—social was also significantly higher at time two compared to time one, 95% CIs [0.57, 2.38], p < .001 and greater quality of life—social at time three compared to time one, 95% CIs [0.93, 1.33], p < .001. Finally, a similar pattern for quality of life—environmental was shown with greater quality of life—environmental at time two compared to time one, 95% CIs [0.68, 2.20], p < .001, and at time three compared to time one, 95% CIs [0.96, 2.51], p < .001.

Social Support

A RMANOVA showed social support was significantly higher following the SYL program, F(2,110) = 9.49, p < .001, η² = .15, observed power = 0.98. Bonferroni adjustment revealed that participants experienced greater perceived interpersonal support at time three compared to time point one, 95% CIs [−7.78, −2.02], p < .001.

Self-Esteem

The RMANOVA for self-esteem showed a significant change over the course of the intervention, F(2,110) = 20.27, p < .001, η² = .27, observed power = 1.00. Self-esteem was higher at time two compared to time one, 95% CIs [1.06, 4.33], p < .001, and at time three compared to time one, 95% CIs [2.35, 5.72], p < .001.

Resilience

For resilience, RMANOVA showed a significant difference in resilience, F(2,110) = 25.05, p < .001, η² = .31, observed power = 1.00; specifically, participants reported greater resilience at time two compared to time one, 95% CIs [4.92, 17.83], p < .001; greater resilience at time three compared to time one, 95% CIs [11.73, 24.01], p < .001; and greater resilience at time three compared to time two, 95% CIs [0.16, 12.84], p < .001.

Perceived Physical Ability

A RMANOVA showed a significant difference in PPA, F(2,110) = 23.20, p < .000, η² = .30, observed power = 1.00. Post hoc analysis revealed that participants reported higher PPA at time two compared to time one, 95% CIs [1.20, 5.29], p < .001; at time three compared to time one, 95% CIs [3.65, 8.54], p < .001; and at time three compared to time two, 95% CIs [0.65, 5], p < .001.

Agency

The RMANOVA for personal agency showed a significant increase, F(2,110) = 8.99, p < .001, η² = .14, observed power = 0.97, with increases seen at both time two compared to time one, 95% CIs [0.00, 0.32], p < .001, and time three compared to time one, 95% CIs [0.95, 0.40], p < .001. For interpersonal agency, RMANOVA also showed significant increases, F(2,110) = 6.54, p < .001, η² = .11, observed power = 0.90. Post hoc analysis revealed greater interpersonal agency at time two compared to time one, 95% CIs [0.22, 0.39], p < .001, and at time three compared to time one, 95% CIs [0.05, 0.40], p < .001.

Financial Strain

A RMANOVA showed no difference in financial strain over time, F(2,110) = 1.47, p = .236, η² = .03, observed power = 0.31.

Discussion

This study was the first to investigate the mental and physical health outcomes in woman-identified survivors of GBV in the context of a trauma-informed, noncontact boxing program. The study demonstrated the benefits of implementing trauma-informed, noncontact boxing as a body-oriented therapy for survivors of violence, demonstrating that trauma-informed physical activity outside of yoga can lead to improvements in physical and mental health. While the number of study participants was smaller than anticipated (as is typical in previous studies examining trauma-informed physical activity; Darroch et al., 2020), the results were promising and support previous qualitative findings that demonstrate the positive impact of the SYL boxing program. The primary research question examined whether the program led to improvements in physical and mental health and quality of life pre-to-post intervention. The secondary research question determined whether there were positive changes in social support, self-esteem, resilience, PPA, personal and interpersonal agency, and financial strain across the 14 weeks. In general, the hypotheses were supported, with all variables except financial strain showing improvements across the intervention.

Physical and Mental Health and Quality of Life

As hypothesized, physical and mental health as well as all dimensions of quality of life improved significantly from time one to time three. In this study, physical health included participants’ perceptions of physical functioning and general health, and there are a few reasons why these perceptions of physical health improved. The physical and mental health benefits of physical activity across diverse populations are widely known (e.g., Pate et al., 1995; Penedo & Dahn, 2005), and it could be simply that knowing they were participating in a healthy behavior led participants to perceive improvements in health. It is also possible that these increases in physical activity led to improvements in participants’ abilities to do daily activities (e.g., climb stairs, moderate intensity activity) as assessed by the SF-12. It should be noted that these benefits occurred with a relatively low dose of physical activity (i.e., once per week). In addition, quality of life, an indicator of overall well-being, across all four domains (physical, psychological, social, and environmental) also significantly improved in these women. This increase in quality of life may have resulted directly from the engagement in physical activity or as a result of improvements in perceptions of physical and mental health. It is important to note that these improvements in all outcomes except physical health (which may take longer for physical changes to happen) occurred by program midpoint and were maintained at program end. Thus, these benefits occurred relatively quickly. Furthermore, effect sizes were large in magnitude (Cohen, 1992) for all variables, suggesting the robustness of the intervention.

Secondary Outcomes

In addition to improvements in the primary outcomes of interest, we also found improvements in a variety of secondary outcomes focused on strengths or capacities, including self-esteem, PPA, resilience, agency, and social support. SYL was built on trauma-informed principles. The researchers, staff, coaches, and social worker all recognized the impact of violence and trauma on participants and strove to maximize participants’ choices and control in the program, fostering a safe and welcoming environment, which are critical components of trauma-informed services (Elliott et al., 2005; Huntington et al., 2005; Wilson et al., 2015). The provision of choice over all aspects of the program likely enhanced participants’ sense of agency.

In addition, as all the participants in this study had experienced GBV, the recognition of and social support between women in the program may have contributed to improvements in fostering supportive relationships, and reducing social isolation and negative emotions (Brecklin et al., 2014; Hollander, 2004; Stevenson, 2006). The program may have allowed participants to develop and foster a positive peer relationship where women could witness their peers’ physical, mental, and emotional strength, thereby empowering and increasing their confidence. Also, encouragement from their peers and coaches may have created a healthy and welcoming environment where women felt emotionally supported, creating important social bonds (Fraser & Russell, 2000; Gaddis, 1990; Shim, 1998).

Of note, given the intervention was focused on physical activity, we were interested in changes in PPA. Unlike traditional therapies for those who have experienced trauma (e.g., talk therapy, medication), physical activity can provide other benefits including perceptions of physical competence. This study's results are consistent with Hollander (2004), who reported a significant increase in PPA using the same measure pre- to 10-week post in 36 women who participated in a feminist self-defense training course. The increase in PPA in this study supports the idea that physical activity elicits positive perceptions and feelings about one’s body (i.e., physical competence). Hollander (2004) reported postintervention that women grew to love their bodies, felt stronger, powerful, and more confident in their skin, and had a sense of control. Although SYL is explicitly not a self-defense program, some similar effects may have been experienced by participants in this study. Boxing training is very visceral and may have shown participants that their bodies are strong and powerful, giving them the confidence to learn and execute boxing techniques.

Although financial strain was not significant, there were improvements such that financial strain decreased across the 14 weeks. The program was designed such that participants in the study were supported financially; they were provided with transit tokens if needed, which may have reduced the stress of saving money for bus or subway fare. Furthermore, healthy snacks and food were provided, which provided some food security for the time the participant was at the gym. The program also provided the participants with a stipend to cover the cost of childcare, which may have contributed to the decrease in financial strain.

Limitations and Future Direction

This study was subject to limitations from small sample size. Furthermore, of the women participating in the program, those who also chose to complete the research portion, on average reported at least some postsecondary education. Thus, generalizability of these findings is limited and future research must endeavor to recruit a more diverse sample of women. We must also acknowledge that a single group design was utilized; without a control group, we cannot conclude that improvements in study outcomes were a result of SYL. Finally, our measure of physical health, while widely used, relied on self-report of perceptions, and more objective measures of physical health should also be investigated. Despite these limitations, large effect sizes across almost all variables indicate the potential benefits of SYL for improving a variety of physical and mental health outcomes, including strengths, in female survivors of violence.

Future research should also investigate the continued impact of SYL beyond the program conclusion. It is unclear what happens to the improvements made once the program has ended and women are no longer participating in the study. Furthermore, although we followed recommendations to study more diverse outcomes (e.g., Darroch et al., 2020; Pebole et al., 2020), future studies could measure specific mental health outcomes (e.g., depression, anxiety), substance and alcohol usage, and trauma symptom frequency and severity pre- and postintervention to better understand how these outcomes may change in the context of a trauma-informed program. It would also be worthwhile to compare a traditional talk-based, trauma-informed program to SYL to determine whether a body-oriented program is more effective in improving overall well-being as it incorporates a physical component most trauma-informed programs do not offer. Finally, it would be important to begin to investigate mechanisms of changes in physical and mental health. For example, it is possible that improvements in perceptions of physical competence (i.e., PPA) may have been associated with improvements in quality of life or physical health. It will be critical moving forward to understand not just the benefits of SYL, but how these benefits occur.

Conclusion

There is growing literature supporting the use of body-oriented trauma therapy like yoga as an effective intervention for survivors of GBV. However, it is important to explore other forms of trauma-informed physical activity, such as noncontact boxing, that can anchor a vital connection with our bodies. Furthermore, those experiencing trauma are diverse and have differing needs and preferences for physical activity; thus, it is critical to investigate trauma-informed physical activity beyond yoga to these types of programs not only have physical health benefits but also to increase accessibility and recruitment to these programs (Darroch et al., 2020). This was the first study to explore the short-term mental and physical health outcomes, as well as strengths, across a 14-week trauma-informed, noncontact boxing program for woman-identified survivors of GBV. As van der Kolk has outlined:

Our sense of agency, how much we feel in control, is defined by our relationship with our bodies and its rhythms. … In order to find our voice, we have to be in our bodies—-able to breath fully and able to access our inner sensations. (2014, p. 333)

Noncontact boxing, when offered in a supportive and trauma-informed approach, can be a transformative experience and a promising adjunct to other, more traditional interventions.

Footnotes

Acknowledgments

The authors would like to sincerely thank the study participants for their involvement in this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors declare the following financial support with respect to the research, authorship, and/or publication of this article: Research reported in this article was supported by the Public Health Agency of Canada, Innovation Strategy: Supporting the Health of Victims of Domestic Violence and Child Abuse Through Community Programs.

ORCID iD

Cathy van Ingen

Author Biographies

Kimberly L. Gammage is an exercise psychologist in the Department of Kinesiology at Brock University. She studies the impact of physical activity and exercise on mental health outcomes in diverse populations, including older adults and individuals with chronic disease. Her work focuses on body image and how it can both be affected by physical activity and affects physical activity experiences. She is particularly interested in how physical activity can be used to promote positive body image and well-being.

Cathy van Ingen is a professor in the Department of Kinesiology at Brock University. In 2007, she cofounded the Shape Your Life () program that has served over 2,500 participants. In 2019, she also founded the Shape Your Life Youth program that works with youth across Canada who have experienced violence. Her research broadly examines the relationship between sport, inequality, and social change.

Kirina Angrish is a PhD student at Brock University, in the Faculty of Applied Health Sciences, specializing in Behavioural and Population Health. Her research interests include understanding the relationship between physical activity and positive body image in pregnant women. Her dissertation includes designing an online prenatal yoga program to examine its effects on positive body image and mental health outcomes.

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