Journal of Community Health Nursing, 32: 39–52, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2015.991668
Adolescent Dating Violence: Supports and Barriers in Accessing Services Angela Moore, BSN, RN, Krysten Marie Sargenton, BSN, RN, Dina Ferranti, BSN, RN, and Rosa M. Gonzalez-Guarda, PhD, MPH, RN University of Miami School of Nursing and Health Studies, Coral Gables, Florida
The purpose of this literature review is to describe the state of the science on teen dating violence (TDV) research identifying support and barriers in accessing services. This review will help identify gaps in dating violence (DV) research and inform secondary and tertiary prevention services, as well as ways that these could be integrated into comprehensive primary prevention efforts. This review was conducted via electronic search through CINAHL, PubMed, and PsychINFO. Results show a serious lack of research in the content area and the importance of increasing research efforts in discovering supports for accessing DV services is emphasized.
INTRODUCTION Dating violence (DV) is a form of intimate partner violence that occurs between two individuals that are, or have been, intimately or romantically involved with each other (current or former boyfriend/girlfriends). Adolescence, defined as the developmental period between childhood and adulthood, spanning from 10 to 24 years (U.S. Department of Health and Human Services [DHHS], 2013), is a time where dating relationships often first emerge and DV is first experienced. Adolescent DV can start with something that appears as innocent as teasing, but can eventually lead to harmful offenses toward the aggressor’s partner. This abuse often progresses into other types of psychological, physical, and sexual forms of abuse (Center for Disease Control and Prevention [CDC], 2012a). According to the CDC, about 1 in 5 women and 1 in 7 men who ever experienced rape, physical abuse, and stalking by an intimate partner have experienced some form of partner violence while between the age of 11 and 17 (CDC, 2012a). This is a serious public health problem, considering that adolescent victims of DV are more likely to experience negative physical, psychological, and social health outcomes such as injuries, substance abuse, depression, sexually transmitted infections, and poor school performance than adolescents who do not experience conflict and abuse in their intimate relationships (CDC, 2012b). The topic of DV is delicate and many of the adolescent victims do not report the offense or seek help. In a nationally representative survey of adolescents in the United States, approximately 9% of high school students reported being hit, slapped, or physically hurt on purpose Address correspondence to Angela Moore, BSN, RN, University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL 33146. E-mail: [email protected]
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by a boyfriend or girlfriend in the 12 months before they were surveyed in 2011 (CDC, 2012b). However, only 33% of victims of DV ever told anyone about the violent relationships they were in (Office of Adolescent Health, 2013). This places the adolescent victim at an increased risk for further victimization and from suffering from the negative effects that have been associated with DV. With the recognition of adolescent DV becoming more of a national concern in the United States, there has been a stimulated effort to develop prevention programs in the recent years. Although great progress has been made in the prevention of DV, most of the research in the area has been focused on primary prevention. Little has been done to elucidate factors contributing to supports and barriers to adolescents disclosing DV (secondary prevention) and seeking the health and social services that they may need (tertiary prevention). This knowledge is essential for informing the development of age- and culturally appropriate services for victims of adolescent DV. The purpose of this systematic review of the literature is to describe the state of the science on research identifying supports and barriers in accessing services among adolescent victims of DV. This review will help identify gaps in DV research and inform secondary and tertiary prevention services, as well as ways that these could be integrated into comprehensive primary prevention efforts.
METHODS The review was conducted by the first two authors via electronic search through CINAHL, PubMed, and PsychINFO on July 9, 2013, and then again on March 3, 2014. The search was restricted to studies in English that were published since 2002. The key words searched were dating violence, services, barriers, supports, adolescents, and victims, used in numerous combinations. Inclusion criteria included the following: (a) Research focused on adolescents from the age of 10 to 24 years of age (DHHS, 2013); (b) studies that used either qualitative, quantitative, or mixed methods; (c) studies that focused on secondary and tertiary prevention DV services; and (d) studies that identify supports and/or barriers to seeking access to DV services. The studies that appeared were then reviewed by the first two authors by title and abstract. The articles that were excluded for review were research-based studies not published in the United States and that focused on mainly primary prevention. Ten studies met the criteria for further review. Data from these studies were abstracted using a standardized data abstraction table that included information regarding the title, publication year, purpose, methods, design, support, and barriers to access services, and recommendations made by the authors of each of the original research studies that were reviewed. Finally, the third author reviewed the accuracy of the data that was abstracted through the review.
RESULTS The ten studies included in this review varied greatly in the populations sampled, methodologies used, and their findings for supports and barriers to accessing services for DV among adolescents. Table 1 provides details for the data that was abstracted from each individual study.
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To understand peer factors within a campus culture associated with seeking help in response to violence within a campus environment.
To report physical injury, mental health symptoms, and healthcare associated with violence in the dating experiences of college women.
To examine if sororities have formal and informal support systems to address dating violence, and the best ways to address the issue.
N = 64 Age: 18–25 years Race/Ethnicity: White (23%), Black (31%), Hispanic (16%), Other (13%) Geographic area: A private, all-women’s college in New England
N = 863 (women) Age: 18–25 years Race/Ethnicity: White (17%), Black (70.5%), Hispanic (1.3%), Asian/Pacific Islander (6.1%) Geographic area: A private, historically Black university in the South, and a private college in the mid-Atlantic
N = 35 (women) Age: 19–24 years Race/Ethnicity: White (69%), Black (31%) Geographic area: A large Midwestern public university
Amar and Gennaro, (2005). Dating violence in college women: Associated physical injury, healthcare usage, and mental health symptoms
Anderson and Danis (2007). Collegiate sororities and dating violence: An exploratory study of informal and formal helping strategies
Purpose
Amar, Sutherland, Laughon, Bess, and Stockbridge (2012). Peer influences within the campus environment on help seeking related to violence
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 Summary of Studies
Type of Study: Qualitative Design: Focus groups Analysis: A constant comparative method
Type of Study: Quantitative Design: Cross-sectional, surveys Analysis: ANOVA and MANOVA
Type of study: Qualitative Design: Focus groups Analysis: Narrative analysis
Methods
(Continued)
Supports: • “Angel board/watch lists” • Friends-Initiation of consciousness surrounding ADV in participants Barriers: • Lack of policies and protocols to address ADV • Stigma • Lack of awareness of ADV • Lack of formal and informal supports
Supports: • Friends most common informal disclosure Barriers: • Less than half of victims sought healthcare
Supports: • None Barriers: • Victim blaming • Feeling unsafe to intervene to help peers • Alcohol consumption of victim may prevent help seeking
Findings
42 To examine the prevalence and sociodemographic correlates of help-seeking and helping sources used by adolescent victims and perpetrators of dating violence.
To determine to what extent national headquarters of collegiate sororities have developed formal support systems to address dating violence.
N = 225 (victims) N = 140 (perpetrators) Age: 14–17+ years Race/Ethnicity: White (72.1%), Black (22.8%), and other (5.2%) Geographic area: Rural North Carolina
N = 10 (executive directors of sororities) N = 41 reviews of the sororities’ organizational Web sites Age: Doesn’t specify Race/Ethnicity: Doesn’t specify Geographic area: Collegiate sororities in the United States
Danis and Anderson (2008). An underserved population and untapped resource: A preliminary study of collegiate sorority response to dating violence
Purpose
Ashley and Foshee (2005). Adolescent help-seeking for dating violence: Prevalence, sociodemographic correlates, and sources of help
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 (Continued)
Type of Study: Qualitative Design: An open ended survey via telephone Analysis: Directed content analysis
Type of Study: Quantitative Design: Cross-sectional, questionnaire Analysis: Odds ratios, logistic regression
Methods
Barriers: • Lack of or safety protocol to assist members in abusive relationship
Supports: • Sorority interest in obtaining more information about dating violence and how other sororities were addressing the issue. • Philanthropic service initiative in domestic violence and child abuse
Supports: • Friends most common source of help among both victims and perpetrators • Male victims more likely than female victims to seek help from formal sources Barriers: • Preference to informal sources of help • Majority of victims and perpetrators did not seek help
Findings
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To assess the perceptions and practices of school counselors on adolescent DV.
To assess the perception and practices of school nurses regarding adolescents’ DV.
N = 305 (school counselors) Age: 20–60+ years Race/Ethnicity: White (85%), Black (10%), Hispanic (2%), Asian (3%), Other (1%) Geographic area: Urban, suburban and rural high schools in United States
N = 404 (school nurses) Age: 20–60+ years Race/Ethnicity: White (94.1%), Black (2.7%), Hispanic (1.5%), Asian (0.7%), Other (1%) Geographic area: Urban, suburban, and rural high schools in the United States
Khubchandani et al. (2012). Adolescent dating violence: A national assessment of school counselors
Khubchandani et al. (2013). Providing assistance to the victims of adolescents dating violence: A national assessment of school nurses’ practices
Type of Study: Quantitative Design: Cross-sectional, questionnaire Analysis t-tests, logistic regression analyses, and chi-square tests
Type of study: Quantitative Design: Cross-sectional, questionnaire Analysis: t-tests, logistic regression analyses, ANOVA, and chi-square tests
(Continued)
Supports: • School education about healthy relationships, DV, and where to report DV Barriers: • Lack of school policy to address DV • Lack of nurse training to assist a victim of DV • Some nurses view DV as a minor issue compared to other student health issues
Barriers: • Lack of counselor protocol to respond to DV • Lack of counselor training to assist a victim of DV
Supports: • School education about healthy relationships, DV, and where to report DV
44 To explore a prototype smart phone application (app) that is a safety decision aid for female survivors of DV.
To explore youths’ descriptions of dating violence, including how drama fits in, to whom teens would prefer to talk about violence, and desired elements of a hypothetical teen dating violence resource center, among urban adolescents.
N = 38 (females) Age: 18–25 years Race/Ethnicity: White (52.6%), Hispanic (23.7%), African American (7.9%), Multiracial (13.2%), Other (2.6%) Geographic area: Arizona, Missouri, Maryland, and Oregon
N = 32 Age: 13–24 years Race/Ethnicity: African American Geographic area: Urban
Martin, Houston, Mmari, and Decker (2011). Urban teens and young adults describe drama, disrespect, dating violence and help-seeking preferences
Purpose
Lindsay et al. (2013). Survivor feedback on a safety decision aid smartphone application for college-age women in abusive relationships
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 (Continued)
Type of Study: Qualitative Design: Focus groups Analysis: Long-table approach
Type of Study: Qualitative Design: Focus groups and individual interviews Analysis: Content analysis
Methods
Supports: • Empathetic staff for support services • Resource center qualities: comfort, safety, and confidentiality • Reaching out to friendsfemale friends in similar relationships Barriers: • Fear of further violence • Shame in reaching out to family • Formal services identified as a barrier for men
Barriers: • Concern regarding safety if abusive partner discovers app • May not be appropriate for women that are in denial • May cause emotional distress upon reading results
Supports: • App useful, effective, easy to understand • App gives user ideas of where to seek help • An alternative for those who are hesitant or unwilling to seek help from friends or campus counselors
Findings
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N = 16 (men) N = 28 (women) Age: 15–17 years Race/Ethnicity: Mexican American Geographic area: Southwest urban community
Note. DV = dating violence.
Williams, Adams and Altamirano (2012). Mexican American adolescents’ perceptions of dating violence programs: Recommendations for effective program design and implementation
To offer culturally tailored recommendations toward the development or modification of effective teen dating violence (TDV) programs and/or to identify potential barriers to Mexican American youths’ participation in TDV programs.
Type of Study: Qualitative Design: Focus groups Analysis: Phenomenology, content analysis
Barriers: • Machismo • Machismo • DV programs that are not bilingual • Lecture-styled programs
Supports: • Informal group setting for TDV programs facilitate discussion • Interactive programs (e.g. role-play) • Non-threatening curriculum • Diverse forms of peer involvement
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Populations Researched The studies identified in this review included diverse samples of adolescents across the United States that varied in age and geographic setting. Three of the studies included samples of adolescents in early adolescence. One of these studies sampled male and female adolescent victims and perpetrators of DV from the ages of 14 to 17 and examined the factors that influenced or hindered their ability to access services in a primarily rural North Carolina county (Ashley & Foshee, 2005). Another study elicited input from Mexican American boys and girls (ages 15–17) within a Southwest urban community regarding the development of effective DV programs and the identification of possible barriers to their involvement in these programs (Williams, Adams, & Altamirano, 2012). The last study in this group engaged African American girls (ages 13 to 24 years old) from a single urban geographic setting and explored who they would prefer to talk about violence with and what elements they would prefer in a DV program (Martin, Houston, Mmari, & Decker, 2011). Of the nine studies, five studies included samples of college women. Two of these studies focused solely on collegiate sororities (Anderson & Danis, 2007; Danis & Anderson, 2008). Anderson and Danis researched collegiate sorority members at a large Midwestern public university and examined organizational and individual responses to DV, and how these served as a support or barrier to accessing services. These investigators also conducted research with the executive directors of sororities and sought to determine if there were standing policies and programs established within their sorority to address DV (Danis & Anderson 2008). Lindsay et al. (2013) explored the use of a smart phone application (app) as a safety tool among female college students who had previously experienced DV. The other two studies focused more generally on college women. One of these studies sampled college women (ages 18 to 25) in a private university in the South and the mid-Atlantic to gain insight on common injuries, mental health symptoms, and the use of healthcare services (i.e., outpatient appointments with a healthcare provider, student health services, emergency services, mental health professional visitation, inpatient hospitalization, and ambulance/paramedic services) among women who experienced DV (Amar & Gennaro, 2005). The influence that peers have in contributing to the DV victim’s helpseeking behaviors has also been examined among a similar sample of college women (Amar, Sutherland, Laughon, Bess, & Stockbridge, 2012). The perspectives and practices of school counselors and school nurses regarding support and barriers for accessing DV services have also been examined. Khubchandani and colleagues (2012) sampled school counselors from rural, urban, and suburban high school areas across the United States to determine their perceptions and practices on DV. The same group of investigators also explored this phenomena among school nurses in similar settings (Khubchandani, Telliohann, Price, Dake, & Hendershot, 2013). Methodology The methodological approaches taken by investigators examining supports and barriers for accessing DV services varied with five studies taking on a qualitative approach and four using quantitative methodologies. Five out of the six qualitative studies obtained their information through holding focus groups (Amar et al., 2012; Anderson & Danis, 2007; Martin et al., 2011; Williams et al., 2012). The study investigating effective DV programs within the Mexican American adolescent population was unique in that they conducted focus groups with adolescents
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grouped according to their level of acculturation and gender (Williams et al., 2012). Various analytic approaches were taken to identify major themes from these focus groups, including content analysis (Amar et al., 2012; Lindsay et al., 2013; Martin et al., 2012), a constant comparative method (Anderson & Danis, 2007), and phenomenology (Williams et al., 2012). The last qualitative study utilized a telephone survey to obtain data from participants (Danis & Anderson, 2008) The other four quantitative studies acquired their information through self-administered questionnaires. Amar and Gennaro (2005) studied DV in college women by having their sample complete the Abuse Assessment Screen (Soeken, McFarlane, Parker & Lominack, 1998), a physical injury checklist, and the Symptom Checklist-90-R (Derogatis & Savitz, 1999) to determine common physical injuries, their mental health symptoms, and their usage of the healthcare system. In the study focusing on school counselors’ perceptions and practices regarding DV (Khubchandani et al., 2012), counselors were asked to complete a 4-page, 17-item questionnaire where they answered various closed-ended questions about DV, ranging from their perceptions of the DV problem in the United States to the types of assistance provided to survivors of DV. The study assessing school nurses’ practices and perceptions of DV also had their participants complete the same 4-page, 17-item questionnaire (Khubchandani et al., 2013). In the study investigating adolescent preferences for seeking help for DV, data were collected from questionnaires completed by adolescents in school as part of a larger study testing the effectiveness of an DV prevention program (Safe Dates program; Foshee et al., 1996) in which they further evaluated characteristics associated with DV (Ashley & Foshee, 2005). Supports for Accessing Services The results reported by the articles included in this review made it apparent that there were not a lot of supports for accessing services for DV. In the study conducted by Ashley and Foshee (2005) on adolescents who had been involved in violent relationships, it was found that most victims and perpetrators did not seek help for DV—60% percent of victims and 79% of perpetrators reported that they did not seek out help. A note-worthy finding from this study was that male victims were more likely than female victims (63% of 19 boys vs. 34% of 71 girls) to use formal sources of help, which included social workers, teachers, school counselors or nurses, therapists, police officers, and various other professionals. Among the victims who sought help, 93% sought help from informal sources and 40% sought help from formal sources. Also, out of perpetrators who sought help, 90% reported seeking help from informal sources and 62% reported seeking help from formal sources. Informal sources of help including a friend, family member, or any other nonprofessional was much more common among the help seekers, as 89% of victims and 83% of perpetrators sought help from friends. After friends, the next most utilized sources of help sought by victims were siblings or extend family (40%) and their mothers (30%). Perpetrators also utilized teachers (31%), mothers (28%), lawyers (28%), and telephone hotlines (28%; Ashley & Foshee, 2005). Qualitative research identified specific ways in which informal sources of help supported accessing DV service. In the study that conducted focus groups with college sorority members, it was identified that some sororities have instituted angel boards or watch lists in which sorority members keep an eye on other members that they suspect have a problem. This system helps identify members that need help and pairs them with a member of the sorority’s executive council for victims to have someone to meet with regularly and to obtain assistance with their situation
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(Anderson & Danis, 2007). Another qualitative study that targeted female college students who had experienced DV elicited excellent feedback as the mobile phone app regarding DV was seen not only as a useful and effective tool, but also one that could be of service to victims who are unwilling or hesitant in seeking formal services of help (Lindsay et al., 2013). Barriers for Accessing Services Numerous barriers for victims and perpetrators in accessing DV services were identified. The main barriers that were identified in the literature included: (a) the stigma attached to DV, (2) a preference for seeking informal sources of help, and (3) lack of protocols for screening and assisting adolescents in DV relationships. Stigma attached to DV. Many victims of DV are reluctant to seek help because this issue is not socially acceptable to address. In a study conducted by Anderson and Danis (2007), sorority members discussed the difficulty in discussing DV because it is a sensitive topic, creating a “barrier of silence.” During a focus group with sorority members, the concept of DV being stigmatized is highlighted by one member’s statement: “Relationship violence is not something that’s out in the open or something that’s brought up readily in meetings or even with your friends, I think because it’s almost a point of embarrassment” (Anderson & Danis, 2007, p. 92). The stigma related to DV also makes victims hesitant to speak out and seek help because they may believe that the violence was their fault or may fear that others will assume that it is the victim’s fault (Amar et al., 2012). Most adolescents seek other sources of informal help. As aforementioned, adolescents who do seek help for DV are more likely to choose informal sources, rather than formal sources of help, with friends being the most common source of disclosure among both high school (Ashley & Foshee, 2005) and college students (Amar & Gennaro, 2005). Although it is supportive that an adolescent seeks initial help, it can also be considered a barrier as their friends, who are most likely also adolescents, may not be developmentally mature enough to handle a situation such as DV. Regardless of maturity, the friend may not feel safe in directly intervening in a peer’s violent relationship (Amar et al., 2012). The focus group among college women who had experienced DV further developed this notion, as it was sometimes thought that formal services, such as student health clinics, are not completely confidential (Lindsay et al, 2013). This is one potential reason for why informal sources of help are more common among victims of DV. Lack of protocols for screening and assisting adolescents in violent relationships. If there are not adequate DV policies for screening and assisting adolescents affected by DV implemented in schools and in other organizations, then the likelihood of identifying and providing services for victims and perpetrators of DV is unlikely. In the two studies assessing the perceptions and practices of school counselors and school nurses, it was found that 81.3% of the school counselors and 86.4% of school nurses reported that there was not a school protocol/procedure established to respond to DV. Additionally, it was discovered that 90% of school counselors and 88.1% of school nurses reported that training to assist victims of DV had not been provided to school personnel within the last 2 years. It was also revealed that neither nurses nor counselors have the time, training, or the space to aid victims of DV. Also, it was found that school nurses and school counselors feel that it is not their responsibility to help survivors of DV and do not see DV a major health issue, as compared to other health issues that they deal with (Khubchandani
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et al., 2013; Khubchandani et al., 2012). There also seems to be a lack of policies and protocols for addressing DV among peers. In a study determining the policies and programs available to collegiate sororities, it was discovered that none of the sororities in the study recognized that they had specific policy procedures to provide assistance for members who are in, or suspected to be, in a violent relationship (Danis & Anderson, 2008). Recommendations The authors of the studies included in this literature review offer a range of recommendations regarding DV services. One of the main recommendations made by the authors of these studies was the development of policies and protocols to help assist adolescents who have been in a violent relationship. The authors of the two studies investigating DV in collegiate sororities recommended the establishment of policies that are victim-centered and nonblaming, and that consider the safety of the victim that aide in addressing DV among its members (Anderson & Danis, 2007; Danis & Anderson, 2008). It was also recommended that sororities should participate in community service projects that could extend their member’s understanding, awareness, and abilities to help victims of DV. Participating in these projects would also serve as a way to make discussing DV easier among peers. Although the studies specifically targeting school counselors and nurses called upon similar actions to be taken, they also underscored the importance of legislators in determining the role that schools should play in addressing DV (Khubchandani et al., 2013, Khubchandani et al., 2012). Increased screening of adolescents for DV was also called upon by various authors. The authors of the study reporting on the different experiences of college women in violent relationships recommended that routine screening of all adult and adolescent women for the experiences of intimate partner violence be conducted in health care settings (Anderson & Danis, 2007; Danis & Anderson, 2008). Additional research was called upon to determine which screening techniques work best with college women and to identify barriers to screening in this population (Amar & Gennaro, 2005). The authors of the studies that examined school nurses and school counselor’s perceptions of DV also highly recommend that schools should screen their student population periodically to determine the magnitude of DV within its students and to help identify victims to provide assistance (Khubchandani et al., 2013, Khubchandani et al., 2012). Authors also suggested that additional training was needed in addressing and providing assistance to those who have experienced DV. The authors investigating the practices and perceptions of DV in school counselors and school nurses recommend ongoing education and training for school personnel on how to assist student victims of DV and how to improve the DV prevention efforts in schools (Khubchandani et al., 2013, Khubchandani et al., 2012). The authors studying DV in the collegiate sorority population also highly encouraged further training to national staff and chapter leaders on ways to respond to members who are currently, or who might be, in an abusive relationship, to effectively assist these victims (Anderson & Danis, 2007; Danis & Anderson, 2008).
DISCUSSION This systematic literature review summarizes research that has identified supports and barriers to DV services. Few supports have been identified in accessing DV services. This appears to be
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related, in part, to the fact that adolescents are more likely to access informal sources of help such as peers, educators, and family members (Ashley & Foshee, 2005) who have not been formally trained in addressing DV, than formal sources of help such as school counselors and nurses. The stigma associated with DV and the lack of protocols for screening and assisting adolescents in DV relationships further serve as obstacles for adolescents in accessing the services that they need. Overcoming these barriers is essential in mitigating the health and social consequences of DV and is fundamental to a positive developmental trajectory for the adolescent population. Although this review illuminates several factors influencing access to DV services, the state of the science in this area appears to be in its infancy. Only 10 studies were identified as addressing this phenomenon, and none explored the efficacy or effectiveness of strategies included in formalized DV services for adolescents beyond primary prevention. Clearly more research is needed to identify factors that can help increase the access that adolescents have to DV services and qualities of services that effectively address DV. The body of research included in this systematic review is further limited by small samples of adolescents and healthcare providers that are likely not to represent the diverse perspectives of other key stakeholders involved in addressing DV across the country. Despite the limitations, several implications for research, policy, and practice can be drawn from this review. Recommendations were made regarding the development of formalized policies and protocols regarding how to address DV among adolescents. Nevertheless, little guidance has been provided as to what form these should include. Research needs to be conducted to identify effective elements of policies and protocols to address DV so that these can be used to inform actions taken by schools, student groups, healthcare settings, and other potential organizations where DV can be addressed. This research also needs to shed light on the effectiveness of state laws that direct schools and other settings to address DV. Currently, there are only 15 states that require DV education and 9 that support its use, but it is not a mandated requirement (State Legislative Chart, 2011; Teen Dating Violence, 2014). Although there is research addressing program effectiveness of DV programs (Hickman, Jaycox, & Aronoff, 2004; Meyer & Stein, 2004), there is a need in understanding how state laws encourage and enforce the actual implementation of the DV education curricula. This demonstrates not only a need for future research in those states mandating DV education, but also policy changes in states that are neglecting to address DV as a pertinent public health issue. There are also important implications for the practice of community health nurses. The authors from the studies reviewed recommend routine screening for DV in healthcare settings (Amar & Gennaro, 2005) and in schools (Khubchandani et al., 2013, Khubchandani et al., 2012). The U.S. Preventative Taskforce recommendation that women of childbearing age should be screened for intimate partner violence (IPV) and those who are experiencing IPV should be referred to services (U.S. Preventative Task Force, 2013). Current research similarly recommends that all adolescents, 13 years and older, be screened for DV regardless of reason for visit or diagnosis (Herman 2009; Miller et al., 2010). Comprehensive screening programs are essential in assuring recognition of DV and proper referral to services for victims. This includes institutional support for implementing screening, formalized screening protocols, staff training both prior to initiating the screening program and throughout, and access to services onsite or through a strong referral system (O’Campo et al., 2011). Although these recommendations are important, screening will only occur if the community health nurse recognizes DV as a salient issue to address when working with adolescents. Some authors noted that nurses and counselors did not find DV to be an important issue compared to
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other health issues (Khubchandani et al., 2013, Khubchandani et al., 2012), which indicates a need for education and a shift in attitudes surrounding DV. Therefore, more research is needed to evaluate the effectiveness of screening for DV and factors that help ensure its success. Further, when screening elicits that an adolescent is experiencing DV, it is extremely important to help community health nurses feel confident and competent in responding to DV. It is also important to consider that responding to DV is not the sole responsibility of the community health nurse and may include a variety of social, legal, and health services. Overall, these gaps in screening and response to DV can be addressed through education, training, and organizations that support a culture promoting the salience of DV. Community health nurses should receive proper training within all levels of prevention, including primary prevention. Recently, the CDC (2014) has launched a comprehensive DV prevention program, called Dating Matters, that has a strong primary prevention component. Dating Matters includes an online training for educators, youth leaders, and others interested in DV prevention. Although the evaluation of Dating Matters is still ongoing, the online training seems to be an appropriate approach to addressing DV, given the important role that both formal and informal sources of help appear to play in influencing access to DV services. Dating Matters and similar efforts should expand their training on DV prevention to also build competency in screening for DV and actions that should be taken when adolescents disclose DV.
CONCLUSION DV is an important public health concern that must continue to be addressed through research, policy, and clinical care. Although the review is limited in scope, important supports and barriers emerged in support of future research and policy needs. Nurses and other healthcare professionals are in an important position to advocate for the needs of this vulnerable population. DV is a pertinent issue affecting the health of adolescents and, as new research and policies emerge, it will be important to reevaluate the health care needs of this vulnerable population.
FUNDING This publication was supported by The Robert Wood Johnson Foundation Nurse Faculty Scholars Program, Grant #69341 to Dr. Rosa M. Gonzalez-Guarda. REFERENCES Amar, A. F., & Gennaro, S. (2005). Dating violence in college women: Associated physical injury, healthcare usage, and mental health symptoms. Nursing Research, 54(4), 235–242. Amar, A. F., Sutherland, M., Laughon, K., Bess, R., & Stockbridge, J. (2012). Peer influences within the campus environment on help seeking related to violence. Journal of National Black Nurses’ Association: JNBNA, 23(1), 1–7. Anderson, K. M., & Danis, F. S. (2007). Collegiate sororities and dating violence: An exploratory study of informal and formal helping strategies. Violence Against Women, 13, 87–100. doi:10.1177/1077801206294808 Ashley, O. S., & Foshee, V. A. (2005). Adolescent help-seeking for dating violence: Prevalence, sociodemographic correlates, and sources of help. Journal of Adolescent Health, 36(1), 25–31. doi:10.1016/j.jadohealth.2003.12.014
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Centers for Disease Control and Prevention. (2012a, August 22). Teen dating violence. Retrieved from http://www.cdc. gov/violenceprevention/intimatepartnerviolence/teen_dating_violence.html Centers for Disease Control and Prevention. (2012b). Understanding teen dating violence: Fact sheet. Retrieved from http://www.cdc.gov/violenceprevention/pdf/teendatingviolence2012-a.pdf Centers for Disease Control and Prevention. (2014). Dating matters: Understanding teen dating violence prevention. Retrieved from http://vetoviolence.cdc.gov/datingmatters/ Danis, F. S., & Anderson, K. M. (2008). An underserved population and untapped resource: A preliminary study of collegiate sorority response to dating violence. Journal of Aggression, Maltreatment & Trauma, 17, 336–351. doi:10.1080/10926770802406478 Derogatis, L. R., & Savitz, K. L. (1999). The SCL-90-R, brief symptom inventory, and matching clinical rating scales. Foshee, V. A., Linder, G. F., Bauman, K. E., Langwick, S. A., Arriaga, X. B., Heath, J. L., . . . Bangdiwala, S. (1996). The Safe Dates project: Theoretical basis, evaluation design, and selected baseline findings. American Journal of Preventative Medicine, 12(Suppl), 39–47. Herrman, J. (2009). There’s a fine line. . . . Adolescent dating violence and prevention. Pediatric Nursing, 35(3), 164–170. Hickman, L. J., Jaycox, L. H., & Aronoff, J. (2004). Dating violence among adolescents: Prevalence, gender distribution, and prevention program effectiveness. Trauma, Violence, & Abuse, 5(2), 123–142. doi:10.1177/1524838003262332 Khubchandani, J., Price, J. H., Thompson, A., Dake, J. A., Wiblishauser, M., & Telljohann, S. K. (2012). Adolescent dating violence: A national assessment of school counselors’ perceptions and practices. Pediatrics, 130, 202–210. doi:10.1542/peds.2011-3130 Khubchandani, J., Telljohann, S. K., Price, J. H., Dake, J. A., & Hendershot, C. (2013). Providing assistance to the victims of adolescent dating violence: A national assessment of school nurses’ practices. Journal of School Health, 83, 127–136. doi:10.1111/josh.12008 Lindsay, M., Messing, J. T., Thaller, J., Baldwin, A., Clough, A., Bloom, T., . . . Glass, N. (2013). Survivor feedback on a safety decision aid smartphone application for college-age women in abusive relationships. Journal of Technology in Human Services, 31, 368–388. doi:10.1080/15228835.2013.861784 Martin, C. E., Houston, A. M., Mmari, K. N., & Decker, M. R. (2012). Urban teens and young adults describe drama, disrespect, dating violence and help-seeking preferences. Maternal and Child Health Journal, 16, 957–966. doi:10.1007/s10995-011-0819-4 Meyer, H., & Stein, N. (2004). Relationship violence prevention education in schools: What’s working, what’s getting in the way, and what are some future directions. American Journal of Health Education, 35(4), 198–204. Miller, E., Decker, M. R., Raj, A., Reed, E., Marable, D., & Silverman, J. G. (2010). Intimate partner violence and health care-seeking patterns among female users of urban adolescent clinics. Maternal and Child Health Journal, 14, 910–917. O’Campo, P., Kirst, M., Tsamis, C., Chambers, C., & Ahmad, F. (2011). Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review. Social Science & Medicine, 72(6), 855–866. Office of Adolescent Health. (2013, July 19). Teen dating violence – awareness and prevention. Retrieved from http:// www.hhs.gov/ash/oah/news/e-updates/eupdate-11.html Soeken, K. L., McFarlane, J., Parker, B., & Lominack, M. C. (1998). The abuse assessment screen: a clinical instrument to measure frequency, severity, and perpetrator of abuse against women. Sage Series On Violence Against Women, 10, 195–203. State Legislative Chart. (2011, October 24). National Foundation for Women Legislators. Retrieved from http://www. womenlegislators.org/library/NFWL-LINA_DV_State_Legislative_Chart_10-24-11.pdf Teen Dating Violence. (2014, January 1). National Conference of State Legislators. Retrieved from http://www.ncsl.org/ research/health/teen-dating-violence.aspx Williams, L. R., Adams, H. L., & Altamirano, B. N. (2012). Mexican American adolescents’ perceptions of dating violence programs: Recommendations for effective program design and implementation. Qualitative Social Work, 11, 395–411. doi:10.1177/1473325012438633 U.S. Department of Health and Human Services (2013). What is adolescence? Retrieved from http://www.hhs.gov/opa/ familylife/tech_assistance/etraining/adolescent_brain/Overview/what_is_adolescence/ U.S. Preventive Services Task Force. (2013, January). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication No. 12-05167-EF-2. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderfinalrs. htm.
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Adolescent Dating Violence: Supports and Barriers in Accessing Services Angela Moore, BSN, RN, Krysten Marie Sargenton, BSN, RN, Dina Ferranti, BSN, RN, and Rosa M. Gonzalez-Guarda, PhD, MPH, RN University of Miami School of Nursing and Health Studies, Coral Gables, Florida
The purpose of this literature review is to describe the state of the science on teen dating violence (TDV) research identifying support and barriers in accessing services. This review will help identify gaps in dating violence (DV) research and inform secondary and tertiary prevention services, as well as ways that these could be integrated into comprehensive primary prevention efforts. This review was conducted via electronic search through CINAHL, PubMed, and PsychINFO. Results show a serious lack of research in the content area and the importance of increasing research efforts in discovering supports for accessing DV services is emphasized.
INTRODUCTION Dating violence (DV) is a form of intimate partner violence that occurs between two individuals that are, or have been, intimately or romantically involved with each other (current or former boyfriend/girlfriends). Adolescence, defined as the developmental period between childhood and adulthood, spanning from 10 to 24 years (U.S. Department of Health and Human Services [DHHS], 2013), is a time where dating relationships often first emerge and DV is first experienced. Adolescent DV can start with something that appears as innocent as teasing, but can eventually lead to harmful offenses toward the aggressor’s partner. This abuse often progresses into other types of psychological, physical, and sexual forms of abuse (Center for Disease Control and Prevention [CDC], 2012a). According to the CDC, about 1 in 5 women and 1 in 7 men who ever experienced rape, physical abuse, and stalking by an intimate partner have experienced some form of partner violence while between the age of 11 and 17 (CDC, 2012a). This is a serious public health problem, considering that adolescent victims of DV are more likely to experience negative physical, psychological, and social health outcomes such as injuries, substance abuse, depression, sexually transmitted infections, and poor school performance than adolescents who do not experience conflict and abuse in their intimate relationships (CDC, 2012b). The topic of DV is delicate and many of the adolescent victims do not report the offense or seek help. In a nationally representative survey of adolescents in the United States, approximately 9% of high school students reported being hit, slapped, or physically hurt on purpose Address correspondence to Angela Moore, BSN, RN, University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL 33146. E-mail: [email protected]
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by a boyfriend or girlfriend in the 12 months before they were surveyed in 2011 (CDC, 2012b). However, only 33% of victims of DV ever told anyone about the violent relationships they were in (Office of Adolescent Health, 2013). This places the adolescent victim at an increased risk for further victimization and from suffering from the negative effects that have been associated with DV. With the recognition of adolescent DV becoming more of a national concern in the United States, there has been a stimulated effort to develop prevention programs in the recent years. Although great progress has been made in the prevention of DV, most of the research in the area has been focused on primary prevention. Little has been done to elucidate factors contributing to supports and barriers to adolescents disclosing DV (secondary prevention) and seeking the health and social services that they may need (tertiary prevention). This knowledge is essential for informing the development of age- and culturally appropriate services for victims of adolescent DV. The purpose of this systematic review of the literature is to describe the state of the science on research identifying supports and barriers in accessing services among adolescent victims of DV. This review will help identify gaps in DV research and inform secondary and tertiary prevention services, as well as ways that these could be integrated into comprehensive primary prevention efforts.
METHODS The review was conducted by the first two authors via electronic search through CINAHL, PubMed, and PsychINFO on July 9, 2013, and then again on March 3, 2014. The search was restricted to studies in English that were published since 2002. The key words searched were dating violence, services, barriers, supports, adolescents, and victims, used in numerous combinations. Inclusion criteria included the following: (a) Research focused on adolescents from the age of 10 to 24 years of age (DHHS, 2013); (b) studies that used either qualitative, quantitative, or mixed methods; (c) studies that focused on secondary and tertiary prevention DV services; and (d) studies that identify supports and/or barriers to seeking access to DV services. The studies that appeared were then reviewed by the first two authors by title and abstract. The articles that were excluded for review were research-based studies not published in the United States and that focused on mainly primary prevention. Ten studies met the criteria for further review. Data from these studies were abstracted using a standardized data abstraction table that included information regarding the title, publication year, purpose, methods, design, support, and barriers to access services, and recommendations made by the authors of each of the original research studies that were reviewed. Finally, the third author reviewed the accuracy of the data that was abstracted through the review.
RESULTS The ten studies included in this review varied greatly in the populations sampled, methodologies used, and their findings for supports and barriers to accessing services for DV among adolescents. Table 1 provides details for the data that was abstracted from each individual study.
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To understand peer factors within a campus culture associated with seeking help in response to violence within a campus environment.
To report physical injury, mental health symptoms, and healthcare associated with violence in the dating experiences of college women.
To examine if sororities have formal and informal support systems to address dating violence, and the best ways to address the issue.
N = 64 Age: 18–25 years Race/Ethnicity: White (23%), Black (31%), Hispanic (16%), Other (13%) Geographic area: A private, all-women’s college in New England
N = 863 (women) Age: 18–25 years Race/Ethnicity: White (17%), Black (70.5%), Hispanic (1.3%), Asian/Pacific Islander (6.1%) Geographic area: A private, historically Black university in the South, and a private college in the mid-Atlantic
N = 35 (women) Age: 19–24 years Race/Ethnicity: White (69%), Black (31%) Geographic area: A large Midwestern public university
Amar and Gennaro, (2005). Dating violence in college women: Associated physical injury, healthcare usage, and mental health symptoms
Anderson and Danis (2007). Collegiate sororities and dating violence: An exploratory study of informal and formal helping strategies
Purpose
Amar, Sutherland, Laughon, Bess, and Stockbridge (2012). Peer influences within the campus environment on help seeking related to violence
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 Summary of Studies
Type of Study: Qualitative Design: Focus groups Analysis: A constant comparative method
Type of Study: Quantitative Design: Cross-sectional, surveys Analysis: ANOVA and MANOVA
Type of study: Qualitative Design: Focus groups Analysis: Narrative analysis
Methods
(Continued)
Supports: • “Angel board/watch lists” • Friends-Initiation of consciousness surrounding ADV in participants Barriers: • Lack of policies and protocols to address ADV • Stigma • Lack of awareness of ADV • Lack of formal and informal supports
Supports: • Friends most common informal disclosure Barriers: • Less than half of victims sought healthcare
Supports: • None Barriers: • Victim blaming • Feeling unsafe to intervene to help peers • Alcohol consumption of victim may prevent help seeking
Findings
42 To examine the prevalence and sociodemographic correlates of help-seeking and helping sources used by adolescent victims and perpetrators of dating violence.
To determine to what extent national headquarters of collegiate sororities have developed formal support systems to address dating violence.
N = 225 (victims) N = 140 (perpetrators) Age: 14–17+ years Race/Ethnicity: White (72.1%), Black (22.8%), and other (5.2%) Geographic area: Rural North Carolina
N = 10 (executive directors of sororities) N = 41 reviews of the sororities’ organizational Web sites Age: Doesn’t specify Race/Ethnicity: Doesn’t specify Geographic area: Collegiate sororities in the United States
Danis and Anderson (2008). An underserved population and untapped resource: A preliminary study of collegiate sorority response to dating violence
Purpose
Ashley and Foshee (2005). Adolescent help-seeking for dating violence: Prevalence, sociodemographic correlates, and sources of help
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 (Continued)
Type of Study: Qualitative Design: An open ended survey via telephone Analysis: Directed content analysis
Type of Study: Quantitative Design: Cross-sectional, questionnaire Analysis: Odds ratios, logistic regression
Methods
Barriers: • Lack of or safety protocol to assist members in abusive relationship
Supports: • Sorority interest in obtaining more information about dating violence and how other sororities were addressing the issue. • Philanthropic service initiative in domestic violence and child abuse
Supports: • Friends most common source of help among both victims and perpetrators • Male victims more likely than female victims to seek help from formal sources Barriers: • Preference to informal sources of help • Majority of victims and perpetrators did not seek help
Findings
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To assess the perceptions and practices of school counselors on adolescent DV.
To assess the perception and practices of school nurses regarding adolescents’ DV.
N = 305 (school counselors) Age: 20–60+ years Race/Ethnicity: White (85%), Black (10%), Hispanic (2%), Asian (3%), Other (1%) Geographic area: Urban, suburban and rural high schools in United States
N = 404 (school nurses) Age: 20–60+ years Race/Ethnicity: White (94.1%), Black (2.7%), Hispanic (1.5%), Asian (0.7%), Other (1%) Geographic area: Urban, suburban, and rural high schools in the United States
Khubchandani et al. (2012). Adolescent dating violence: A national assessment of school counselors
Khubchandani et al. (2013). Providing assistance to the victims of adolescents dating violence: A national assessment of school nurses’ practices
Type of Study: Quantitative Design: Cross-sectional, questionnaire Analysis t-tests, logistic regression analyses, and chi-square tests
Type of study: Quantitative Design: Cross-sectional, questionnaire Analysis: t-tests, logistic regression analyses, ANOVA, and chi-square tests
(Continued)
Supports: • School education about healthy relationships, DV, and where to report DV Barriers: • Lack of school policy to address DV • Lack of nurse training to assist a victim of DV • Some nurses view DV as a minor issue compared to other student health issues
Barriers: • Lack of counselor protocol to respond to DV • Lack of counselor training to assist a victim of DV
Supports: • School education about healthy relationships, DV, and where to report DV
44 To explore a prototype smart phone application (app) that is a safety decision aid for female survivors of DV.
To explore youths’ descriptions of dating violence, including how drama fits in, to whom teens would prefer to talk about violence, and desired elements of a hypothetical teen dating violence resource center, among urban adolescents.
N = 38 (females) Age: 18–25 years Race/Ethnicity: White (52.6%), Hispanic (23.7%), African American (7.9%), Multiracial (13.2%), Other (2.6%) Geographic area: Arizona, Missouri, Maryland, and Oregon
N = 32 Age: 13–24 years Race/Ethnicity: African American Geographic area: Urban
Martin, Houston, Mmari, and Decker (2011). Urban teens and young adults describe drama, disrespect, dating violence and help-seeking preferences
Purpose
Lindsay et al. (2013). Survivor feedback on a safety decision aid smartphone application for college-age women in abusive relationships
Authors, Year, Title
Target Population (Total N, Age, Race/Ethnicity, Geographic Area)
TABLE 1 (Continued)
Type of Study: Qualitative Design: Focus groups Analysis: Long-table approach
Type of Study: Qualitative Design: Focus groups and individual interviews Analysis: Content analysis
Methods
Supports: • Empathetic staff for support services • Resource center qualities: comfort, safety, and confidentiality • Reaching out to friendsfemale friends in similar relationships Barriers: • Fear of further violence • Shame in reaching out to family • Formal services identified as a barrier for men
Barriers: • Concern regarding safety if abusive partner discovers app • May not be appropriate for women that are in denial • May cause emotional distress upon reading results
Supports: • App useful, effective, easy to understand • App gives user ideas of where to seek help • An alternative for those who are hesitant or unwilling to seek help from friends or campus counselors
Findings
45
N = 16 (men) N = 28 (women) Age: 15–17 years Race/Ethnicity: Mexican American Geographic area: Southwest urban community
Note. DV = dating violence.
Williams, Adams and Altamirano (2012). Mexican American adolescents’ perceptions of dating violence programs: Recommendations for effective program design and implementation
To offer culturally tailored recommendations toward the development or modification of effective teen dating violence (TDV) programs and/or to identify potential barriers to Mexican American youths’ participation in TDV programs.
Type of Study: Qualitative Design: Focus groups Analysis: Phenomenology, content analysis
Barriers: • Machismo • Machismo • DV programs that are not bilingual • Lecture-styled programs
Supports: • Informal group setting for TDV programs facilitate discussion • Interactive programs (e.g. role-play) • Non-threatening curriculum • Diverse forms of peer involvement
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Populations Researched The studies identified in this review included diverse samples of adolescents across the United States that varied in age and geographic setting. Three of the studies included samples of adolescents in early adolescence. One of these studies sampled male and female adolescent victims and perpetrators of DV from the ages of 14 to 17 and examined the factors that influenced or hindered their ability to access services in a primarily rural North Carolina county (Ashley & Foshee, 2005). Another study elicited input from Mexican American boys and girls (ages 15–17) within a Southwest urban community regarding the development of effective DV programs and the identification of possible barriers to their involvement in these programs (Williams, Adams, & Altamirano, 2012). The last study in this group engaged African American girls (ages 13 to 24 years old) from a single urban geographic setting and explored who they would prefer to talk about violence with and what elements they would prefer in a DV program (Martin, Houston, Mmari, & Decker, 2011). Of the nine studies, five studies included samples of college women. Two of these studies focused solely on collegiate sororities (Anderson & Danis, 2007; Danis & Anderson, 2008). Anderson and Danis researched collegiate sorority members at a large Midwestern public university and examined organizational and individual responses to DV, and how these served as a support or barrier to accessing services. These investigators also conducted research with the executive directors of sororities and sought to determine if there were standing policies and programs established within their sorority to address DV (Danis & Anderson 2008). Lindsay et al. (2013) explored the use of a smart phone application (app) as a safety tool among female college students who had previously experienced DV. The other two studies focused more generally on college women. One of these studies sampled college women (ages 18 to 25) in a private university in the South and the mid-Atlantic to gain insight on common injuries, mental health symptoms, and the use of healthcare services (i.e., outpatient appointments with a healthcare provider, student health services, emergency services, mental health professional visitation, inpatient hospitalization, and ambulance/paramedic services) among women who experienced DV (Amar & Gennaro, 2005). The influence that peers have in contributing to the DV victim’s helpseeking behaviors has also been examined among a similar sample of college women (Amar, Sutherland, Laughon, Bess, & Stockbridge, 2012). The perspectives and practices of school counselors and school nurses regarding support and barriers for accessing DV services have also been examined. Khubchandani and colleagues (2012) sampled school counselors from rural, urban, and suburban high school areas across the United States to determine their perceptions and practices on DV. The same group of investigators also explored this phenomena among school nurses in similar settings (Khubchandani, Telliohann, Price, Dake, & Hendershot, 2013). Methodology The methodological approaches taken by investigators examining supports and barriers for accessing DV services varied with five studies taking on a qualitative approach and four using quantitative methodologies. Five out of the six qualitative studies obtained their information through holding focus groups (Amar et al., 2012; Anderson & Danis, 2007; Martin et al., 2011; Williams et al., 2012). The study investigating effective DV programs within the Mexican American adolescent population was unique in that they conducted focus groups with adolescents
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grouped according to their level of acculturation and gender (Williams et al., 2012). Various analytic approaches were taken to identify major themes from these focus groups, including content analysis (Amar et al., 2012; Lindsay et al., 2013; Martin et al., 2012), a constant comparative method (Anderson & Danis, 2007), and phenomenology (Williams et al., 2012). The last qualitative study utilized a telephone survey to obtain data from participants (Danis & Anderson, 2008) The other four quantitative studies acquired their information through self-administered questionnaires. Amar and Gennaro (2005) studied DV in college women by having their sample complete the Abuse Assessment Screen (Soeken, McFarlane, Parker & Lominack, 1998), a physical injury checklist, and the Symptom Checklist-90-R (Derogatis & Savitz, 1999) to determine common physical injuries, their mental health symptoms, and their usage of the healthcare system. In the study focusing on school counselors’ perceptions and practices regarding DV (Khubchandani et al., 2012), counselors were asked to complete a 4-page, 17-item questionnaire where they answered various closed-ended questions about DV, ranging from their perceptions of the DV problem in the United States to the types of assistance provided to survivors of DV. The study assessing school nurses’ practices and perceptions of DV also had their participants complete the same 4-page, 17-item questionnaire (Khubchandani et al., 2013). In the study investigating adolescent preferences for seeking help for DV, data were collected from questionnaires completed by adolescents in school as part of a larger study testing the effectiveness of an DV prevention program (Safe Dates program; Foshee et al., 1996) in which they further evaluated characteristics associated with DV (Ashley & Foshee, 2005). Supports for Accessing Services The results reported by the articles included in this review made it apparent that there were not a lot of supports for accessing services for DV. In the study conducted by Ashley and Foshee (2005) on adolescents who had been involved in violent relationships, it was found that most victims and perpetrators did not seek help for DV—60% percent of victims and 79% of perpetrators reported that they did not seek out help. A note-worthy finding from this study was that male victims were more likely than female victims (63% of 19 boys vs. 34% of 71 girls) to use formal sources of help, which included social workers, teachers, school counselors or nurses, therapists, police officers, and various other professionals. Among the victims who sought help, 93% sought help from informal sources and 40% sought help from formal sources. Also, out of perpetrators who sought help, 90% reported seeking help from informal sources and 62% reported seeking help from formal sources. Informal sources of help including a friend, family member, or any other nonprofessional was much more common among the help seekers, as 89% of victims and 83% of perpetrators sought help from friends. After friends, the next most utilized sources of help sought by victims were siblings or extend family (40%) and their mothers (30%). Perpetrators also utilized teachers (31%), mothers (28%), lawyers (28%), and telephone hotlines (28%; Ashley & Foshee, 2005). Qualitative research identified specific ways in which informal sources of help supported accessing DV service. In the study that conducted focus groups with college sorority members, it was identified that some sororities have instituted angel boards or watch lists in which sorority members keep an eye on other members that they suspect have a problem. This system helps identify members that need help and pairs them with a member of the sorority’s executive council for victims to have someone to meet with regularly and to obtain assistance with their situation
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(Anderson & Danis, 2007). Another qualitative study that targeted female college students who had experienced DV elicited excellent feedback as the mobile phone app regarding DV was seen not only as a useful and effective tool, but also one that could be of service to victims who are unwilling or hesitant in seeking formal services of help (Lindsay et al., 2013). Barriers for Accessing Services Numerous barriers for victims and perpetrators in accessing DV services were identified. The main barriers that were identified in the literature included: (a) the stigma attached to DV, (2) a preference for seeking informal sources of help, and (3) lack of protocols for screening and assisting adolescents in DV relationships. Stigma attached to DV. Many victims of DV are reluctant to seek help because this issue is not socially acceptable to address. In a study conducted by Anderson and Danis (2007), sorority members discussed the difficulty in discussing DV because it is a sensitive topic, creating a “barrier of silence.” During a focus group with sorority members, the concept of DV being stigmatized is highlighted by one member’s statement: “Relationship violence is not something that’s out in the open or something that’s brought up readily in meetings or even with your friends, I think because it’s almost a point of embarrassment” (Anderson & Danis, 2007, p. 92). The stigma related to DV also makes victims hesitant to speak out and seek help because they may believe that the violence was their fault or may fear that others will assume that it is the victim’s fault (Amar et al., 2012). Most adolescents seek other sources of informal help. As aforementioned, adolescents who do seek help for DV are more likely to choose informal sources, rather than formal sources of help, with friends being the most common source of disclosure among both high school (Ashley & Foshee, 2005) and college students (Amar & Gennaro, 2005). Although it is supportive that an adolescent seeks initial help, it can also be considered a barrier as their friends, who are most likely also adolescents, may not be developmentally mature enough to handle a situation such as DV. Regardless of maturity, the friend may not feel safe in directly intervening in a peer’s violent relationship (Amar et al., 2012). The focus group among college women who had experienced DV further developed this notion, as it was sometimes thought that formal services, such as student health clinics, are not completely confidential (Lindsay et al, 2013). This is one potential reason for why informal sources of help are more common among victims of DV. Lack of protocols for screening and assisting adolescents in violent relationships. If there are not adequate DV policies for screening and assisting adolescents affected by DV implemented in schools and in other organizations, then the likelihood of identifying and providing services for victims and perpetrators of DV is unlikely. In the two studies assessing the perceptions and practices of school counselors and school nurses, it was found that 81.3% of the school counselors and 86.4% of school nurses reported that there was not a school protocol/procedure established to respond to DV. Additionally, it was discovered that 90% of school counselors and 88.1% of school nurses reported that training to assist victims of DV had not been provided to school personnel within the last 2 years. It was also revealed that neither nurses nor counselors have the time, training, or the space to aid victims of DV. Also, it was found that school nurses and school counselors feel that it is not their responsibility to help survivors of DV and do not see DV a major health issue, as compared to other health issues that they deal with (Khubchandani
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et al., 2013; Khubchandani et al., 2012). There also seems to be a lack of policies and protocols for addressing DV among peers. In a study determining the policies and programs available to collegiate sororities, it was discovered that none of the sororities in the study recognized that they had specific policy procedures to provide assistance for members who are in, or suspected to be, in a violent relationship (Danis & Anderson, 2008). Recommendations The authors of the studies included in this literature review offer a range of recommendations regarding DV services. One of the main recommendations made by the authors of these studies was the development of policies and protocols to help assist adolescents who have been in a violent relationship. The authors of the two studies investigating DV in collegiate sororities recommended the establishment of policies that are victim-centered and nonblaming, and that consider the safety of the victim that aide in addressing DV among its members (Anderson & Danis, 2007; Danis & Anderson, 2008). It was also recommended that sororities should participate in community service projects that could extend their member’s understanding, awareness, and abilities to help victims of DV. Participating in these projects would also serve as a way to make discussing DV easier among peers. Although the studies specifically targeting school counselors and nurses called upon similar actions to be taken, they also underscored the importance of legislators in determining the role that schools should play in addressing DV (Khubchandani et al., 2013, Khubchandani et al., 2012). Increased screening of adolescents for DV was also called upon by various authors. The authors of the study reporting on the different experiences of college women in violent relationships recommended that routine screening of all adult and adolescent women for the experiences of intimate partner violence be conducted in health care settings (Anderson & Danis, 2007; Danis & Anderson, 2008). Additional research was called upon to determine which screening techniques work best with college women and to identify barriers to screening in this population (Amar & Gennaro, 2005). The authors of the studies that examined school nurses and school counselor’s perceptions of DV also highly recommend that schools should screen their student population periodically to determine the magnitude of DV within its students and to help identify victims to provide assistance (Khubchandani et al., 2013, Khubchandani et al., 2012). Authors also suggested that additional training was needed in addressing and providing assistance to those who have experienced DV. The authors investigating the practices and perceptions of DV in school counselors and school nurses recommend ongoing education and training for school personnel on how to assist student victims of DV and how to improve the DV prevention efforts in schools (Khubchandani et al., 2013, Khubchandani et al., 2012). The authors studying DV in the collegiate sorority population also highly encouraged further training to national staff and chapter leaders on ways to respond to members who are currently, or who might be, in an abusive relationship, to effectively assist these victims (Anderson & Danis, 2007; Danis & Anderson, 2008).
DISCUSSION This systematic literature review summarizes research that has identified supports and barriers to DV services. Few supports have been identified in accessing DV services. This appears to be
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related, in part, to the fact that adolescents are more likely to access informal sources of help such as peers, educators, and family members (Ashley & Foshee, 2005) who have not been formally trained in addressing DV, than formal sources of help such as school counselors and nurses. The stigma associated with DV and the lack of protocols for screening and assisting adolescents in DV relationships further serve as obstacles for adolescents in accessing the services that they need. Overcoming these barriers is essential in mitigating the health and social consequences of DV and is fundamental to a positive developmental trajectory for the adolescent population. Although this review illuminates several factors influencing access to DV services, the state of the science in this area appears to be in its infancy. Only 10 studies were identified as addressing this phenomenon, and none explored the efficacy or effectiveness of strategies included in formalized DV services for adolescents beyond primary prevention. Clearly more research is needed to identify factors that can help increase the access that adolescents have to DV services and qualities of services that effectively address DV. The body of research included in this systematic review is further limited by small samples of adolescents and healthcare providers that are likely not to represent the diverse perspectives of other key stakeholders involved in addressing DV across the country. Despite the limitations, several implications for research, policy, and practice can be drawn from this review. Recommendations were made regarding the development of formalized policies and protocols regarding how to address DV among adolescents. Nevertheless, little guidance has been provided as to what form these should include. Research needs to be conducted to identify effective elements of policies and protocols to address DV so that these can be used to inform actions taken by schools, student groups, healthcare settings, and other potential organizations where DV can be addressed. This research also needs to shed light on the effectiveness of state laws that direct schools and other settings to address DV. Currently, there are only 15 states that require DV education and 9 that support its use, but it is not a mandated requirement (State Legislative Chart, 2011; Teen Dating Violence, 2014). Although there is research addressing program effectiveness of DV programs (Hickman, Jaycox, & Aronoff, 2004; Meyer & Stein, 2004), there is a need in understanding how state laws encourage and enforce the actual implementation of the DV education curricula. This demonstrates not only a need for future research in those states mandating DV education, but also policy changes in states that are neglecting to address DV as a pertinent public health issue. There are also important implications for the practice of community health nurses. The authors from the studies reviewed recommend routine screening for DV in healthcare settings (Amar & Gennaro, 2005) and in schools (Khubchandani et al., 2013, Khubchandani et al., 2012). The U.S. Preventative Taskforce recommendation that women of childbearing age should be screened for intimate partner violence (IPV) and those who are experiencing IPV should be referred to services (U.S. Preventative Task Force, 2013). Current research similarly recommends that all adolescents, 13 years and older, be screened for DV regardless of reason for visit or diagnosis (Herman 2009; Miller et al., 2010). Comprehensive screening programs are essential in assuring recognition of DV and proper referral to services for victims. This includes institutional support for implementing screening, formalized screening protocols, staff training both prior to initiating the screening program and throughout, and access to services onsite or through a strong referral system (O’Campo et al., 2011). Although these recommendations are important, screening will only occur if the community health nurse recognizes DV as a salient issue to address when working with adolescents. Some authors noted that nurses and counselors did not find DV to be an important issue compared to
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other health issues (Khubchandani et al., 2013, Khubchandani et al., 2012), which indicates a need for education and a shift in attitudes surrounding DV. Therefore, more research is needed to evaluate the effectiveness of screening for DV and factors that help ensure its success. Further, when screening elicits that an adolescent is experiencing DV, it is extremely important to help community health nurses feel confident and competent in responding to DV. It is also important to consider that responding to DV is not the sole responsibility of the community health nurse and may include a variety of social, legal, and health services. Overall, these gaps in screening and response to DV can be addressed through education, training, and organizations that support a culture promoting the salience of DV. Community health nurses should receive proper training within all levels of prevention, including primary prevention. Recently, the CDC (2014) has launched a comprehensive DV prevention program, called Dating Matters, that has a strong primary prevention component. Dating Matters includes an online training for educators, youth leaders, and others interested in DV prevention. Although the evaluation of Dating Matters is still ongoing, the online training seems to be an appropriate approach to addressing DV, given the important role that both formal and informal sources of help appear to play in influencing access to DV services. Dating Matters and similar efforts should expand their training on DV prevention to also build competency in screening for DV and actions that should be taken when adolescents disclose DV.
CONCLUSION DV is an important public health concern that must continue to be addressed through research, policy, and clinical care. Although the review is limited in scope, important supports and barriers emerged in support of future research and policy needs. Nurses and other healthcare professionals are in an important position to advocate for the needs of this vulnerable population. DV is a pertinent issue affecting the health of adolescents and, as new research and policies emerge, it will be important to reevaluate the health care needs of this vulnerable population.
FUNDING This publication was supported by The Robert Wood Johnson Foundation Nurse Faculty Scholars Program, Grant #69341 to Dr. Rosa M. Gonzalez-Guarda. REFERENCES Amar, A. F., & Gennaro, S. (2005). Dating violence in college women: Associated physical injury, healthcare usage, and mental health symptoms. Nursing Research, 54(4), 235–242. Amar, A. F., Sutherland, M., Laughon, K., Bess, R., & Stockbridge, J. (2012). Peer influences within the campus environment on help seeking related to violence. Journal of National Black Nurses’ Association: JNBNA, 23(1), 1–7. Anderson, K. M., & Danis, F. S. (2007). Collegiate sororities and dating violence: An exploratory study of informal and formal helping strategies. Violence Against Women, 13, 87–100. doi:10.1177/1077801206294808 Ashley, O. S., & Foshee, V. A. (2005). Adolescent help-seeking for dating violence: Prevalence, sociodemographic correlates, and sources of help. Journal of Adolescent Health, 36(1), 25–31. doi:10.1016/j.jadohealth.2003.12.014
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Centers for Disease Control and Prevention. (2012a, August 22). Teen dating violence. Retrieved from http://www.cdc. gov/violenceprevention/intimatepartnerviolence/teen_dating_violence.html Centers for Disease Control and Prevention. (2012b). Understanding teen dating violence: Fact sheet. Retrieved from http://www.cdc.gov/violenceprevention/pdf/teendatingviolence2012-a.pdf Centers for Disease Control and Prevention. (2014). Dating matters: Understanding teen dating violence prevention. Retrieved from http://vetoviolence.cdc.gov/datingmatters/ Danis, F. S., & Anderson, K. M. (2008). An underserved population and untapped resource: A preliminary study of collegiate sorority response to dating violence. Journal of Aggression, Maltreatment & Trauma, 17, 336–351. doi:10.1080/10926770802406478 Derogatis, L. R., & Savitz, K. L. (1999). The SCL-90-R, brief symptom inventory, and matching clinical rating scales. Foshee, V. A., Linder, G. F., Bauman, K. E., Langwick, S. A., Arriaga, X. B., Heath, J. L., . . . Bangdiwala, S. (1996). The Safe Dates project: Theoretical basis, evaluation design, and selected baseline findings. American Journal of Preventative Medicine, 12(Suppl), 39–47. Herrman, J. (2009). There’s a fine line. . . . Adolescent dating violence and prevention. Pediatric Nursing, 35(3), 164–170. Hickman, L. J., Jaycox, L. H., & Aronoff, J. (2004). Dating violence among adolescents: Prevalence, gender distribution, and prevention program effectiveness. Trauma, Violence, & Abuse, 5(2), 123–142. doi:10.1177/1524838003262332 Khubchandani, J., Price, J. H., Thompson, A., Dake, J. A., Wiblishauser, M., & Telljohann, S. K. (2012). Adolescent dating violence: A national assessment of school counselors’ perceptions and practices. Pediatrics, 130, 202–210. doi:10.1542/peds.2011-3130 Khubchandani, J., Telljohann, S. K., Price, J. H., Dake, J. A., & Hendershot, C. (2013). Providing assistance to the victims of adolescent dating violence: A national assessment of school nurses’ practices. Journal of School Health, 83, 127–136. doi:10.1111/josh.12008 Lindsay, M., Messing, J. T., Thaller, J., Baldwin, A., Clough, A., Bloom, T., . . . Glass, N. (2013). Survivor feedback on a safety decision aid smartphone application for college-age women in abusive relationships. Journal of Technology in Human Services, 31, 368–388. doi:10.1080/15228835.2013.861784 Martin, C. E., Houston, A. M., Mmari, K. N., & Decker, M. R. (2012). Urban teens and young adults describe drama, disrespect, dating violence and help-seeking preferences. Maternal and Child Health Journal, 16, 957–966. doi:10.1007/s10995-011-0819-4 Meyer, H., & Stein, N. (2004). Relationship violence prevention education in schools: What’s working, what’s getting in the way, and what are some future directions. American Journal of Health Education, 35(4), 198–204. Miller, E., Decker, M. R., Raj, A., Reed, E., Marable, D., & Silverman, J. G. (2010). Intimate partner violence and health care-seeking patterns among female users of urban adolescent clinics. Maternal and Child Health Journal, 14, 910–917. O’Campo, P., Kirst, M., Tsamis, C., Chambers, C., & Ahmad, F. (2011). Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review. Social Science & Medicine, 72(6), 855–866. Office of Adolescent Health. (2013, July 19). Teen dating violence – awareness and prevention. Retrieved from http:// www.hhs.gov/ash/oah/news/e-updates/eupdate-11.html Soeken, K. L., McFarlane, J., Parker, B., & Lominack, M. C. (1998). The abuse assessment screen: a clinical instrument to measure frequency, severity, and perpetrator of abuse against women. Sage Series On Violence Against Women, 10, 195–203. State Legislative Chart. (2011, October 24). National Foundation for Women Legislators. Retrieved from http://www. womenlegislators.org/library/NFWL-LINA_DV_State_Legislative_Chart_10-24-11.pdf Teen Dating Violence. (2014, January 1). National Conference of State Legislators. Retrieved from http://www.ncsl.org/ research/health/teen-dating-violence.aspx Williams, L. R., Adams, H. L., & Altamirano, B. N. (2012). Mexican American adolescents’ perceptions of dating violence programs: Recommendations for effective program design and implementation. Qualitative Social Work, 11, 395–411. doi:10.1177/1473325012438633 U.S. Department of Health and Human Services (2013). What is adolescence? Retrieved from http://www.hhs.gov/opa/ familylife/tech_assistance/etraining/adolescent_brain/Overview/what_is_adolescence/ U.S. Preventive Services Task Force. (2013, January). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication No. 12-05167-EF-2. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderfinalrs. htm.
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