"Strength at Home" Intervention for Male Veterans Perpetrating Intimate Partner Aggression: Perceived Needs Survey of Therapists and Pilot Effectiveness Study

Veteran and active duty populations evidence higher rates of intimate partner aggression (IPA) than comparable civilian groups, perhaps due in part to their unique service-related experiences. IPA offender treatment programs that take military background into consideration are not widely available, and it is unclear to what extent there is a perceived need for them among clinicians who serve service members and Veterans. Strength at Home (SAH) is a promising 12-session cognitive-behavioral group intervention designed to address IPA perpetration in military populations. While clinical support for SAH is emerging, the extent to which service members and Veterans find it appropriate and helpful is not yet known. Goals of the current study were threefold: (a) assess the perceived need for a military-specific IPA program among Veterans Administration and community domestic violence (DV) program providers; (b) conduct a pilot study to examine the feasibility and preliminary effectiveness of SAH in a sample drawn from a diverse, multicultural community; and (c) conduct focus groups to obtain participant feedback on the SAH protocol. Findings from the provider survey suggested a need for specialty programs to treat military personnel who perpetrate IPA of mildtomoderate severity. Results of the SAH pilot study (n = 6) indicated decreased psychological aggression and increased anger control from baseline to 6-month follow-up. Focus group feedback indicated participants found the program to be helpful and appropriate across a wide variety of ethno-cultural variables. As more service members and Veterans of the Iraq/Afghanistan war era reintegrate into our communities, it will become increasingly important for providers in both private and public sectors of care to understand the unique needs of this treatment population, and to have access to effective IPA treatment programs.

Men's Perceptions of an Acquaintance Rape: The Role of Relationship Length, Victim Resistance, and Gender Role Attitudes

Sexual aggression is a persistent and prevalent issue in the United States, which often results in a number of psychological, emotional, and physical consequences for victims. The current study examined whether the length of relationship between the victim and perpetrator, level of victim resistance, and observers' gender role attitudes play a role in observers' perceptions of an alleged sexual assault. Participants included 297 male college students from a public university in the Northeastern United States. Contrary to hypotheses, there were no significant effects for length of relationship on participants' attributions. Relative to no resistance, verbal and physical strategies by the victim predicted higher levels of victim credibility, perpetrator culpability, and perpetrator guilt, as well as lower levels of victim culpability and perceived victim pleasure. Endorsement of traditional adversarial sex role beliefs and hostile sexist attitudes, as opposed to egalitarian attitudes, were associated with the attribution of less credibility to the victim, perceived victim trauma, perpetrator culpability, perpetrator guilt, and shorter recommended prison sentences, as well as greater victim culpability and perceived victim pleasure. Laypersons' perceptions of sexual assault merit further study, as they are relevant to juror decision making and third party responses to sexual victimization (e.g., peer support for victim) and can contribute to the secondary victimization and recovery of survivors of sexual assault.

Intimate Partner Violence Among Hong Kong Young Adults: Prevalence, Risk Factors, and Associated Health Problems

Intimate partner violence is a serious social problem and public health issue affecting the well-being of the young adults. However, there is very little epidemiological evidence on the incidence and associated health problems in contemporary Chinese society. Using a representative community sample of 1,223 young adults aged 18 to 27 years conducted by Hong Kong Family Planning Association in 2011, this study aimed to estimate the prevalence, risk factors, and possible health consequences of intimate partner violence among young adults in Hong Kong. It is found that the prevalence of lifetime and preceding 1-year intimate partner violence by former or current partners was 8.6% and 4.9% respectively. Male youths who were older were less likely to experience past-year intimate partner violence (odds ratio [OR] = 0.21, p < .05) and those who had a university degree or were unemployed were more likely to experience past-year intimate partner violence (OR = 8.48, p < .01 and OR = 8.14, p < .05 respectively). Female youths who had a full-time job were less likely to experience the lifetime violence (OR = 0.15, p < .05) and those who were ever pregnant with current partner were more likely to experience both lifetime intimate partner violence (OR = 5.00, p < .05) and past-year violence (OR = 5.63, p < .05). Both female and male victims were more likely to be subjected to mental health problems and only female victims felt fear for the violent partner.

Posttraumatic stress and emotion regulation in survivors of intimate partner violence

Rates of posttraumatic stress symptoms (PTSS) are high among female survivors of intimate partner violence (IPV), and children of parents experiencing PTSS are at increased risk for emotional and behavioral problems. However, little is known about the factors that may explain this relation. We examined child's emotion regulation as a moderator and mother's emotion regulation as a mediator of the relation between mother PTSS and child adjustment. Sixty-four female survivors of IPV and their 6-12-year-old children participated. Mothers reported their own PTSS and their children's adjustment. Child emotion regulation was measured using respiratory sinus arrhythmia, a physiological index of emotion regulation. Mother's emotion regulation was measured from observer coding of the Parent Meta-Emotion Interview (Katz & Gottman, 1986), which asked mothers about their awareness and regulation of emotion. Child emotion regulation moderated the relation between mother's PTSS and child depression and child PTSS. Mothers' total trauma symptom severity showed significant indirect effects on children's internalizing, externalizing, and total problems via mothers' emotion regulation. Results suggest that children's as well as mothers' emotion-regulation abilities represent factors that affect associations between maternal PTSS and child adjustment in families exposed to IPV.

Number of deployments, relationship satisfaction and perpetration of partner violence among U.S. Navy members

The present brief report examined whether number of deployments, relationship satisfaction, and the interaction between number of deployments and relationship satisfaction predicted Navy members' reports of perpetrating physical partner violence. Participants were 80 U.S. Navy members assigned to an Arleigh Burke-class destroyer anticipating an 8-month deployment after Operation Enduring Freedom/Operation Iraqi Freedom. The effect that the number of deployments had on perpetrating physical partner violence diminished as relationship satisfaction increased. Results suggest the importance of designing domestic violence intervention and treatment efforts toward those who report high levels of deployment and low relationship satisfaction.

Community-based intervention for women exposed to intimate partner violence: A randomized control trial

A community-based intervention, The Moms' Empowerment Program, was tested with 181 mothers exposed to intimate partner violence (IPV) during the past year. Following consent, a sequential randomized control assignment procedure allocated participants to 3 conditions: mother-plus-child received intervention (M + C), child-only received intervention (CO), and a wait list comparison group (CG). A 2-level hierarchical linear model consisting of repeated observations within individuals and individuals assigned to conditions was used to evaluate the effects of time from baseline to postintervention comparing the 3 conditions and from postintervention to 8-month follow-up for both intervention conditions. Outcomes were individual women's positive parenting and depression. Women in the M + C condition showed the greatest improvement over time of the 3 conditions in both positive parenting and depression. Without intervention parenting grew significantly worse over time for women in the comparison group. Thus, this short-term group intervention program was successful in showing moderate change in both domains.

The Relationship Between Child Maltreatment and Partner Violence Victimization and Perpetration Among College Students: Focus on Auditory Status and Gender

Partner violence is a pervasive public health concern that has received significant attention over the past three decades. Although a number of studies have reported that college students who are Deaf or hard of hearing are at an increased risk of experiencing partner violence compared with their hearing counterparts, little is known about partner violence perpetration among college students who are Deaf or hard of hearing. Furthermore, beyond disability, studies examining partner violence among students with disabilities tend to ignore other potential risk factors that may increase the risk of partner violence as a victim and/or a perpetrator. This exploratory study examines the extent of partner violence among male and female college students by auditory status and the relationship between experiencing and perpetrating partner abuse (i.e., physical abuse and psychological abuse) and child maltreatment (i.e., witnessing abuse and experiencing child physical abuse). The study also examines gender differences in the relationship between child maltreatment and physical and psychological abuse victimization and perpetration. Data were collected from a sample of approximately 680 college students at a northeastern university. Findings indicate that having witnessed interparental abuse as a child was only significant for being an adult victim of physical abuse. Having been a child victim of parental abuse was not significant for any of the abuse measures. Gender was only significant for being an adult victim of physical abuse. Deaf students were significantly more likely to report all abuse measures. Implications and directions for further research are discussed.

Intimate Partner Violence and the Rural-Urban-Suburban Divide: Myth or Reality? A Critical Review of the Literature

The author of this article presents a review of the published empirical and theoretical literature to date on similarities and differences in intimate partner violence (IPV) in rural locales compared to urban and suburban locales. A review of 63 studies indicates that (1) the rates of IPV are generally similar across rural, urban, and suburban locales, although some groups of rural women (e.g., multiracial and separated/divorced) may be at increased risk for IPV compared to similar groups of urban women, and rates of intimate partner homicide may be higher in rural locales than urban and suburban locales; (2) IPV perpetrator and victim characteristics in rural locales are generally similar to IPV perpetrator and victim characteristics in other locales with the exception of some demographic characteristics that can generally be accounted for by broader rural-urban-suburban demographic differences; (3) IPV perpetrators in rural locales, compared with perpetrators in urban locales, may perpetrate more chronic and severe IPV, which could be due to the higher rates of substance abuse and unemployment documented among rural perpetrators; (4) IPV victims in rural locales may have worse psychosocial and physical health outcomes due to the lack of availability, accessibility, and quality of IPV services; and (5) attitudes about IPV vary to some extent across locales, with individuals in rural locales generally supporting less governmental involvement in IPV issues than in urban locales. Limitations of the literature are reviewed and suggestions for research are provided as well as implications for practice and policy efforts, which primarily center on improving availability, accessibility, and quality of IPV services in rural locales.

A Methodological Review of Intimate Partner Violence in the Military: Where Do We Go From Here?

A significant number of military personnel report engaging in or experiencing intimate partner violence (IPV). To advance current research and understanding of this behavior, we conducted a methodological review of the literature on IPV in military personnel and veterans. Research from 1980 to the present, which consisted of 63 empirical studies, was objectively coded by two independent raters on a number of variables important to the methodological quality of research on IPV in the military. In addition, areas of importance to the future of IPV research are presented.

Building resilience: A qualitative study of Spanish women who have suffered intimate partner violence

The scientific literature reveals the importance of the resilience process in females who have experienced intimate partner violence (IPV). However, despite the importance of the cultural context in the process of resilience, there are no investigations exploring this phenomenon in Spain. This study used grounded theory to explore the factors that contribute to building resilience in Spanish women who have undergone IPV. A sample of 22 women who had experienced IPV participated in the study (mean age = 46.45 years, SD = 10.49). Findings revealed that these women were capable of using various factors, both individual and external, that promoted resilience. The women employed the following individual factors: physical activity, rediscovering oneself, altruism, control over one's life, creativity, spirituality, focus on the present, sense of humor, introspection, optimism, and projects and goals. The external resilience factors were housing, informal social support, and formal social support. Findings indicate that these factors can vary from one woman to the next and that some of these factors promoted the use of other factors in the development of resilience. The implications for clinical interventions with survivors are discussed.

Intimate Partner Violence and Correlates With Risk Behaviors and HIV/STI Diagnoses Among Men Who Have Sex With Men and Men Who Have Sex With Men and Women in China: A Hidden Epidemic

BACKGROUND

Intimate partner violence (IPV) research has primarily focused on heterosexual couples but has largely ignored IPV among men who have sex with men (MSM). We examined IPV prevalence among MSM and men who have sex with men and women (MSMW) in China.

METHODS

Men who have sex with men older than 16 years were recruited through 3 MSM-focused Web sites in China. An online survey containing items on sociodemographics, risk behaviors, IPV, and self-reported HIV or sexually transmitted infection diagnosis was completed. Multivariate regression was used to examine associations between IPV and risk behaviors and an HIV or sexually transmitted infection diagnosis.

RESULTS

Among 610 participants, 182 (29.8%) reported experiencing at least 1 type of IPV. Men who have sex with both men and women were at significantly greater risk for IPV (adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI], 1.08-2.53) compared with MSM. Men who had experienced IPV were more likely to have participated in group sex (AOR, 1.86; 95% CI, 1.08-3.21), to have had sex in exchange for gifts or money (AOR, 5.06; 95% CI, 2.47-10.35), and to report a positive HIV diagnosis (AOR, 2.59; 95% CI, 1.22-5.51).

CONCLUSIONS

There is a hidden epidemic of IPV among MSM in China, especially among MSMW. The hidden nature of MSM and MSMW suggests the need for a clinical environment more conducive to disclosure. Research is needed to understand the pathways linking IPV and HIV risk among MSM to optimize the design of effective interventions.

Real-World Barriers to Assessing and Treating Mental Health Problems With IPV Survivors: A Qualitative Study

Barriers to assessing and treating mental health problems with intimate partner violence (IPV) survivors were identified with qualitative responses from 62 IPV helping professionals who participated in an online survey question. Data were analyzed using a concept mapping approach, which resulted in following eight distinct clusters: (a) unsure, (b) limited IPV specific resources, (c) barriers to access, (d) systems-taboos, (e) immediate crisis needs, (f) fear-stigma, (g) offender's control and (h) cultural concerns. The opinions expressed in these clusters help to better explain logistic, relational, and intrapersonal obstacles that can limit women IPV survivors' ability to receive care for mental health conditions. Extending previous quantitative work by the authors (Simmons, Whalley, & Beck, 2014), the current portion of this project generates new ways of looking at barriers to service delivery, which can be used to develop theory and guide further research.

Intimate Partner Violence in Pakistan: A Systematic Review

Intimate partner violence (IPV) is a major social and public health problem affecting people in various cultures and societies. Though the issue of IPV in Pakistan has been researched since the 1990 s, no attempt has been made systematically to review the available evidence on IPV in Pakistan. This article presents findings of a systematic review of available empirical literature related to IPV in Pakistan. Using various key words, MEDLINE, CINAHL, and PsycINFO were searched to identify relevant studies. This resulted in the identification of 55 potential studies for inclusion. After application of exclusion criteria 23 studies were identified, 20 of which used quantitative research designs, two used qualitative designs and one adopted a mixed method case study approach. All studies reported men as the perpetrators of IPV and women as its victims. Findings are presented and discussed for IPV for its forms, predictors, effects and victims' responses. Pakistani peoples' perceived reasons for and their attitudes towards IPV are also presented and discussed.

Intimate partner violence perpetrators in a forensic psychiatric outpatient setting: criminal history, psychopathology, and victimization

This study investigated criminological, psychopathological, and victimological profiles of intimate partner violence (IPV) perpetrators in a sample of 119 Dutch female and male forensic psychiatric outpatients aged 18 to 58 years. In addition, differences in criminological, psychopathological, and victimological factors between IPV perpetrators (n = 61, 51.3%) and non-intimate violence (NIV) perpetrators (n = 58, 48.7%) were examined. All data, including information on demographics, criminal history, history of psychological, sexual, and physical victimization during childhood or adolescence, family history of psychopathology, history of psychopathology in childhood and adolescence, and mental disorders, were derived from archival electronic medical records. Mental disorders were measured using structured psychiatric interviews and final consensus diagnoses were established during weekly case consultations. Both IPV and NIV perpetrators displayed high rates of criminal history, psychopathology, and previous victimization, but the two groups did not differ in these factors with two exceptions. IPV perpetrators were significantly more likely to have higher rates of previous physical victimization and intermittent explosive disorder than NIV perpetrators. The current study suggests that a history of physical victimization and intermittent explosive disorder are specific characteristics of IPV perpetrators in a forensic psychiatric outpatient setting. Future research should focus on mechanisms explaining the association of childhood victimization and IPV and increase our understanding of the role of intermittent explosive disorder in IPV.

Intimate Partner Sexual Violence: A Review of Terms, Definitions, and Prevalence

Intimate partner sexual violence (IPSV) is a significant aspect of intimate partner violence (IPV). While intimate partners commit one third of sexual assaults, IPSV is often overlooked in studies about IPV and in research on sexual violence. There are difficulties identifying, defining, and measuring IPSV, and research lacks consistency in terminology and measurement. The purpose of this article is to review the terms, definitions, and measurements associated with IPSV. Academic journals and nonscholarly documents from the United States were searched for articles and reports associated with the study of sexual violence and IPV. Forty-nine documents met the criteria for inclusion. A four-part taxonomy defining IPSV was developed, which included IPSV, intimate partner sexual coercion, intimate partner sexual abuse, and intimate partner forced sexual activity. The average weighted prevalence rates of these various forms of IPSV were calculated across included research studies. However, the measurements generally used to assess IPV do not adequately measure IPSV. Future research should consist terms to ensure consistent conceptualization and measurement of IPSV and to inform practice with survivors.

Intimate partner violence, partner notification, and expedited partner therapy: a qualitative study

Over one-third of women experience intimate partner violence (IPV) in their lifetime. IPV increases the risk of infection and re-infection with sexually transmitted infections (STIs). The extent to which health care providers consider IPV when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers' views on IPV and STIs when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients' safety and believed assessing for IPV was needed before provision of expedited partner therapy, nearly a third had not considered the links between IPV and STIs. Strategies used by health care providers to assess for IPV did not include inquiry about specific behaviours related to IPV, STI risk, and sexual coercion. Many health care providers understand the risk for IPV in the setting of STI treatment, yet a significant portion of those interviewed failed to recognise the link between IPV and STIs. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about IPV to more safely recommend expedited partner therapy.

The unholy trinity: The Dark Triad, coercion, and Brunswik-Symmetry

Psychopathy, Narcissism, and Machiavellianism (the Dark Triad) have each been hypothesized as predictors of socially deviant behavior including sexual coercion, but the three traits also covary significantly with one another. The purpose of this study was to examine several alternative Multisample Structural Equation Models (MSEMs) exploring the relations between the Dark Triad and Sexually Coercive Behavior, testing whether any or all of the three specific "Dark Personality" traits uniquely contributed to predicting sexually coercive behavior. Self-report questionnaires measuring Primary and Secondary Psychopathy, Narcissism, Machiavellianism, and Sexually Coercive Behavior were administered to a sample of undergraduates. The relative fit of each of the MSEMs to the data was examined by means of hierarchically nested model comparisons. The most parsimonious yet explanatory model identified was one in which a single common factor composed of the three Dark Triad indicators explained the relationships among the Dark Triad traits and Sexually Coercive Behavior without any direct contributions from the specific Dark Triad indicators. Results indicate that the three Dark Triad traits, controlling for the common factor, do not differentially predict Sexually Coercive Behavior. These results are interpreted with respect to the principle of Brunswik-Symmetry.

Lasting effect of intimate partner violence exposure during preschool on aggressive behavior and prosocial skills

Intimate partner violence (IPV) exposure can negatively affect children's social behavior. However, it is unknown if the negative effects of IPV exposure during the preschool years are sustained through the early school years, if maladaptive behavior in one domain (e.g., aggressive behavior) is linked to subsequent maladaptive behavior in a different developmental domain (e.g., prosocial skill deficits), and if these relations differ by gender. This study addresses these gaps by using data from a sample of 1,125 children aged 3 to 4 at Time 1 and aged 5 to 7 at Time 2 from the National Survey of Child and Adolescent Well-Being. A series of nested longitudinal structural equation models were tested. Aggressive behavior and prosocial skills were stable across time. Time 1 IPV was associated with increased aggressive behavior at Time 1, which in turn was related to increased Time 2 aggressive behavior. Gender differences emerged; Time 2 IPV was associated with prosocial skills deficits for girls but not boys. A cross-domain relation existed between Time 1 aggressive behavior and Time 2 prosocial skills deficits for boys but not girls. These findings support that behavioral problems demonstrated later in childhood may emerge from earlier adverse developmental experiences and that difficulties in one domain may spill over into other developmental domains. Gender-specific interventions to promote competence in children may contribute to diverting children from maladaptive developmental outcomes.

Masculine discrepancy stress, teen dating violence, and sexual violence perpetration among adolescent boys

PURPOSE

Addressing gender norms is integral to understanding and ultimately preventing violence in both adolescent and adult intimate relationships. Males are affected by gender role expectations which require them to demonstrate attributes of strength, toughness, and dominance. Discrepancy stress is a form of gender role stress that occurs when boys and men fail to live up to the traditional gender norms set by society. Failure to live up to these gender role expectations may precipitate this experience of psychological distress in some males which, in turn, may increase the risk to engage in physically and sexually violent behaviors as a means of demonstrating masculinity.

METHODS

Five-hundred eighty-nine adolescent males from schools in Wayne County, Michigan completed a survey assessing self-perceptions of gender role discrepancy, the experience of discrepancy stress, and history of physical and sexual dating violence.

RESULTS

Logistic regression analyses indicated boys who endorsed gender role discrepancy and associated discrepancy stress were generally at greater risk to engage in acts of sexual violence but not necessarily physical violence.

CONCLUSIONS

Boys who experience stress about being perceived as "sub-masculine" may be more likely to engage in sexual violence as a means of demonstrating their masculinity to self and/or others and thwarting potential "threats" to their masculinity by dating partners. Efforts to prevent sexual violence perpetration among male adolescents should perhaps consider the influence of gender socialization in this population and include efforts to reduce distress about masculine socialization in primary prevention strategies.

Disclosure experiences of sexual minority college student victims of intimate partner violence

Although research on disclosure following intimate partner violence (IPV) victimization is burgeoning, sexual minority young adults' (lesbian, gay, bisexual, queer, questioning, etc.; LGBQ+) experiences have not received equal attention. The current study employed the minority stress framework to examine disclosure experiences of LGBQ+ college students across the United States reporting physical IPV victimization within their current relationship (n = 77). Participants completed measures assessing minority stress and IPV disclosure, and answered open-ended questions regarding the most and least helpful persons/responses to disclosure or reasons for non-disclosure. Results indicated that approximately one-third (35 %) of victims disclosed to at least one person, with friends being the most common recipients. Thematic analyses indicated that talking or listening to the victim was considered the most helpful response and not understanding the situation least helpful. Reasons for non-disclosure centered on themes of the victims' perception that the IPV was not a big deal. Quantitative findings regarding physical IPV disclosure indicated that non-disclosers experienced greater minority stress than disclosers. The current study suggests the presence of differences between sexual minority (i.e., LGBQ +persons) and non-sexual minority persons, as well as between LGBQ+ young adults/college students and older adults and presents a theoretical structure (i.e., minority stress framework) through which these differences may be understood.

The effects of social capital and neighborhood characteristics on intimate partner violence: a consideration of social resources and risks

Intimate partner violence (IPV) is a growing public health problem, and gaps exist in knowledge with respect to appropriate prevention and treatment strategies. A growing body of research evidence suggests that beyond individual factors (e.g., socio-economic status, psychological processes, substance abuse problems), neighborhood characteristics, such as neighborhood economic disadvantage, high crime rates, high unemployment and social disorder, are associated with increased risk for IPV. However, existing research in this area has focused primarily on risk factors inherent in neighborhoods, and has failed to adequately examine resources within social networks and neighborhoods that may buffer or prevent the occurrence of IPV. This study examines the effects of neighborhood characteristics, such as economic disadvantage and disorder, and individual and neighborhood resources, such as social capital, on IPV among a representative sample of 2412 residents of Toronto, Ontario, Canada. Using a population based sample of 2412 randomly selected Toronto adults with comprehensive neighborhood level data on a broad set of characteristics, we conducted multi-level modeling to examine the effects of individual- and neighborhood-level effects on IPV outcomes. We also examined protective factors through a comprehensive operationalization of the concept of social capital, involving neighborhood collective efficacy, community group participation, social network structure and social support. Findings show that residents who were involved in one or more community groups in the last 12 months and had high perceived neighborhood problems were more likely to have experienced physical IPV. Residents who had high perceived social support and low perceived neighborhood problems were less likely to experience non-physical IPV. These relationships did not differ by neighborhood income or gender. Findings suggest interesting contextual effects of social capital on IPV. Consistent with previous research, higher levels of perceived neighborhood problems can reflect disadvantaged environments that are more challenged in promoting health and regulating disorder, and can create stressors in which IPV is more likely to occur. Such analyses will be helpful to further understanding of the complex, multi-level pathways related to IPV and to inform the development of effective programs and policies with which to address and prevent this serious public health issue.

How does intimate partner violence affect condom and oral contraceptive Use in the United States?: A systematic review of the literature

INTRODUCTION

Intimate partner violence (IPV) is estimated to affect 25% of adult women in the United States alone. IPV directly impacts women's ability to use contraception, resulting in many of unintended pregnancies and STIs. This review examines the relationship between IPV and condom and oral contraceptive use within the United States at two levels: the female victim's perspective on barriers to condom and oral contraceptive use, in conjunction with experiencing IPV (Aim 1) and the male perpetrator's perspective regarding condom and oral contraceptive use (Aim 2).

STUDY DESIGN

We systematically reviewed and synthesized all publications meeting the study criteria published since 1997. We aimed to categorize the results by emerging themes related to each study aim.

RESULTS

We identified 42 studies that met our inclusion criteria. We found 37 studies that addressed Aim 1. Within this we identified three themes: violence resulting in reduced condom or oral contraceptive use (n=15); condom or oral contraceptive use negotiation (n=15); which we further categorized as IPV due to condom or oral contraceptive request, perceived violence (or fear) of IPV resulting in decreased condom or oral contraceptive use, and sexual relationship power imbalances decreasing the ability to use condoms or oral contraceptives; and reproductive coercion (n=7). We found 5 studies that addressed Aim 2. Most studies were cross-sectional, limiting the ability to determine causality between IPV and condom or oral contraceptive use; however, most studies did find a positive relationship between IPV and decreased condom or oral contraceptive use.

CONCLUSIONS

Quantitative, qualitative, and mixed methods research has demonstrated the linkages between female IPV victimization/male IPV perpetration and condom or oral contraceptive use. However, additional qualitative and longitudinal research is needed to improve the understanding of dynamics in relationships with IPV and determine causality between IPV, intermediate variables (e.g., contraceptive use negotiation, sexual relationship power dynamics, reproductive coercion), and condom and oral contraceptive use. Assessing the relationship between IPV and reproductive coercion may elucidate barriers to contraceptive use as well as opportunities for interventions to increase contraceptive use (such as forms of contraception with less partner influence) and reduce IPV and reproductive coercion.

Examining trauma and posttraumatic stress disorder symptoms in court-mandated intimate partner violence perpetrators

There is a dearth of empirical literature characterizing the various forms of trauma experienced by men court mandated to intervention for intimate partner violence (IPV) perpetration. We investigated the potentially traumatic events (PTEs) experienced by men (N = 217) court mandated to enroll in a 41-week group IPV perpetrator program, as well as the relationships between PTEs, posttraumatic stress disorder (PTSD) symptoms, and IPV. Findings indicated that 94% of participants reported experiencing at least 1 PTE in their lifetime, and participants experienced an average of over 6 out of 14 types of PTEs. A significant association was found between the number of PTEs experienced and frequency of self-reported perpetration of physical and psychological IPV. PTSD symptoms were also related to both forms of IPV perpetration and mediated the relationship between experiencing PTEs and psychological IPV perpetration. Our findings have implications for understanding how trauma and PTSD symptoms may increase risk for IPV and for developing trauma-informed interventions for this population.

Exploring risk of experiencing intimate partner violence after HIV infection: a qualitative study among women with HIV attending postnatal services in Swaziland

OBJECTIVE

To explore risks of experiencing intimate partner violence (IPV) after HIV infection among women with HIV in a postnatal care setting in Swaziland.

DESIGN

A qualitative semistructured in-depth interview study, using thematic analysis with deductive and inductive coding, of IPV experiences after HIV infection extracted from service-integration interview transcripts.

SETTING

Swaziland.

PARTICIPANTS

19 women with HIV, aged 18-44, were purposively sampled for an in-depth interview about their experiences of services, HIV and IPV from a quantitative postnatal cohort participating in an evaluation of HIV and reproductive health services integration in Swaziland.

RESULTS

Results indicated that women were at risk of experiencing IPV after HIV infection, with 9 of 19 disclosing experiences of physical violence and/or coercive control post-HIV. IPV was initiated through two key pathways: (1) acute interpersonal triggers (eg, status disclosure, mother-to-child transmission of HIV) and (2) chronic normative tensions (eg, fertility intentions, initiating contraceptives).

CONCLUSIONS

The results highlight a need to mitigate the risk of IPV for women with HIV in shorter and longer terms in Swaziland. While broader changes are needed to resolve gender disparities, practical steps can be institutionalised within health facilities to reduce, or avoid increasing, IPV pathways for women with HIV. These might include mutual disclosure between partners, greater engagement of Swazi males with HIV services, and promoting positive masculinities that support and protect women.

TRIAL REGISTRATION NUMBER

NCT01694862.

Male Veteran Intimate Partner Violence (IPV) Program Outcomes

The prominence and incidence of intimate partner violence (IPV) with male military veterans vary, but generally there is consensus that screening and intervention does help reduce IPV. Intervention is generally provided in the community via Batterer Intervention Programs. However, at the Department of Veterans Affairs (VA) intervention is provided via the Domestic Relations Clinic. Nationally the VA has limited treatment for male IPV. An aggregate sample (n = 178) of participants was assessed using the Domestic Violence/Abuse Screen to measure covariate pre-test and post-test outcomes, program failure, and recidivism. The treatment approach is psycho-educationally based to meet the challenging and unique needs of the military veteran population. The results contribute to a more comprehensive understanding of IPV and highlight the need for more intervention and prevention approaches.

The relationship between self-harm and teen dating violence among youth in Hawaii

The connection between teen dating violence (TDV) and self-harm is important to consider because of the serious consequences for teens who engage in these behaviors. Self-harm includes nonsuicidal self-injury (NSSI) and suicide behaviors such as suicide attempts or deaths. Although prior research shows that these two public health problems are related, the context in which they occur is missing, including what leads teens to engage in self-harm and the timing of self-harming behaviors within the relationship. To fill this gap, we conducted focus groups with 39 high-school-aged teens, all of whom had experienced prior relationship violence. Teens described incidents in which they and their partners engaged in NSSI and suicide attempts. Incidents often were associated with extreme alcohol and drug use and occurred during the break-up stage of the relationship. Prevention and intervention programs are needed that consider the intersections of TDV, substance use, and self-harm.

Intimate partner violence and new-onset depression: a longitudinal study of women's childhood and adult histories of abuse

BACKGROUND

Studies indicate that women victims of intimate partner violence are at increased risk for poor mental health. This research disentangled the effect of partner violence on new-onset depression and psychosis spectrum symptoms from effects of child maltreatment and other confounding factors, including substance abuse and antisocial personality.

METHODS

Participants were 1,052 mothers involved in the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative cohort of families followed prospectively. To test the directionality of associations between partner violence and depression, only women without a history of depression at the beginning of the study were considered (n = 978). Partner violence and mental health were assessed during face-to-face interviews with women across three time points.

RESULTS

Four of 10 women reported being the victim of violence from their partner in a 10-year period. They represent 33% of our cohort and they account for 51% of new-onset depression. These women had a twofold increase in their risk of suffering from new-onset depression once the effect of childhood maltreatment, socioeconomic deprivation, antisocial personality, and young motherhood were controlled. Women who were abused both in childhood and adulthood were four to seven times more likely to suffer from depression than never-abused women. We observed similar associations with psychosis spectrum symptoms.

CONCLUSIONS

Women victims of partner violence account for more than their share of depression. Findings strengthen existing evidence that partner violence independently contributes to women's poor mental health. Psychological difficulties among a considerable number of women could be reduced by stopping partner violence.

A theory-based approach to understanding suicide risk in shelter-seeking women

Women seeking shelter from intimate partner violence are at an increased risk for suicide ideation and attempts compared to women in the general population. Control-based violence, which is common among shelter-seeking women, may play a pivotal role in the development of suicide ideation and attempts. Current risk assessment and management practices for shelter-seeking women are limited by the lack of an empirically grounded understanding of increased risk in this population. We argue that in order to more effectively promote risk assessment and management, an empirically supported theory that is sensitive to the experiences of shelter-seeking women is needed. Such a theory-driven approach has the benefits of identifying and prioritizing targetable areas for intervention. Here, we review the evidence for the link between coercive control and suicide ideation and attempts from the perspective of Baumeister's escape theory of suicide. This theory has the potential to explain the role of coercive control in the development of suicide ideation and eventual attempts in shelter-seeking women. Implications for suicide risk assessment and prevention in domestic violence shelters are discussed.

Anger, hostility, internalizing negative emotions, and intimate partner violence perpetration: A meta-analytic review

Prior reviews have identified elevated trait anger as a risk factor for intimate partner violence (IPV) perpetration. Given that 10 years have passed since the last comprehensive review of this literature, we provide an updated meta-analytic review examining associations among anger, hostility, internalizing negative emotions, and IPV for male and female perpetrators. One hundred and five effect sizes from 64 independent samples (61 studies) were included for analysis. IPV perpetration was moderately associated with the constructs of anger, hostility, and internalizing negative emotions. This association appeared stronger for those who perpetrated moderate to severe IPV compared to those who perpetrated low to moderate IPV, and did not vary across perpetrator sex, measurement method, relationship type, or perpetrator population. Implications and limitations of findings were reviewed in the context of theoretical models of IPV, and future directions for empirical and clinical endeavors were proposed.

An examination of the factors related to dating violence perpetration among young men and women and associated theoretical explanations: a review of the literature

This article provides a review of the literature on dating violence (DV) perpetration, specifically sex similarities and differences in the correlates and predictors of DV perpetration and the utility of current theories to explain young men's and women's DV perpetration. Overall, many of the correlates and predictors of DV perpetration are similar among young men and women (e.g., witnessing interparental violence, experiencing child abuse, alcohol abuse, traditional gender roles, relationship power dynamics). However, young women's perpetration of DV is more strongly related to internalizing symptoms (e.g., depression), trait anger and hostility, and experiencing DV victimization than young men's perpetration, whereas young men's perpetration of DV is more consistently related to lower socioeconomic status and educational attainment, antisocial personality characteristics, and increased relationship length than young women's perpetration. Each theory offers insights into but does not fully account for the correlates and predictors of DV perpetration. Sociocultural theories may be useful in explaining the use of coercive control in relationships, and learning/intergenerational transmission of violence theories may be useful in explaining bidirectional couple violence. Future research should focus on integrative theories, such as in the social-ecological theory, in order to explain various forms of DV. Our understanding of young men's and young women's DV perpetration is limited by cross-sectional research designs, methodological inconsistencies, a lack of sex-specific analytic approaches, and a lack of focus on contextual factors; more multivariate and longitudinal studies are needed. Further, as DV prevention programming is often presented in mixed-sex formats, a critical understanding of sex differences and similarities in DV perpetration could ultimately refine and improve effectiveness of programming efforts aimed at reducing DV.

Economic solvency in the context of violence against women: a concept analysis

The aim of this concept analysis is to define economic solvency in the context of violence against women. Poverty, or lack of resources, is often discussed as a risk factor for intimate partner violence. The concept of economic solvency, which may be a protective factor for women, is less often discussed and not well defined. Databases searched for the analysis included EBSCOhost, CINAHL, PubMed and Gender Watch. The Rodgers evolutionary method was used to perform the concept analysis. A total of 134 articles were retrieved, using the specified search terms 'economic solvency and women', 'economic self-reliance and women' and 'economic self-sufficiency and women'. Articles were included if they were peer reviewed, contained the keywords with sufficient context to determine the author's intended meaning, and focused on women only or contrasted men to women. Thirty-five articles were used in the concept analysis. The definition of economic solvency drawn from the concept analysis is: a long-term state that occurs when there is societal structure that supports gender equity and external resources are available and can be used by a woman who has necessary human capital, sustainable employment and independence. Just as poverty and violence are cyclical, so are economic solvency and empowerment of women. To decrease women's risk of intimate partner violence around the world and further improve the status of women, we recommend continued research on economic solvency, including the individual, family, community and societal resources required to obtain economic solvency and the human capital characteristics needed for sustainability.

Alcohol outlet density, drinking contexts and intimate partner violence: a review of environmental risk factors

Alcohol use is a robust predictor of intimate partner violence (IPV). A critical barrier to progress in preventing alcohol-related IPV is that little is known about how an individual's specific drinking contexts (where, how often, and with whom one drinks) are related to IPV, or how these contexts are affected by environmental characteristics, such as alcohol outlet density and neighborhood disadvantage. The putative mechanism is the social environment in which drinking occurs that may promote or strengthen aggressive norms. Once these contexts are known, specific prevention measures can be put in place, including policy-oriented (e.g., regulating outlet density) and individually oriented (e.g., brief interventions to reduce risk for spousal aggression) measures targeting at-risk populations. This paper reviews applicable theories and empirical research evidence that links IPV to drinking contexts and alcohol outlet density, highlights research gaps, and makes recommendations for future research.

Pregnant mothers' perceptions of how intimate partner violence affects their unborn children

OBJECTIVE

To explore the perceptions of pregnant women on the experience of intimate partner violence (IPV) as it affects maternal and fetal health.

DESIGN

Secondary qualitative content analysis.

SETTING

Individual interviews conducted within three urban obstetric and gynecologic clinics.

PARTICIPANTS

Our sample included a subset of eight pregnant women experiencing IPV during the current pregnancy. Participants were selected from a larger parent study that included qualitative data from 13 women.

METHODS

We analyzed in-depth individual interview transcripts in which participants discussed how they perceived IPV to affect their health as well as the health of their unborn children. Constant comparative techniques and conventional content analysis methodology were used in analysis.

RESULTS

Three themes emerged to illustrate mothers' perceptions of how IPV influenced maternal and fetal outcomes: protection, fetal awareness, and fetal well-being.

CONCLUSIONS

This analysis provides important insights into concerns that pregnant women experiencing IPV shared about maternal attachment and fetal well-being. Health care providers can use these findings to better assess the physical and psychological concerns of pregnant women experiencing IPV. Further research is needed to better understand how IPV contributes to adverse neonatal outcomes, particularly from a biological perspective.

Investigating the Role of Child Sexual Abuse in Intimate Partner Violence Victimization and Perpetration in Young Adulthood From a Propensity Score Matching Approach

The link between child sexual abuse and adult intimate partner violence surfaces throughout prior research. Nonetheless, methodologies investigating this cycle of violence predominantly involve descriptive, correlational, or traditional regression-based analyses that preclude more definitive statements about the empirical relationship between child sexual abuse and adult partner violence. In recognition of these limitations, the current study presents a quasi-experimental investigation into the relationship between sexual abuse in childhood and physical partner violence victimization and/or perpetration in young adulthood. Propensity score matching analysis of a national data set sampling over 4,000 young adults suggests that experiencing child sexual abuse influences adult intimate partner violence victimization and perpetration. Study implications and directions for future research are discussed.

Justification beliefs of violence, myths about love and cyber dating abuse

BACKGROUND

Distorted beliefs about violence and love are often associated with the presence of violence in dating relationships. This study analyzes the relationship between beliefs that justify violence and myths about love in two types of cyber dating abuse (control and direct aggression).

METHOD

The sample consisted of 656 young people between the ages of 18 and 30 years (79.5% women).

RESULTS

Regression analysis showed that justification of cyber dating abuse was significantly associated with a higher likelihood of direct aggression in online dating relationships. Myths about love were associated with a greater likelihood of control in online dating relationships. Furthermore, the relationship between justification of cyber dating abuse and perpetration of direct aggression was stronger in women. The relationship between myths about love and perpetration of online control was stronger among the youngest individuals.

CONCLUSION

The justification of abuse and myths about love are important aspects in the development of different kinds of online abuse among young couples. This finding has important implications for the prevention of and intervention in these behaviors.

Elaborations on sexual assault on dates among Israeli students: risk, detrimental effect, and resilience factors

The current study of 668 Israeli male and female students examines the prevalence of gendered risk factors for sexual assault (SA) on dates, posttraumatic stress disorder (PTSD) as a detrimental effect of SA, and self-efficacy as resiliency to refuse unwanted sex following SA. Two different sets of risk factors that increased the likelihood of SA on dates emerged from the hierarchical regression. Sexual experience, use of drugs, and private location increased the risk of being SA victims among males, whereas sexual experience, perceived provocative behavior, and alcohol use increased the risk among females. In addition, PTSD and self-efficacy to refuse unwanted sex following SA on dates were predicted by the extent of coercive sexual victimization. PTSD was also predicted by subjective perception of sexual behavior and rape myths, whereas efficacy was predicted by private location. The findings contribute to the literature by showing the contribution of various risk factors to experiencing SA, and by showing SA effect on PTSD and self-efficacy.

Intimate relationship involvement, intimate relationship quality, and psychiatric disorders in adolescents

Prior research has shown that poor relationship quality in marriage and other intimate relationships demonstrates cross-sectional and longitudinal associations with a variety of psychiatric disorders in adults. In comparison, there has been less research on the covariation between relationship quality and psychiatric disorders in adolescents, a developmental period that is associated with elevated risk of incidence of several disorders and that is important for the acquisition and maintenance of intimate relationships. The present study was conducted to examine the associations between intimate relationship involvement, intimate relationship quality, and psychiatric disorders in a population-based sample of adolescents. The associations between relationship involvement, positive and negative relationship quality, and 12-month prevalence of mood, anxiety, and substance use disorders were evaluated in adolescents from the National Comorbidity Survey-Adolescent Supplement. Participants completed an interview-based assessment of psychiatric disorders and a self-report measure of relationship quality. Results indicated that the prevalence of broad categories of mood, anxiety, and substance use disorders, and several specific disorders were significantly associated with (a) being married, cohabiting, or involved in a serious relationship; and (b) reporting more negative (but not less positive) relationship quality. For several disorders, the association between the disorder and relationship involvement was moderated by age, wherein the strength of the association decreased in magnitude with increasing age. Findings suggest that being in an intimate relationship and reporting higher levels of negative relationship quality are associated with the prevalence of several common psychiatric disorders in adolescents.

Relational vulnerabilities of incarcerated and reentry mothers: therapeutic implications

A qualitative study involving a follow-up interview with 10 incarcerated and reentry mothers in rural southwest and central Virginia was conducted to explore the influence that women's close relationships have on their reentry experiences with their families. The Vulnerability Conceptual Model (VCM) was used to sensitize an examination of how incarcerated and reentry mothers negotiate relational vulnerabilities in the context of varying situational vulnerability. Grounded theory analysis revealed three themes that characterized relational vulnerabilities. Given our focus on close relationships and the potential of the VCM to identify opportunities for resilience and vulnerability, we highlighted the influence of ambiguous and ambivalent relationships and unresolved loss and grief due to relationship dissolution or the death of a parent, sibling, child, or intimate partner in the reentry process. The data revealed two types of reentry mothers with divergent trajectories for social reintegration. Implications of these types for therapeutic treatment approaches for reentry women are discussed.

Linking community protective factors to intimate partner violence perpetration

This study explores how community factors moderate men's individual risk for physical and psychological intimate partner violence (IPV) perpetration. The sample of 604 male first-semester undergraduate students supports a connection between county-level protective and risk factors, an individual risk factor, and IPV perpetration. For each unit increase in the proportion of women in powerful positions within a county, there was a 71% decrease in the risk that control-seeking respondents would perpetrate physical IPV, controlling for other factors including population density and violent crime. This article presents a multilevel analysis using hierarchical generalized linear modeling and discusses practice and research implications.

A feasibility study to assess the effectiveness of safe dates for teen mothers

OBJECTIVE

To determine the effectiveness of the adapted Safe Dates curriculum as an intervention for pregnant and/or parenting teens to prevent teen dating violence (TDV).

DESIGN

This pre-/posttest, single-sample study provided a means to assess the effectiveness of an adapted Safe Dates curriculum for teen mothers.

SETTING

The adapted Safe Dates curriculum was implemented in three schools designed for the unique needs of teens who are pregnant and/or parenting.

PARTICIPANTS

The final sample of 41 teen participants, with a mean age of 16.27, completed 80% of the curriculum and two of the three assessments. Most of the teens were pregnant during participation in the curriculum, and six had infants between age 1 and 3 months.

METHODS

The teen mothers completed the pretest, participated in the 10-session adapted Safe Dates curriculum, and completed the posttest at the end of the program and 1 month after program completion. The pre/posttest was adapted from the Safe Dates curriculum-specific evaluation instrument. Senior, undergraduate nursing students were trained in and implemented the curriculum.

RESULTS

Participation in the adapted Safe Dates program yielded significant differences in the areas of responses to anger, gender stereotyping, awareness of resources for perpetrators and victims, and psychological violence perpetration.

CONCLUSIONS

This adapted program may be effective in changing selected outcomes. The implementation of a larger scale, experimental/control group study may demonstrate the program's efficacy at reducing the incidence of TDV among teen mothers.

Urban adolescent girls' perspectives on romantic relationships: initiation, involvement, negotiation, and conflict

The purpose of this paper was to describe romantic relationships from the perspective of urban, adolescent girls, to address gaps in our understanding of their relationship dimensions. Minority adolescent girls (n  =  17) participated in private semi-structured interviews aimed to elicit the understanding of the adolescents' perspectives on their own relationship experiences and dynamics. The research team conducted conventional content analysis of the interview transcripts. Four major themes emerged about romantic relationships: (1) influence of male pursuit and social norms on relationship initiation factors; (2) a romantic partner is a confidant, friend, and companion; (3) negotiating intimacy respectfully; and (4) relationship conflict through control and abuse. Adolescents described sub-themes of social norms of male pursuit and relationship pressures that dictated relationship initiation. Relationships were depicted by emotional support, caring, and companionship. Adolescents described positive negotiation skills. However, relationship conflict, including controlling behaviors and violence, was illustrated in these same relationships. This study provides a rich description of romantic relationships from the perspectives of urban, adolescent girls. Most salient findings included social pressures and a combination of both positive and negative attributes. Implications include the need for intervention development at the community level to address social pressures, recognition of positive adolescent relationship attributes, and facilitation of skills to identify and address low-quality relationship characteristics.

The narrative of men who murder their partners: how reliable is it?

This article deals with the strategies the storyteller uses to influence the listener's perception and thinking. It is based on qualitative research, which examined the narratives of 12 men who killed their female partners. After entering prison, the murderer attempts to salvage some part of his social image. He does this using an assortment of means in two areas: the content of the narrative and its linguistic style. In terms of content, all the storytellers present themselves as extremely positive and their wives as very negative. With respect to language, the killers use verbs that distance them from responsibility, they hedge, repeat words and phrases to persuade, and use figures of speech they expect will impress their listeners. This artificial discourse is cunningly interwoven in terms of content and story art to recreate an alternative reality of a man who is normative and whom society can accept.

From violence to hope: the construction of professional knowledge in treating imprisoned male batterers in Israel

The treatment of incarcerated batterers has not been as thoroughly studied as that of men who take part in community treatment programs. The current study describes and analyzes the “practice wisdom” of professionals in a special unit that focuses on treating batterers in an Israeli prison. The analysis is based on in-depth semistructured interviews aimed at facilitating a self-reflective process among the participating social workers. In understanding the construction of tacit knowledge by the social workers, we observe four major dialectical themes in their construction of their practice knowledge: (a) the dialectics of behavior modification and psychodynamic change, (b) the paradoxical use of authority in the service of treatment, (c) the multiple meanings of gender, and (d) the question of change--what really makes the difference? While such opposites might never be fully reconciled, the tension and changes can contribute to construction of professional knowledge.

Motivational and Cognitive Predictors of the Propensity to Intervene Against Intimate Partner Violence

A survey using a community-based sample (N = 650) was conducted to identify motivational and cognitive predictors of individuals' propensity to intervene against intimate partner violence (IPV). A hierarchical regression analysis showed that motivational factors accounted for the greatest proportion of the variance in self-reported propensity. Specifically, personal norm (i.e., an individual's felt obligation to intervene) was the strongest individual predictor, followed by affective response (i.e., the extent to which an individual responds to IPV with negative emotions). Although cognitive factors explained only a small portion of the variance, the propensity to intervene was significantly higher for respondents who perceived IPV as a prevalent issue and who did not view the perpetrator as responsible for the solution of IPV. The findings suggest that attempts to facilitate public intervention should target specific, rather than general, aspects of public norms and beliefs about IPV.

Promoting resilience in adults with experience of intimate partner violence or child maltreatment: a narrative synthesis of evidence across settings

BACKGROUND

People who have experienced intimate partner violence (IPV) or child maltreatment (CM) are at risk of having lower resilience and adverse psychological outcomes. In keeping with the social and environmental factors that support resilience, there is a need to take a public health approach to its investigation and to identify existing initiatives in particular settings and populations that can guide its deliberate promotion.

METHOD

This narrative synthesis examines quantitative and qualitative studies of interventions with resilience-related outcomes in specified health and other settings. Clinical RCTs are excluded as beyond the scope of this review.

RESULTS

Twenty studies were identified for review in several settings, consisting of 14 quantitative studies, 2 review studies, 2 qualitative studies and 2 mixed-methods studies. Three quantitative studies produced strong evidence to support: a home visitation program for at-risk mothers; a methadone program for women and a substance abuse program. This review reveals that few studies use specific resilience measures.

CONCLUSIONS

The topic has been little studied despite high needs for public health interventions in countries of all types. Interventions and research studies that use specific resilience measures are likely to help measure and integrate what is currently a disparate area.

IMPLICATIONS

The participation of people with IPV or CM history in program and research design and implementation is indicated to support advocacy, innovation and sustainable interventions. This is especially pertinent for interventions in LAMIC and indigenous settings where continuing programs are sorely needed.