Family violence is a global problem; however, with the upcoming 2015 conference of the National Council on Family Relations being held in Canada, it seems timely to refer to Canadian data and examples in discussing the need to "break down silos" in determining approaches to family violence prevention. As Guedes and Mikton (2013) recently highlighted, it is imperative to recognize intersections among different types of violence that have traditionally been addressed in isolation. We use the four-step public health approach — (a) defining the problem, (b) identifying risk and protective factors, (c) finding out what works, and (d) determining approaches to implementation — to break down silos in the area of family violence.

Major public health problem

Family violence, defined by the Canadian Federal Family Violence Initiative as "a range of abusive behaviours that occur within relationships based on kinship, intimacy, dependency or trust" (Public Health Agency of Canada, 2013), is a major public health problem leading to a broad range of physical and mental health conditions across the lifespan. Two of the most common types of family violence are child maltreatment and intimate partner violence (IPV). Recent findings from the 2012 Canadian Community Health Survey, which included a representative sample of respondents living in 10 provinces, indicated that 32% of the adult population has experienced one or more of the following in childhood: physical abuse, sexual abuse, and/or exposure to IPV (Afifi et al., 2014). According to the population-based General Social Survey, conducted in 2009 (see Sinha, 2013), similar proportions of women and men reported experiencing IPV in the past 5 years (6%); women were more likely to report the most frequent and severe forms of IPV victimization. Certain groups are at much higher risk of IPV; the rate of self-reported violence victimization among Aboriginal women was more than twice as high as the rate reported by non-Aboriginal women. Results of the most recent General Social Survey focusing on victimization, and conducted in 2014, are forthcoming.

Canadian prevalence studies have not addressed the important question of overlap between child maltreatment and IPV, or the association between children's exposure to IPV and other types of violence, as well as subsequent violence in adulthood. As outlined in Figure 1, there is increasing evidence for the associations between types of child maltreatment and IPV, including dating violence, often considered a subtype of IPV, yet there is little information available about the co-occurrence of these types of family violence—or, most important—how exposure to one type potentially leads to another.

Figure 1. Relationships among types of family violence. IPV = intimate partner violence

By including survey questions about both child maltreatment and IPV, and asking about the timing and correlates of such exposure (see next section), we could have a much better understanding of how these types of family violence are associated, which in turn could provide important information in developing approaches to prevention.

Overlap of risk and protective factors

In addition to the increased risk for IPV among those who have been exposed to child maltreatment, and the higher likelihood of child maltreatment when IPV is occurring in the home, there is a growing recognition of the overlap in sociodemographic risk factors across these two types of family violence. For example, parental history of maltreatment, substance misuse, social isolation, low socioeconomic status, and unemployment are each associated with increased risk of child maltreatment and IPV. One of the challenges is to identify those risk factors that are causal in nature; this is essential in developing prevention programs as well as ways of preventing recurrence of family violence and associated impairment (see "Prevention" section).

Even less is known about protective factors, for child maltreatment and IPV individually as well as for their co-occurrence. We need to know not only about factors that are protective in reducing exposure to family violence but also about those that are protective in reducing revictimization as well as other types of impairment. Positive outcomes following exposure to family violence are often conceptualized as resilience, although there is lack of agreement about what constitutes this entity. A 2011 review referred to resilience as interactive and as indicating a "relative resistance to environmental risk experiences" (Herrman et al., 2011). An expanded definition refers to resilience as "a dynamic process in which psychological, social, environmental and biological factors interact to enable an individual at any stage of life to develop, maintain or regain their mental health despite exposure to adversity" (Stewart & Riazantseva, 2014). A narrative review that examined protective factors associated with resilience following maltreatment identified supportive relationships and stable family environment as showing a consistent relationship with resilience across studies (Afifi & MacMillan, 2011).

Prevention

In addition to thinking more broadly about family violence it is important to consider prevention across a spectrum. As outlined in Figure 2, prevention includes preventing not only the occurrence of family violence but also its recurrence and associated impairment.

Figure 2. Preventing family violence across a spectrum. From "Interventions to Prevent Child Maltreatment and Associated Impairment, by H. L. MacMillan et al., 2009, The Lancet, 373. Adapted with permission.

Development of intervention programs has generally focused on either child maltreatment or IPV, and approaches have typically been conceptualized as either preventative or treatment oriented in nature. An example of how one program is being evaluated to determine its potential to reduce both child maltreatment and IPV by considering prevention across a spectrum involves research being led by Canadian investigators in partnership with U.S. colleagues. The Nurse–Family Partnership (NFP) , an evidence-based nurse home visitation program for low-income first-time mothers, has been shown in three randomized controlled trials (RCTs) to improve maternal and child health, including the reduction of child maltreatment and associated injuries (Olds, Sadler & Kitzman, 2007). Prompted by the finding from the first NFP trial that the beneficial program effect on child maltreatment was not found in nurse-visited households with moderate to severe levels of IPV (Eckenrode et al., 2000), and following a preliminary needs assessment with NFP nurses, an intervention was developed to address IPV (Jack et al., 2012). Although the original aim was to develop an approach to reduce ongoing IPV, once identified it became clear that the model has the potential to prevent IPV and its recurrence and associated impairment and, in turn, reduce children's exposure to IPV, all within the context of a program demonstrated to be effective in reducing child maltreatment. After an exploratory multiple-case study to determine core components of the intervention, a pilot study was undertaken to examine feasibility (Jack et al., 2012). An RCT to evaluate the effectiveness of the augmented NFP in preventing IPV, its recurrence, and associated impairment, as well as its impact on child maltreatment, has been underway since 2011. Results of the trial should be available in 2015 or early 2016.

Implementation

An essential element to consider in implementing interventions aimed at reducing family violence is to avoid "scaling up" before there is evidence of a program's effectiveness. This may seem obvious, but there are many examples in Canada and elsewhere where programs have been disseminated without knowing whether they do more harm than good (MacMillan, 2000). A welcome exception to premature implementation that is happening in Canada currently is an RCT being conducted by the NFP in British Columbia to determine whether the benefits observed in the U.S. trials can be replicated in Canada (Jack & MacMillan, 2014). Through a close partnership with British Columbia's provincial government, an RCT has been underway since 2013; measures of both child maltreatment and IPV are being included to determine its effect on family violence broadly. In addition, a mixed-methods process evaluation is taking place concurrently to examine implementation of the program.

In regard to existing interventions that have been demonstrated effective in reducing either child maltreatment or IPV, as programs are implemented there is still the opportunity to include outcomes for evaluation that were not part of the original RCT. It may be that programs showing benefit in reducing one type of family violence will also be effective in reducing other types.

Moving forward

The Public Health Agency of Canada (PHAC) has historically focused mainly on the epidemiology of specific types of family violence. The development of approaches to the prevention and response of family violence has recently become a PHAC priority; PHAC has provided funding to the NFP trial of the IPV intervention described above (the pilot study and initial 2 years of the trial were funded by the Centers for Disease Control and Prevention as well as the Annie E. Casey Foundation). PHAC is also supporting the process evaluation of the British Columbia trial. Of huge significance to Canada is the fact that earlier this year, the federal Minister of Health announced a 10-year, $100 million investment to prevent, detect, and respond to family violence, including both child maltreatment and IPV. The Canadian government has recognized the importance of breaking down silos in the family violence field; it is our fervent hope that this investment will lead to major benefits both in Canada and beyond.

Selected references

Afifi, T. O., & MacMillan, H. L. (2011). Resilience following child maltreatment: A review of protective factors. Canadian Journal of Psychiatry, 56, 266–272.

Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, 186, E324–E332.

Eckenrode, J., Ganzel, B., Henderson, C.R., Jr., Smith, E., Olds, D.L., Powers, J., . . . Sidora, K. (2000). Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. Journal of the American Medical Association, 284, 1385–1391.

Guedes, A., & Mikton, C. (2013). Examining the intersections between child maltreatment and intimate partner violence. Western Journal of Emergency Medicine, 14, 377–379.

Herrman, H., Stewart, D. E., Diaz-Granados, N., Berger, E. L., Jackson, B., & Yuen, T. (2011). What is resilience? Canadian Journal of Psychiatry, 56, 258–265.

Jack, S. M., Ford-Gilboe, M., Wathen, C. N., Davidov, D. M., McNaughton, D. B., Coben, J. H., . . . NFP IPV Research Team. (2012). Development of a nurse home visitation intervention for intimate partner violence. BioMed Central Health Services Research, 12, 50.

Jack, S. M., & MacMillan, H. L. (2014). Adaptation and evaluation of the Nurse–Family Partnership in Canada. Early Childhood Matters, 122, 43–46.

MacMillan, H. L. (2000). Child maltreatment: What we know in the year 2000. Canadian Journal of Psychiatry, 45, 702–709.

MacMillan, H. L., Wathen, C. N., Barlow, J., Fergusson, D. M., Leventhal, J. M., & Taussig, H. N. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet, 373, 250–266.

Olds, D. L., Sadler, L., & Kitzman, H. (2007). Programs for parents of infants and toddlers: Recent evidence from randomized trials. Journal of Child Psychology and Psychiatry, 483, 355–391.

Public Health Agency of Canada. (2013). Family Violence Initiative. Retrieved from http://www.phac-aspc.gc.ca/ncfv-cnivf/initiative-eng.php

Sinha, M. (2013). Measuring violence against women: Statistical trends. Retrieved from http://www.statcan.gc.ca/pub/85-002-x/2013001/article/11766-eng.pdf

Stewart, D. E., & Riazantseva, E. (2014). Resilience and mental health outcomes. London, Ontario, Canada: Preventing Violence Across the Lifespan Research Network.

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