Responding to the Needs of Culturally Diverse Women Who Experience Intimate Partner Violence Who Experience Intimate Partner Violence

Abstract

This paper presents the findings from a community based participatory research (CBPR) study that investigated the interface between culture and intimate partner violence (IPV) for women in selected cultural groups in Hawaii: Native Hawaiian, Filipino, Samoan, and Chuukese. The research question was, “What are the cultural perceptions, responses, and needs regarding IPV of selected individuals and groups served through a variety of programs that are affiliated with the three participating Community Health Centers (CHCs)?” This cross sectional, descriptive study collected both qualitative and quantitative data. Individual interviews were conducted with women who had experienced IPV. Focus groups were also conducted with other women from the same culture. Five common themes were identified across the four cultural groups: Living within a Collective; Cultural Protective Factors; Cultural Barriers to Helpseeking; Gender Specific Roles; and Belonging to a Place. The outcome from this study is increased knowledge that will be used to develop culturally appropriate interventions. Specific findings from each cultural group have been published.^1–4 The purpose of this paper is to present common perceptions and responses to IPV from the four groups and suggest interventions based on the findings. Implications for practice are presented.

Introduction

Intimate partner violence (IPV) is a complex health and social issue affecting women around the world.^5,6 Annually in the United States, IPV is responsible for forty to fifty per cent of all murders of women, approximately 1,300 deaths.⁷ Approximately 25% of women and 7.6% of men reported being assaulted either sexually or physically, or both, during their lifetime.⁸ Approximately 5–6% of women are abused during pregnancy.⁹ An estimated $5.6 billion was spent on medical care for the more than 2.5 million injuries due to interpersonal and self-directed violence.¹⁰ Women in the United States lose nearly 8 million days of paid work each year because of IPV. In 2000 alone, the total costs associated with nonfatal injuries and deaths due to IPV were more than $70 billion. Most of this cost ($64.4 billion or 92%) was due to lost productivity. If household chores are included, it results in a total of 13.6 million days of lost productivity. Clearly, IPV places a significant burden on society.⁷

IPV has a significant negative impact on the well-being of women and their children. The effects may last well into adulthood and may include chronic pain,¹¹ depression and physical symptoms¹² including autoimmune diseases in adults.¹³

Impact of Culture

The population of women who are victims is not homogenous;¹⁴ differences in cultural perspectives may lead to barriers that prevent women from receiving effective care.¹⁵ Services are geared to women in general and do not account for the unique perspectives of different cultures. Intervention strategies have traditionally been based on Western notions of family and family life. Clinical interventions for abused women should be based on principles that include cultural competence and empowerment.¹⁶

Reported rates of IPV have a wide range of variation from one cultural group to another.^1,8 There is a growing body of literature regarding the incidence and prevalence of IPV in women who are of a variety of cultural groups.^2–4,17,18 Women who are categorized as Asian and Pacific Islander (API) report a lower rate of IPV than other cultural groups.⁸ Researchers have estimated that the prevalence is as great in API populations and call for more research to ascertain the extent to which this phenomenon can be explained by the level of willingness of these groups to disclose abuse. IPV maybe hidden in the context of other civil and criminal complaints such as assault or in the skewed proportion of emergency room visits by API Americans (18% of all visits) versus European American (12% of all visits).¹⁷

IPV in Hawai‘i

In Hawai‘i's diverse population,¹⁸ twenty per cent of women age 19–64 have been victims of IPV in their lifetimes. In 2006,22,000 adults reported IPV, 2.4% of the adult population, and 10% of high school students reported being physically hurt by partners.¹⁹ Hawai‘i frequently tops the annual national average for IPV murders per capita. Between 2000 and 2010 there were 63 murders of women resulting from IPV.²⁰ Only a small percentage of abuse situations are reported to police and by the time an arrest is made, the violence has continued for a number of years.²¹

In a 2003 retrospective review of records in four primary care settings,¹ 16% of IPV occurred in Filipino women (the specific dialect spoken was not indicated in the chart review) although Filipinos make up only 14% of the total population of the state. In that same study 32.3% of the total reports of IPV were Native Hawaiian women, contrasted with Hawaiians comprising approximately 20% of the population. Other Pacific Islanders comprised 16.1% of the total IPV reports; however, Pacific Islanders are only 4.5% of the population. These data provide an indication that the scope of this problem in these cultural groups is significant.

Methods

Critical social theory (CST) provided the theoretical framework for this research. The intent of this theory is to “challenge conventional assumptions and social arrangements.”²² Community based participatory research (CBPR) is consistent with the perspective of CST. An expected outcome of CBPR is the attainment of new knowledge that guides actions, increases the relevancy of studies and leads to a deeper understanding.^23,24

In this study the concern about IPV led to the development of a CBPR team, comprised of personnel from three community health centers (CHC's) and two nurse scientists from the University of Hawai‘i.²⁴ The participating CHCs identified the specific cultural groups to be included based on their questions about meeting the unique needs of the people they serve. The CHC prioritized Native Hawaiian, Filipino, Samoan, and Chuukese because there was documentation of high rates of IPV in these populations, and little was known regarding their perceptions of IPV.

Research Design

This cross sectional, descriptive study collected both qualitative and quantitative data. Individual interviews were conducted with women who had experienced IPV. Focus groups were also conducted with other women from the same culture who might or might not have experienced IPV. Inclusion criteria included: women, 18 years and older, served through a variety of programs that were affiliated with the agency. Purposive sampling was used and phased so that women who had experienced IPV and participated in the individual interviews were not recruited to participate in the focus groups. The study was approved by the institutional review boards of the University of Hawaii and the Waianae Coast Comprehensive Health Center. Safety of the participants, researchers, and staff guided every aspect of this research. World Health Organization guidelines,²⁵ a confidentiality agreement, and an NIH Certificate of Confidentiality were instituted at the sites, and safety plans were developed.

Population and Setting

A total of 53 women ranging in age from 21–64 years participated. Demographic information is included in Table 1.

Table 1.

Demographic Information of Participants

	Chuukese	Filipino	Native Hawaiian	Samoan	Total*
# Participants	22	10	10	11	53
Married/ Partner	14	5	5	8	32
Single/ Widowed	5	2	4	3	10
Sep/Divorced	3	3	1	0	6
# Children
0 – 3	10	3	5	4	22
4 – 7	8	2	4	6	20
10	1	0	0	1	2
Education
Elementary	4	1	0	0	5
< High School Grad.	0	2	0	2	4
(HS) Graduate	2	0	2	5	9
Greater than HS	4	2	8	4	18
Primary Language
English	0	0	10	4	14
Chuukese	22	0	0	0	22
Filipino Dialect	0	10	0	0	10
Samoan	0	0	0	7	7
Years of Residence in Hawai‘i
< 20 years	22	3	0	9	34
> 20 years	0	2	9	1	12

^*Differences in numbers reflect omitted data on demographic forms.

Instrumentation

A demographic form allowed cultural disaggregation. Three tools used during the study included two semi-structured interview guides (one for the individual interviews and one for the focus groups) as well as a quantitative tool, Perceptions of the Acceptability of Violence (PAV).⁴ See Tables 2–4.

Table 2.

Individual Interview Guide Perceptions of the Acceptability of Violence

Please estimate between 0 to 9 the number that best fits each question. Partner refers to the person you are in (or have had) an intimate relationship with.
Questions	Low				Medium			High
a. The American culture as a whole seems to think that it's understandable and sometimes OK for partners to hit each other in certain situations. Within your cultural group, on a scale of 0 to 9, how ok is it for partners to hit each other in certain situations?	0	1	2	3	4	5	6	7	8	9
b. On a scale of 0 to 9, when you were brought up, how ok was it to believe that partners could hit each other?	0	1	2	3	4	5	6	7	8	9
c. On a scale of 0 to 9, how ok do you think it is for partners to hit each other in certain situations?	0	1	2	3	4	5	6	7	8	9
The next three questions ask about your partner:
d. On a scale of 0 to 9, how much of ___________ (your partner's cultural group - identify cultural group), think it's OK for partners to hit each other?	0	1	2	3	4	5	6	7	8	9
e. On a scale of 0 to 9, how ok does your partner's family think it is for partners to hit each other in certain situations?	0	1	2	3	4	5	6	7	8	9
f. On a scale of 0 to 9, how ok does your partner think it is for partners to hit each other in certain situations?	0	1	2	3	4	5	6	7	8	9

These questions were adapted from a study reported by Torres, S., Campbell, J., Campbell, D., Ryan, C., Price, P., Stallings, R., Fuchs, S., & Laude, M. (2000). Abuse before and during pregnancy: Prevalence and Cultural Correlates. Violence & Victims. 15(3), 303–321.

Table 4.

Interview Guide for Focus Groups Intimate Partner Violence: Cultural Perceptions

The Group Leader will make a brief statement clarifying that the focus of the discussion is IPV and does not include other forms of domestic violence such as elder abuse or child abuse. The Group Leader will also explain that women who participate in this group may or may not have any experience with domestic violence. Women are not being asked to say anything about their own personal experience. It will be made clear that the questions pertain to women of this cultural group within this particular community.

1. Perceptions and awareness: What is the perception/awareness women have about IPV? What is the perception/awareness women think the community has about IPV?

The following questions will be asked to elicit discussion about this category:

1a. What do people think about IPV? Do they know what it is? [Cues to be covered: What are examples of abuse? When does abuse become abuse? Does it include physical injury, isolation and intimidation?]

1b. How much do people talk about IPV? What kinds of things do they say?

1c. When IPV occurs, how would you know about it? Who would you most likely talk to about it? Who wouldn't be told about it? What are the reasons? [Cues to be covered: Who most likely talks about IPV?]

1d. How do you teach your children/grandchildren about IPV? When would you do this? [Cues to be covered: How is information passed from one generation to another?]

1e. Tell me about: cultural protective factors, spiritual and religious practices, family rituals, gender roles, art and music, and the roles of individuals and groups related to IPV.

1 f. How ok is it for partners to hit each other in certain situations?

2. Responses: What are the responses of the women participants to IPV?

The following questions will be asked to elicit discussion about this category:

2a. How do women cope with IPV?

2b. Do you think there is a difference between how you understand/experience IPV and how your larger community understands/experiences IPV? If yes, what do you do about it?

2c. How come people don't want to talk about IPV?

3. Actions: The following questions will be asked to elicit discussion about this category:

3a. What are the actions women participants would like the health center to take? What do you think should be done about IPV in the health center? What is the best way to help women experiencing IPV? [Cues to be covered: Awareness of available services and perception of those services; other services needed and how to go about implementing them].

3b. What are the cultural systems that can help when there is IPV?

3c. What are the roles of individuals or groups in dealing with IPV?

These questions were adapted from a study conducted in Seattle, reported by Senturia, K., Sullivan, M., Ciske, S., & Shiu-Thornton, S. (2000). Cultural Issues Affecting Domestic Violence Service Utilization in Ethnic and Hard to Reach Populations. http://www.metrokc.gov/health/dvreport.htm.

Procedure for Individual Interviews and Focus Groups

Women were enrolled after receiving study information and signing the informed consent. The interviews and focus groups were conducted in a private place by researchers who were members of the culture and spoke the appropriate language. They were certified in the Protection of Human Subjects, had advanced knowledge of IPV, and had conducted interviews and focus groups previously.

In total, 20 of the women who screened positive for IPV were invited to participate in the individual interviews (5 from each cultural group). An initial and a validation member-checking focus group were conducted with each cultural group for a total of eight meetings. Each focus group included up to 10 women from the 4 specific cultural groups.

Data Management and Analysis

Quantitative data included the demographics and the results from the PAV. All quantitative data was analyzed using descriptive methods. All qualitative data were audiotaped and subsequently transcribed and analyzed by the research team using content analysis, with line-by-line coding.²⁶ Qualitative analysis was initially undertaken for each cultural group by each researcher, followed by research team analysis with attention paid to the cultural and community context. This ensured trustworthiness²⁷ that is widely used to evaluate qualitative research. The translation of the instruments and discourse contributed to the credibility by providing accurate data. Additional techniques that were used to establish credibility were the researchers' prolonged engagement with the topic, and persistent observation of the participants to give greater depth and understanding of culturally diverse women's experience. The goal was to summarize what was said, determine recurrent themes, and validate with the participants. The research team maintained comprehensive field notes that were integrated together with the other data.

Results

The findings point to the clear importance of the perceptions, responses and needs of participants from the 4 cultural groups as a basis for intervention and policy development. Women from all 4 cultural groups who completed the PAV tool during the individual interviews believed that violence was not acceptable to them individually; however, they indicated their spouse or partners perceived violence as acceptable within a relationship. Many unique cultural aspects emerged; however, there were some points of similarity among groups (Table 5). This paper focuses on the five common themes identified across the four cultural groups: Living within a Collective; Cultural Protective Factors; Cultural Barriers to Help-seeking; Gender Specific Roles; and Belonging to a Place.

Table 5.

Description of Themes Across Cultures

Common Themes	Chuukese	Filipino	Native Hawaiian	Samoan
Living Within a Collective	In Chuuk the head of the clan can provide advice and assistance when IPV occurs. More so in Hawai‘i, the church pastor assumes a role in providing support for the family.	The women believed it is important to defend the collective Filipino culture. In the case of IPV, reporting not only brings shame to the family but it reflects on the broader Filipino community group.	Intimate partner violence is understood to be a “family matter,” dealt with in the family or by one's self. “…family business is family business and don't shame the family.”	Samoan response to violence begins at the family level with the couple's parents advising them. If the abuse continues, the Chief (or pastor) becomes involved. If IPV continues, the perpetrator is asked to leave the village or is dismissed from the village council.
Cultural Protective Factors	In Chuuk, if families are involved in the selection of a spouse it gives them permission to intervene when IPV occurs. There is a protocol for seeking forgiveness where the spouse's family seeks to make amends to the woman's family. This procedure ensures that the husband and his family are accountable on all behaviors directed towards the wife.	Joint decision making is the norm, yet the culture is matriarchal in the household with women dominating in decisions about household budgets and men dominating in decisions of family finances and investments.	Participants recalled that during their parent's/ grandparent's generation, it was the woman's obligation and responsibility to keep the family together. The woman may have had her partner arrested and sent to jail, but still accepted him back because of the need to keep the family together.	In Hawai‘i the protection that was available “back home” in Samoa because of open housing, allowing intervention by others, is lost. In Samoa it is common for newlyweds to reside with the husband's families.
Cultural Barriers to Helpseeking	Women's responsibility in a relationship is to “keep the peace”. There is shame associated with IPV becoming known. Even with injuries, women may choose to stay in an abusive relationship out of duty and to preserve family honor. Women do have the choice to stay, take a break or to leave; but women are expected to be strong and resilient in family and marital life.	Women petitioned to enter the United States by a spouse or family members, have a “debt of gratitude” that never ends. They may be threatened with deportation. They can't return to the Philippines because this would bring “shame”. Pressure from family in the Philippines who rely on the woman for financial support is a deterrent.	Participants described their families reaching a point of “enough is enough.” Families stop helping because the woman continues to go back to the violent relationship or the relationship is interfering with the functioning of the family.	Samoan women are ashamed of being abused and think that people might blame them. Another factor might be that women do not want people to know that they are controlled by their husbands.
Gender Specific Roles	Chuukese women believe IPV is closely linked with marital infidelity but Christians “honor vows”, and all “honor saving face”. Women are expected to endure suffering; a mark of character is when a woman does not cry out during childbirth. Most of the time, when a Chuukese man is finished with an affair, he will come back to his wife.	The participants believed that it was their responsibility to keep the family intact at all costs, particularly if they have children, regardless of IPV being present. They perceived that their faith would sustain them and most relied on prayer and their ability to endure suffering to get them through the abuse.	As above, it was the woman's obligation to keep the family together. Leaving a legacy was important and therefore, women ensured that children knew how to respond appropriately to situations, and the appropriate roles of males and females.	Women believed that violence was often associated with men's alcohol or drug use. They also related that jealousy, a “sickness that affects men”, could be associated with IPV. They believed that the need for power and control prompted some men to be violent. Fathers and brothers are expected to seek reprisal against the spouse.
Belonging to a Place	Communal living in Chuuk offers protection which is lost with the move to Hawai‘i. Land is the number one asset in Chuuk and land is given up with the move to Hawai‘i.	Immigrant women who participated in the study discussed difficulty in making the transition from Filipino culture and expectations to the changed environment in Hawai‘i. They described their resulting problems with their own expectations and identity.	“I'm part Hawaiian, who needs to reconnect with self. I know how to do it, and that is to get back to where I came from, which is to the land.” Feeling “at home” was conveyed in the need to establish or re-establish relationships with their community or the place they came from.	During the process of acculturation to a new environment the roles held as a cultural norm might need to be completely reversed in order to support ones' family. Immigrants may find themselves in situations that deviate from long held cultural norms.

Living Within a Collective

Women described the importance that the collective (family, clan and community) plays in individual decision making. The women viewed themselves as an extension of the clan, in contrast to the more individualized perspective of the American culture. The extended family is the basic unit in all of the cultural groups. This meant that women believed they carried an obligation to preserve family and community relationships. As an example, in the Filipino culture (although the interviews and focus groups were conducted in the Tagalog language, the official language of the Philippines, several of the participants in the focus groups or individual interviews were Ilocano and also spoke Tagalog. Even though there may be major cultural differences between individuals who speak these dialects, their responses regarding IPV were similar across the board, reflecting a shared perspective which is documented in this paper) there is a strong sense of interdependence that leads to the Filipino concept of reciprocity and balance, or utang ng loob. Parents take care of children, and later in life the children care for their parents. Women disclosed that they must consider not only themselves and their nuclear family, but also their extended family in decisions.

Women described their role in “Defending the Collective.” They did not believe they should share their problems with others. They were very concerned about what people might think about their family and the cultural group and believed they would carry an additional burden of shame if their situation became known. They were aware that if one discloses IPV there is a risk that the information could get back to the extended family and other community members. If that occurred, the family's good name would be compromised and they would be judged. The women valued defending the collective.

Cultural Protective Factors

When the abuse became obvious, members of the family could be an important source of support. Families offered a place for the women to “take a break” from the perpetrator, provided a safe place for the children, and allowed the women time and freedom to be away from the abusive situation.

In two of the groups, Chuukese and Samoan, historically there have been protective factors in place whereby families, clans and those responsible for the community's well being had processes to maintain a stable environment. One protective factor was a mechanism for mediating disputes in ways that were acceptable and perpetuated fair treatment of women. When a woman experienced violence the matter came under the protective scrutiny of the family and community structure. Efforts were taken to resolve the situation. If abused women moved back to their family homes to avoid further injury and violence, the perpetrator and his family were expected to make amends. This included providing gifts to the victim's family and asking for forgiveness, pledging their protection for the woman who had been abused.

For these two cultures, the social organizational structure in the country of origin the Chief serves as the community leader. Protective measures at the Chief's level include conflict resolution between the partners and the two families. If these measures are unsuccessful, the Chief can banish the perpetrator from the community. After migration to the United States, the church pastor may take on the role of community leader and provide guidance when IPV occurs.

Cultural Barriers to Helpseeking

Family values, attitudes, and needs created significant barriers for some of the women. In two of the cultural groups (Chuukese & Samoan), fathers and brothers of the abused women were honor bound to seek revenge with further violence against the perpetrators. Women sometimes avoided telling their fathers and brothers about their abuse because they wished to avoid such a confrontation that could lead to arrest or injury of their own family. If a father or brother advised a woman to leave an abusive situation she was honor bound to abide by that mandate.

Samoan women disclosed that mothers might discourage women from leaving an abusive partner because “you made your choice, now you must live with it.” Immigrant Filipina women disclosed that their families often expected them to remain in an abusive situation particularly if the family was benefitting financially or hoping to migrate to the United States. Some violent partners have threatened violence against the woman's family in the Philippines to keep them from leaving the abusive relationship.

Religious views also served as barriers. Some women believed that it was their responsibility to keep the family intact at all costs, particularly if they had children, regardless of IPV being present. They perceived that their faith would sustain them in the face of this difficulty and most relied on prayer and their ability to endure suffering to get them through the abuse. Separation and divorce is frowned upon for moral and religious reasons and not considered a viable alternative. Chuukese women noted changes that are occurring within their cultural group. Although, they won't readily seek divorce, Chuukese women may “take a break” from a relationship.

Gender Specific Roles

Women as Peace Makers:

Women from three of the cultural groups described a cultural norm that placed the blame for IPV on women who are expected to maintain peace in the family. Women's role is centered on the idea that women are “kinder and gentler” than men and it is up to them to maintain a peaceful environment. If they are abused by their partners, the women are expected to tolerate the abuse in silence.

Women's Concerns for Children:

Even though the women believed that it was their responsibility to keep the family intact at all costs, they worried about their children's safety and had concerns about their future. Many of the women had been exposed to violence as children and had been raised in such a way that they had not regarded abuse as “out of the ordinary” until they became involved with an external agency regarding their situation. Even with this misconception that violence was the norm, they discussed the suffering they had experienced as children and realized that it affected their lives.

Men as Head of Household:

Fathers and brothers assumed a protective role for their daughters and sisters. If they became aware that the woman was in an abusive relationship it was their responsibility to provide protection and retribution. Consequently, women will speak to their mothers and sisters but will not disclose abuse to their fathers or brothers.

In the Samoan culture obedience to the family head is the primary responsibility of all members. Punishment for disobedience is corporal and commonly administered to children and adolescents. If wives do not “obey” they, too, may be punished in this way.

Men as Providers:

Males have traditionally been expected to provide economic support and serve as the family decision maker. With changes in society or a move to a new environment these gender roles once held as a cultural norm might need to be completely reversed. Men's traditional role as provider has been eroded in recent years. This has occurred as a result of immigration, but may also be true for Native Hawaiian men as the traditional means of support (fishing, hunting and farming) are replaced. Available work may be more suited for women; therefore, men may find themselves unable to provide for their families.

Belonging to a Place

All groups referred to the importance of the land and their country of origin. As the indigenous peoples of this State, the land has symbolic meaning for Native Hawaiians. Natural elements of the land, mountain, ocean, rain, wind, and stars provided a source of “serenity,” an avenue to release “pilikia” (troubles), a sense of belonging, relaxation or calm, and removed them from the violent experiences. Participants described seeing the ocean and mountains as landmarks, which signified home. Native Hawaiians were identified in this study solely from self-report. Readers should use the findings cautiously, not only with respect to individual Native Hawaiians, but also across communities of Native Hawaiians. These findings present a picture within a context by community and ethnic group, and of course, by those who were willing to speak about it. For the immigrant participants, the sense of belonging felt in their homeland was disrupted by the move away from land they had occupied for generations to a new and foreign environment. This disruption impacts on the cultural protective factors no longer in place.

Discussion

Responses to meet the needs of women

These five themes provide an introduction for meeting the needs of women from these cultural groups. Women wanted the abuse to stop. Understanding why women from these cultural groups choose to stay or leave required an appreciation of the cultural context in which they and their family function. Women wanted alternatives that would allow safety and prevent injuries beyond having to move to a shelter. They sought help that was consistent with their cultural roles and priorities. One culturally specific strategy is for women to seek refuge in the homes of relatives or friends temporarily to heal physically and mentally with space to mitigate the conflict.

Response of Health Center

The issues related to IPV do not have easy answers. The challenge for the CHCs is to recognize that change may be needed in their own system and the systems that support CHCs. Services are currently based on the traditional Western model of screening and treatment. For CHCs serving diverse populations there is a need to base service son the cultural perceptions of the women. Identification and assessment of IPV may be more difficult if culturally sensitive screening instruments are not available. Planning of interventions should be culturally appropriate, and proceed at the women's pace. It is important to avoid stereotyping and to develop an awareness of variation within cultural groups in the context of a specific community. For example young women who are immigrants may not have the same attitudes and beliefs as their parents. The women who participated in this research recommended that members of the same cultural group who are also CHC staff were best suited to respond to their needs. Culturally appropriate care is far deeper than just being sensitive; however, there is a need to exercise caution as hiring within a small group or a specific neighborhood can present barriers to disclosure related to confidentiality.

There are system issues to be considered when planning IPV policies. It takes time for health care providers to develop a trusting relationship that encourages disclosure of IPV and to find the resources that the woman may need. It is important that providers care for themselves and seek reinforcement and assistance when they are working with families where IPV may be occurring. Conventional methods of providing care may not work with culturally specific groups. Training needs to include attention to somatic and behavioral cues.

CHCs are in a position to offer a variety of resources including preventive measures, gender separate counseling, and interventions in the home. Interpretation and translation do not necessarily assure cultural competency or competence in providing IPV services.

Community Response

Beyond typical legal and professional services, individuals, families, and communities should be encouraged to develop their own prevention and intervention strategies. While most participants learned about IPV through their family experiences, they also recognized that prevention begins with the family. Participants expressed the importance of people looking out for each other. They recalled that this was prominent when they were growing up and identified this as a valued resource for families.

CHCs can work with community members and groups to build capacity in order to develop solutions for their cultural group. Strategies to address this include: 1) Identifying gaps in services; 2) Identifying natural helpers who are open to addressing this issue and respected as sources of knowledge or support within their cultural group; 3) Presenting information within a cultural context that is safe and does not judge nor isolate the woman experiencing violence; and 4) Supporting and advocating for community involvement in prevention strategies from a public policy perspective.

Table 3.

Individual Interview Guide Intimate Partner Violence: Cultural Perceptions

The Interviewer will make a brief statement clarifying that the focus of the discussion is IPV and does not include other forms of domestic violence such as elder abuse or child abuse.

1. Perceptions: How do you understand IPV as an individual? Where did this understanding come from?

The following questions will be asked to elicit discussion about this category:

1a. Tell me about IPV? How do you understand this? [Cues to be covered: When does abuse become abuse? Physical injury, isolation, intimidation (when he looks at you and you're absolutely terrified)].

1b. What about your partner? How do you think your partner understands IPV?

1c. What does your family think about IPV?

2. Responses: How have you responded to IPV? How has your family responded?

The following questions will be asked to elicit discussion about this category:

2a. How did you deal with IPV? Did you talk with anyone?

2b. How about your family - what did they say or do?

3. Needs, Satisfaction, and Access: What did you need from the health provider/community? Did you get it?

3a. Was there support (outside of your family) that you needed?

3b. What was it? Was it helpful to you? [Cues to be covered: What health/social services did you need? Were they available? What services have you used? Did they work for you?]

4. Reasons women may or may not have disclosed: Did you talk with your doctor or nurse about IPV? If not, how come? If yes, why did you decide to talk about this?

4a. Did he/she ask you questions about IPV or did you just tell them? What was this like for you? [Cues to be covered: Tell me all your thoughts and feelings of what it's been like for you and how you've reacted when you were in a situation where you could have reported the IPV.]

5. Influence of specific elements of culture regarding IPV.

5a. Tell me about…(the following topics will be individually introduced: cultural protective systems, spiritual and religious practices, family rituals, gender roles, art and music, and the roles of individuals and groups related to IPV).

These questions were adapted from a study conducted in Seattle, reported by Senturia, K., Sullivan, M., Ciske, S., & Shiu-Thornton, S. (2000). Cultural Issues Affecting Domestic Violence Service Utilization in Ethnic and Hard to Reach Populations. http://www.metrokc.gov/health/dvreport.htm.