Plain English summary
Violence between intimate partners (Intimate Partner Violence) is a current relevant public health problem, due to the large number of women that suffer from it and because of the negative consequences it has for their health. This study explores how professionals from education, health and municipal social services understand Intimate Partner Violence among young people as well as their opinions about current programmes and mass media campaigns aimed at preventing this type of violence. To achieve these two objectives, we interviewed 12 professionals and analysed the transcripts of what they said. We found that for the participants, psychological abuse in the form of controlling behaviour was the most common type of partner violence among young people. They described violence as something subtle, daily and normalized, and consequently girls exposed to violence might not be aware of it.
Participants perceived local prevention projects as successful in addressing young people’s needs, but these interventions lacked formal evaluation, political support and continuation. In contrast, participants did not consider that nationwide mass media campaigns reflected the specific characteristics of IPV among young people and, thus, they were perceived to be ineffective.
Background
Intimate partner violence (IPV)
“includes physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)” [
1]. IPV against women has devastating effects on the health of women, including mental distress, depression, chronic pain and an overall poorer health status, to cite just a few outcomes [
2,
3]. Existing studies show that IPV is a global health issue. The World Health Organization (WHO) estimates that one in three women worldwide will suffer from violence during their lifetime [
4] and the results of a recent survey conducted in Europe found that one in five women had experienced physical and/or sexual violence from either a current or previous partner [
5]. In addition, almost 40% of female homicides worldwide have been estimated to be committed by their partners or ex-partners [
6]. In Spain, according to official data from the Ministry of Health, an average of 50 women have been killed each year by partners or ex-partners since 2003, when this registry began [
7].
In the USA, the latest report from The Youth Risk Behavior Surveillance System of the Centers for Disease Control and Prevention states that 13% of women who dated someone during the last few months were exposed to physical dating violence and 14.4% were exposed to sexual dating violence [
8]. Among college-aged students 19 to 25 years old, IPV rates range from 13% to 30% [
9]. In Spain, according to the 2015
Survey on Violence Against Women conducted by the Spanish Ministry of Health, Social Services and Equity, almost 20% of women between 16 and 24 years old reported exposure to psychological control violence during their lifetime, 10.3% to physical violence and 5.7% to sexual violence [
10]. The study
Gender Violence in Spanish Colleges, conducted in six Spanish universities (including the Basque Country University) during 2006–2008, found that 65% of university students had suffered or knew about a gender-based violent act that had occurred in the university environment [
9].
Just as in adulthood, IPV has a detrimental effect on young women’s health, increasing the odds of substance abuse, unhealthy weight control behaviours, sexual risk behaviours, unwanted pregnancy and suicide [
11,
12]. Moreover, negative effects on health increase the longer the time the victimization lasts. Additionally, victimization during adolescence/youth increases the risk of suffering IPV during adulthood [
13].
Although exposure to IPV usually begins at a young age [
14], the attention paid to IPV at early age stages in international research has been for a long time considerably lower than that paid to IPV against adult women and has usually been focused exclusively on teenagers [
15,
16]. During the last few decades, research in this field has markedly increased [
17]. However, there is no strong evidence yet about what must be done to effectively prevent IPV. Prevention strategies to date have focused mainly on school-based programmes, with promising results in terms of changing attitudes and knowledge when intervention is comprehensive and includes communities besides the school [
14,
18,
19]. Less evidence is found regarding long-term behavioural changes [
20]. Systematic reviews trying to assess the effectiveness of these interventions have found important methodological weaknesses in the evaluation of the outcomes [
18‐
20].
In addition to education, although the literature is scarce, there is some evidence which shows that policies enacted as a provision of civil protection orders for women exposed to IPV can have a positive impact in reducing the number of cases [
21]. Frontline professionals play a key role in the impact of implemented policies and programmes [
22]. Policymakers’ and service providers’ discourses do not merely reflect their opinions, but actually influence the services that are made available for young people and the ways they are delivered [
23].
Considering the available evidence on IPV prevention, Spain, including the Basque Country, has enacted policies to address gender inequity and IPV for more than 10 years [
24,
25] and has promoted school-based programmes [
26]. Despite this, research shows little progress has been made and there have even been some backwards steps taken in the process of addressing IPV, as an increased tolerance towards this violence among young people [
17]. Therefore, it is necessary to gain better knowledge of the characteristics of IPV among young people and to understand the role of prevention strategies currently in effect.
We conducted a study aimed at exploring professionals’ perceptions regarding intimate partner violence [IPV] among young people, focusing on the characteristics of the phenomenon and their perceptions of existing programmes and campaigns aimed at addressing it.
Methods
Study setting
This study is part of a larger research project on IPV and young people in Basque Country, Spain. In addition to surveying professionals from different areas, this research project will explore young people’s perspectives and attitudes towards IPV and the role of health services in IPV management.
The Basque Country is one of the 17 autonomous regions into which Spain is divided. In Spain, responsibility for implementing health, education and gender equity policies and programmes lies at the level of these autonomous regions. In the field of IPV and young people, from an institutional perspective, there are four relevant areas to consider in the Basque Country: formal education, non-formal education, health and municipal equity departments.
With respect to formal education, the Basque government is currently piloting a plan for gender violence prevention in the education sector in volunteer schools, with the aim of preventing all forms of gender-based violence. Besides formal education, all municipalities have youth departments, which provide recreational and education services to young people during weekends, holidays and on working days after school.
In the public regional health system, a group of professionals have joined together to enhance the health sector’s response to IPV. They develop awareness-raising campaigns for professionals and the general public, including some activities focused specifically on the prevention of IPV among young girls and boys.
Finally, all municipalities of the Basque Country have at least one full-time or part-time person responsible for gender equity issues. These “equity technicians” are responsible, among other tasks, for IPV prevention and also provide support and follow-up to women exposed to IPV, both in the adult and youth populations.
Participants
For this study, we conducted in-depth interviews with 12 professionals from each of the four sectors in Basque Country involved in IPV and youth (formal education, non-formal education, health and municipal equity). Participants were identified and selected by the study investigators as being the most relevant for this study, due to their work with young people and involvement in the development and/or implementation of IPV prevention interventions. Four of the participants were “equity technicians” actively involved in the implementation of unique region-wide IPV prevention interventions among young people in the Basque Country. Two participants were civil servants from the health system involved in the working group to address IPV. Four were social educators hired by municipalities to provide comprehensive attention to young people, from academic to emotional support as well as follow-up if needed. One study participant was a university lecturer who taught a course on gender issues and IPV and another was a secondary school teacher responsible for the implementation of the gender-based violence prevention project launched by the Basque Government at her school.
Data collection
Data collection took place from April to August 2014. Although saturation had already been achieved, during the data analysis it was considered relevant to interview a key informant from the formal education sector; thus, the last interview was conducted in May 2016. The first author (AM) conducted all individual interviews, following an open guide. Interviewees were asked about their perceptions of IPV and gender relations, measures that were being implemented that they thought were useful, and what was left to do to successfully address this issue, including coordination issues between all the actors involved.
Potential study participants were first contacted by email to explain the aim of the research study and the kind of participation required, and to ask about their willingness to take part. Once participants provided consent, they were contacted again to set a date and place for the interview. A local organization and a politician declined to take part in the study. Despite willingness to participate, it was impossible to find a suitable date for the interview with two other potential participants and we did not receive a response from another organization. Ten of the 12 interviews were held in the workplaces of the interviewees and two in coffee shops. Eleven interviews were recorded (one refused to consent to being recorded, so written notes were taken during the interview) and transcribed verbatim. The interviews lasted on average 1 h. All interviews were conducted in Spanish.
Data analysis
Interview transcripts were entered into Atlas.ti 1.0.16 for analysis. At the beginning of each interview transcript, a brief log of the interview was written, including information about the professional background of the interviewee, the place, hour, duration, and the feelings and perceptions of the interviewer during the conversation, in order to help with the analysis process.
We analysed all the interview transcripts using the thematic analysis described by Braun and Clarke [
27]. Data analysis was inductive, thus thematic construction was data-driven; no initial hypothesis guided the preliminary coding and subsequent thematic development. We adopted a constructionist perspective, as IPV is strongly rooted in societal norms and culture.
The same researcher who conducted the interviews completed the transcriptions and initial coding of the data set. One investigator performed line-by-line coding of interview transcripts, whereby codes were assigned to meaningful pieces of the text. Although the transcripts and codes were in Spanish, themes were developed in English as this was the language in which the final report was to be written. All the authors understand both languages and, thus, were able to participate in the whole analysis process. All the codes were then sorted into potential themes. Thematic maps were used at this stage to help with theme grouping and the analysis of relationships between emerging themes and codes.
The identified themes were refined using the two stages proposed by Braun and Clarke [
27] with the participation of all the authors. First, all the coded extracts for each theme were read thoroughly to check coherence in the pattern that led to that theme definition. Once necessary adjustments had been made, the preliminary thematic map was confronted with the whole data set, refining themes and subthemes. A detailed analysis of each theme, including the meaning and scope, as well as relations with the other themes, was conducted and written based on the data extracts coded in each one, as suggested by Braun and Clarke [
27].
Ethics
Written informed consent was provided by all study participants and, to ensure confidentiality, all names were erased. Ethical approval for this study was granted by the Ethical Committee for Research with Human Beings of the University of the Basque Country.
Discussion
This study identified three themes that describe how participants characterized IPV among young people, and in turn how these characteristics, along with the wider context, affect the visibility of the problem and the characteristics of the existing programmes, as well as how mass media campaigns focused on this issue address it.
According to participants in this study, gender inequity was the basis of IPV. Although there is no agreement in the literature on the causes of IPV, recent research has found gender inequity at country level and normative gender roles to be related to IPV prevalence [
28,
29]. Similarly, a research study conducted in Spain found that the risk of dying due to IPV varied among regions within the country and was related to scores on the Gender Development Index when comparing regions within the country [
30]. Even at an individual level, support for gender equity has been identified as having protective effects against female IPV victimization and male IPV perpetration [
31,
32].
Romantic and sexual relationships among young people were described by study participants as being different from those among adults; i.e., being shorter and having less defined boundaries and commitment. From their point of view, psychological abuse in the form of controlling behaviour is the most prevalent form of IPV which young girls are exposed to. This perception is supported by the results of the National Survey on Gender Violence, which found that as many as 19.4% of women aged 16–24 years reported exposure to this type of violence by current partners, while 1.5% reported physical violence by a current partner [
10]. Psychological violence is the most difficult one to identify, not only for the girls exposed to it, but also for the adults responsible for policies and campaigns to address it [
33].
Participants perceived that there is a gap between the huge strides towards equity in the formal sphere – i.e., legislation, access to the labour market, public discourse, etc. – and the slow changes in gender roles experienced in everyday life. This gap between the discourse about “how things should be” and practice has also been identified in research with young people in the Basque Country. Findings from these studies show that young people described more equitable relations in their discourses than they actually experienced in their own lives [
34,
35]. Similarly, a large study on gender roles and stereotypes with Spanish adolescents found that only 21.8% of the participants questioned traditional gender roles and stereotypes. Moreover, half of the participants strongly supported traditional views about couples, such as the girl being submissive to her partner’s desires [
36]. Other studies have also found that despite changes in recent decades, girls and boys continue to be socialized differently, following traditional gender roles especially regarding the concept of love [
37]. The scarcity of models that challenge traditional norms might to some extent explain this gap. Alternate models of gender equity do have a positive impact on the development of young people’s gender roles, as shown by research done in the Basque Country; however, having such alternate models in their proximity was not commonplace for participants in these studies [
34,
35]. In this regard, the mass media play a key role in the normalization of violent behaviours through the sustainment of “romantic love” as the unique model for romantic relationships in the view of the participants, a perception supported by findings from research on the effect of the media on gender construction [
37,
38]. The model of “romantic love” has been lately described in many studies as being supportive of unequal relations based upon traditional roles for women and men and consequently increasing vulnerability to and normalization of IPV [
37,
39]. Moreover, the mass media contribute to the invisibility of IPV, minimizing its relevance and questioning whether it is something real or something women make up [
40].
The social cognitive theory of gender development [
41] is a useful framework for further analysing the significance of models and mass media in the development of gender roles. According to this theory, gender roles are shaped as a result of the flexible and changing interactions between three influences: modelling, enactive experiences, and direct tuition. Modelling refers to the process of abstracting the rules and structures underlying the (in this case) gender-linked behaviour of significant others (mainly family, peers and media) and putting it into practice. Enactive experience relates to learning through social sanctions or approval received after enacting a gender-linked behaviour. Finally, direct tuition refers to explicit messages about what gender-linked behaviour should be like. In this theory, the influence exerted by modelling and enactive experiences is much stronger than direct tuition. In addition to the scarcity of models that promote equity, especially in the mass media, participants described strong social sanctions for girls who do not follow the gender-linked behaviour expected of them. Other authors have also described the strong pressure society puts on young women to meet traditional gender roles and the negative consequences this has for equity and IPV prevalence [
37]. In this regard, it seems difficult to envisage that the implementation of prevention strategies can counterbalance, through the influence of direct tuition, the enormous effect that modelling and enacted experiences have on maintaining inequity. This might explain the findings of Franco [
17] where, despite all the efforts expended in Spain on addressing IPV among young people during the past decade, rates of victimization remain similar and tolerance towards IPV has increased.
The prevention strategies identified by participants in this study can be broadly divided into two groups: nationwide mass media campaigns and locally implemented school-based projects. Traditionally, mass media campaigns and messages aimed at preventing violence have mainly been focused on adults and physical violence, far removed from the typical characteristics of IPV among young people in the view of the participants. The messages target women exposed to violence, and encourage them to get out of the violent situation. Only one of the campaigns launched by the Spanish Health, Social Services and Equity Ministry during the past 10 years explicitly encouraged society to challenge perpetrators [
42]. According to the participants’ perception, the stereotype of IPV portrayed in these mass media campaigns has been middle-aged white women exposed to physical violence. The positive effect of these campaigns has been to bring IPV into the public sphere and raise awareness about the problem. However, as explained before, physical violence is not the most prevalent type of IPV among youth, and violence usually begins at a young age. More recent campaigns have tried to address this limitation by shifting the focus to young women exposed to psychological abuse, but they still maintain the emphasis on encouraging women to leave the violent relationship as the solution to IPV [
42].
According to the literature, school-based IPV prevention programmes can have a positive impact on changing violence-supporting attitudes, increasing knowledge, and reducing its prevalence [
19,
43,
44]. School-based projects implemented by participants incorporated some of the recommendations found in the literature for successful prevention of IPV, such as including a significant skill-building component, addressing myths and stereotypes relating to IPV [
20], and ensuring flexibility, fidelity and sensitivity to diversity [
45]. Consistent with participants’ views of young people’s agency, these local initiatives put youngsters’ participation at the core of the interventions. Therefore, locally implemented programmes ranged from a short film contest to give a voice to young people about how they understand IPV and its prevention to a peer education programme fully led by secondary school students with the support of equity technicians. However, all of these local initiatives failed to include a rigorous outcome evaluation to demonstrate the effectiveness of the implemented interventions and, thus, failed in producing tools to advocate to politicians for their sustainability as recommended in the literature [
20].
Although participants described some school-based interventions as successful, it is worth pointing out that these interventions focused on the top tiers of the Health Impact Pyramid developed by Frieden [
46]; i.e., at changing individual behaviour. As the author pointed out, these interventions, if universally and effectively applied, can have an impact on the population, but changes are difficult to maintain if the context is not supportive for them [
46,
47]. To effectively prevent IPV, it is therefore essential to first ensure that successful interventions are universally and effectively applied. To achieve this objective, implemented interventions need to address their evaluation deficiency by including experimental outcome evaluations, including the measurement of changes in behaviour in addition to knowledge and attitudes. Secondly, there is a need to change the broader socio-cultural context by challenging mass media messages that support and foster inequity, and offering new models of healthy romantic relationships and of gender-linked behaviour that breach traditional gender roles. This second objective is difficult to achieve with only the commitment of frontline professionals and instead requires strong political commitment.
Methodological considerations
We applied the criteria described by Lincoln and Guba [
48] to enhance credibility in qualitative research. Credibility was enhanced by prolonged engagement, as the first author (AM) grew up, lives, and works in the research setting. To counterbalance the naivety of prolonged engagement, we used a triangulation of researchers, with the other three authors being foreign to the research setting. To stay closer to the text, the original Spanish version was used in the coding process and only when the themes had emerged did translation into English take place. We made an effort to include all the sectors involved in our topic of interest: IPV and young people in the Basque Country. It would have been interesting to incorporate the perspectives of those at a decision-making or political level, but although some politicians were invited to participate in the study, for different reasons (lack of time, suggesting interviews with technical staff instead, or lack of response) they eventually did not do so.
We have tried to describe the setting and context in order to enable readers to assess the applicability of our results to other places and circumstances. In this regard, it is important to highlight the historically longer commitment of the Basque Government to gender equity compared with other regions in Spain, which is reflected in specific legislation and the power of the local Institute for Women’s Affairs, Emakunde.
A possible limitation of this study was the difficulty in getting potential participants to agree to be interviewed. Those who decided to take part might have been driven by a personal commitment to the issue under study and so differ in their perspectives from others who did not respond to the invitation. Including professionals from the four sectors most relevant to our research question results in a more comprehensive perspective on the topic, but might be a limitation in the sense that is difficult to assess whether saturation was reached in all the sectors.
To enhance confirmability, we followed the steps proposed by Braun and Clarke [
27], going back to the interviews many times to check for consistency between the themes developed and the data. With this same aim, many quotations have been included in the results, allowing the readers to judge the interpretations made. This study reflects only the perceptions of the professionals interviewed, which might provide a partial picture. Future studies that are part of this research project will address this limitation, comparing these findings with young people’s perceptions.
Finally, in order to increase dependability, we followed an emerging design, responding to new issues raised by interviewees and including these in later interviews e.g. the role the mass media plays in the construction of equity between women and men.
Conclusions
The study participants showed good knowledge of the characteristics of IPV among young people. They identified psychological abuse in the form of controlling behaviour by partners as the most common type of IPV young women are exposed to, although they were also aware of the exposure to other types of IPV. This violence was described as something subtle, daily and normalized. As a result, it was not easy to recognize by the girls being exposed to it, or even by the adults working with young people.
Their knowledge of IPV was reflected in implemented local IPV prevention projects, which study participants considered successful in addressing young people’s needs. However, these interventions lacked formal evaluation, political support, and continuation.
The study participants did not believe that nationwide mass media campaigns realistically reflected the specific characteristics of IPV among young people. Thus, participants perceived these campaigns to be ineffective.