Systematic Review of Pattern and Prevalence of Drug use Associated with Domestic Violence

Background: Abuse of substance is now recognized as a significant public health problem worldwide. Domestic violence is as serious a cause of death and incapacity among women aged 15-49 years as cancer. Associations have been established between substance abuse and domestic violence. Abused women have more than double the number of medical visits and 8-fold greater mental healthcare usage.

Aim: To examine the pattern and prevalence of drug use and associated domestic violence.

Design: A systematic review.

Data sources: Systematic search for worldwide published literature from Medline, Embase,

Cinahl, ASSIA, ISI, Google Scholar, and Science Direct, databases.

Study eligibility criteria: Studies included in this review reported the methods and/or measures for the pattern and prevalence of drug use and associated domestic violence

Data extraction: The study results were interpreted with respect to their sample size, level of evidence, risk of bias, and level of heterogeneity/homogeneity.

Result: Out of a total of 1,506 publications, which were reduced to 254 after screening the titles and abstracts to assess whether the contents were likely to be within the scope of the review. The researcher also checked and removed studies not meeting the inclusion criteria, accounting for 180 studies removed. A further 64 studies were excluded because they were largely narratives about domestic violence cases, studies of risk factors rather than prevalence or were predominately review articles. 10 studies satisfied all the inclusion and exclusion criteria.

Conclusion: Sensitization to the problem of domestic violence with a background of drug abuse should be incorporated not only in medical training, but into governmental, legal, and judicial organizations. Future research should seek to recognize cultural differences in family functioning without necessarily viewing such differences as 'deviant' or 'pathological'.

Drug abuse is a complex behavior seen amongst young people all over the world [1]. Reports from epidemiological studies in Nigeria [2], Ghana [3], South Africa [4], Kenya [5], and the United States [6] have shown alarming figures of substance abuse among young people. Abuse of substance is now recognized as a significant public health problem worldwide [7]. Historically, policymaking with respect to drugs, alcohol, and violence has focused on aggression in systems of drug distribution, demand and supply [8,9] and violence arising from intoxication in the night-time economy [10].

There is an increasing acknowledgment internationally, however, of the link between drug use and domestic violence [11,12]. The most recent U.K. Drug Strategy [12] notes that women who experience physical and sexual interpersonal violence are more likely to have drug or alcohol problems [13] and that there is a higher prevalence of domestic violence perpetration among men in drug use treatment than in the general population [14]. Worldwide, domestic violence is as serious a cause of death and incapacity among women aged 15-49 years as cancer, and a greater cause of ill health than traffic accidents and malaria combined [15].

In addition to causing injury, violence increases women’s long-term risks of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression [16]. Secondary to the bio psychosocial effects of battering are the high costs of such violence. Abused women have more than double the number of medical visits, an 8-fold greater mental healthcare usage, and an increased hospitalization rate compared to non-abused women [17].

The WHO multi-country study on women’s health and domestic violence has recently confirmed significant associations between lifetime experiences of partner violence and self-reported poor health [13]. Previous research has well established the association between alcohol use and domestic violence and there is growing evidence that drug use is associated with domestic violence. The clearest evidence is that alcohol is a risk factor for domestic violence offending. Although the etiology is complex, males who assault their intimate partners have frequently been drinking prior to the violence, and these men often have alcohol problems.

The prevalence of the domestic violence problem began to be more visible with the publication of the results of the first national survey of family violence in 1980 [18]. This survey indicated that 16% of those surveyed reported some kind of violence between spouses in the previous year, and 28% reported marital violence at some time during the marriage. The 1985 National Family Violence Survey found very similar levels of family violence [19]. These two national surveys are important reasons why so much attention has been paid to the domestic violence problem over the past two decades. The surveys have been analyzed extensively and have stimulated additional research on domestic violence.

From the outset of systematic study of family violence, the association of drinking to male against female domestic assault was apparent. In a review of the literature from the 1970s, Hamilton and Collins [20] estimated that 25% to 50% of male against female domestic violence events involved drinking males and that men who were violent against their partners were disproportionately likely to have alcohol problems. More recent reviews of the literature have shown similar findings [21]. Barnett and Fagan [22] examined drinking patterns among 181 men who were married or cohabiting in the past 12 months. Four groups were studied: martially violent counseled (n = 43), martially violent uncounseled (n = 46), nonviolent unhappily married (n = 42), and nonviolent satisfactorily married (n = 50). The men who had been martially violent drank more than the nonviolent men, and they were different from their nonviolent counterparts specifically on the larger amount of alcohol consumed and their drinking for emotional reasons.

Female victims of domestic violence are sometimes interviewed about their experiences. Victims interviewed for the National Crime Victimization Survey (NCVS) are asked to report whether they think the offenders who assaulted them had been drinking alcohol. Among those who were assaulted by their intimate partners (spouse, former spouse, boyfriend, girlfriend), the victims reported that two-thirds of the offenders had been drinking [23]. This percentage is substantially higher than for victims who were assaulted by no marital relatives (50%), acquaintances (38%), and strangers (31%).

Surveys of jail and prison inmates also indicate substantial percentages of inmates reporting that they were drinking before they committed the offenses that resulted in their incarcerations. A 1991 survey of jail inmates indicates that 41 % of those incarcerated for violent offenses were drinking before the offense [23], and 37% of prison inmates interviewed in 1991 who were incarcerated for violent offenses reported being under the influence of alcohol (or drugs and alcohol) at the time they committed the offense [24]. These inmate data are not presented separately for intimate and other kinds of violence.

Some literature on the evaluation of male batterer treatment also provides evidence that alcohol use is a risk factor for domestic violence offending. Gondolf and his colleagues evaluated batterer interventions in four sites. Longitudinal data for 350 men who participated in batterer treatment showed that a batterer’s drunkenness after program entry was associated with the risk of re-assault [25]. A recent study of domestic violence before and after alcoholism treatment examined the effects of Behavioral Marital Therapy (BMT) on subsequent involvement in domestic violence and the relationship of drinking to domestic violence.

A study of 75 alcoholics and their wives indicated that BMT reduced the use of violence in the 2 years after treatment [26]. The study also found that the alcoholics whose drinking had remitted did not have elevated domestic violence behavior in comparison to a matched control group, but that the alcoholics who relapsed had elevated domestic violence levels. The literature addressing the drug use-domestic violence offending relationship is limited but growing. Kantor and Straus [27] analyzing the: 1985 National Family Violence Survey, found that husband’s drug use was associated with both minor and severe violence against the female domestic partner. Lee & Weinstein [21] reported a relationship between higher Addiction Severity Index (ASI) scores and battering among a cocaine abuse treatment population in Philadelphia.

In a summary of a survey of domestic violence victims who came to the attention of the police in Memphis, [28] reported that 92% of the offenders had used drugs and/or alcohol on the day of the assault, and 67% of the assailants had used a combination of cocaine and alcohol. In another study, Miller [29] reported that an alcohol/drug interaction effect contributed to the level of violence against their spouses by a group of parolees found for the women, but the men who were violent reported more symptoms of alcohol dependence and drug abuse than did their nonviolent peers. Amaro, et al. [30] surveyed pregnant women and their experiences with violence. They found that the male partner’s drug use was associated with the violent victimization of the pregnant women, even after controlling for age, marital status, education, and a history of violence in the 3 months before pregnancy.

Literature searches

This review followed a top-down search strategy. The researcher prioritized studies with the highest level of evidence, i.e., aggregated data in systematic reviews and meta-analyses according to PRISMA [31,32]. Parallel literature searches of 6 databases (Medline, Embase, Cinahl, ASSIA, ISI, and International Bibliography of the Social sciences) were undertaken. The reference lists from retrieved studies and specialized interdisciplinary journals in drug use and domestic violence were hand searched to look for further studies that might not have been retrieved by the database searches. Authors of unpublished studies, e.g., Ph.D theses, were contacted to obtain copies of their studies. All citations were exported into Reference Manager Software (version 11). Searches included MeSH and text words terms, with combinations AND OR Boolean operator. The researcher included studies on the prevalence of drug use and domestic violence against women, published in English and including aged between 18 and 65 years. The researcher excluded studies on people with special disabilities or certain complicated diseases e.g., HIV, people in places of refuge, case reports, reviews, and non-English studies. The researcher also excluded studies conducted on people aged > 65 years and on drug use and violence against pregnant women, where a large number of studies was found, which possibly merit a separate review.

The searches identified 1,653 primary studies, which were reduced to 356 after screening the titles and abstracts to assess whether the contents were likely to be within the scope of the review. The researcher also checked for duplicates between databases, accounting for 180 (10.9%) of the total studies. A further 176 studies were excluded because they were largely narratives about domestic violence cases, studies of risk factors rather than prevalence or were predominately review articles. A final total of 8 studies was selected for further analysis.

Quality assessment

These studies were assessed using structured guidelines [33], and were scored on eight quality criteria as follows: (1) specification of the target population, (2) use of an adequate sampling method (e.g., random, cluster), (3) adequate sample size (> 300 subjects), (4) adequate response rate (> 66%), (5) valid, repeatable case definition, (6) measurement with valid instrument, (7) reporting of confidence intervals or standard errors, and (8) attempts to reduce observer bias. The researcher recorded the date of the study, the prevalence (and/or incidence) estimates of drug use and domestic violence (including life-time and/or current estimates), and the type of violence reported. These variables were coded from each study as categorical or continuous. After quality assessment was completed, studies were stratified according to the total score from 1-8.

Data synthesis

This review applied a qualitative data synthesis approach. An aggregated data analysis could not be used because of the high heterogeneity of primary outcome measures. The study results were interpreted with respect to their sample size, level of evidence, risk of bias, and level of heterogeneity/homogeneity. If there was a case of duplicate primary studies, the following preference criteria was included [34]: the availability of numerical data or results; the highest SIGN-rating (Quality assessment tool for systematic reviews); most recent date of publication; larger number of studies and observations. In some cases, additional analysis conducted after completion of a study was reported in additional publications. In these cases, the researcher used both reports to inform the data extraction.

Out of a total of 1,506 publications, which were reduced to 254 after screening the titles and abstracts to assess whether the contents were likely to be within the scope of the review. The researcher also checked and removed studies not meeting the inclusion criteria, accounting for 180 studies removed. A further 64 studies were excluded because they were largely narratives about domestic violence cases, studies of risk factors rather than prevalence or were predominately review articles. 10 studies satisfied all the inclusion and exclusion criteria. The selection process, based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines [35] for this study is shown in figure 1.

Rydstrom [36] conducted a study on the role substance use play in intimate partner violence. A narrative analysis of in-depth interviews with men in substance use treatment and their current or former female partner was done. The psychopharmacological effects of substance use (including intoxication, craving, and withdrawal) featured in participants’ accounts of Intimate Partner Violence (IPV), it was rarely the only explanation and appeared to be primed and entangled with narratives of sexual jealousy, male participants’ perception of female impropriety and women’s apparent opposition to male authority. The analysis highlights, particularly for men who are poly substance users, an intimate playing out of “economic-compulsive” [9] abuse in disputes that frequently escalated from female partners’ attempts to oppose coercive control.

In co-dependent, drug-using relationships, in particular, substance dependency and gendered power relations combined to make women vulnerable to abuse in disputes that centered on male partners’ control of drug supplies. Some male perpetrators also attempted to coerce women to raise funds to obtain substances and punished them physically when they failed to do so. Our findings support those of According to Gilbert, et al. [37], violence may be more likely where men are financially dependent on their partners. However exploitative, such relationships are not reducible to financial partnerships. Intimate relationships entail sexual vulnerabilities and emotional dependence requiring a trust that renders IPV perpetration, a source of shame for both perpetrators and survivors.

The psychological vulnerabilities that both partners frequently brought to these relationships made them ill equipped to negotiate the situational conflicts that arise from dependence on illicit substances in the context of scarce resources. The hostile sexism and general mistrust of women that were frequently evident in male participants’ explanations for perpetrating IPV, combined with their failure to fulfill the normative role of masculine provider moreover meant that their response to real-and imagined-sexual betrayal was frequently both as a means of reasserting patriarchal authority and a denial of shame.

In their study of 95 couples where men had been arrested for domestic violence–related offenses [38], found men and women disagreed about the nature, frequency, and impact of men’s violence. Likewise, Hyden [39] found in her study of 20 Swedish couples that men were more likely to depict violence as bilateral and transactional elements of disputes and arguments that had escalated, while their female partners referred to the violence as assaults. The study elaborates the differential narratives through which such gender differences are played out where one or both partners use and are in treatment for substance use. Male participants described intoxication with alcohol and cannabis and craving and withdrawal from heroin and crack leading to isolated incidents of perceived uncharacteristic violence in the context of escalating disputes. They commonly justified such loss of control as a result of female impropriety, sexual jealousy, and betrayal, the latter of which could include criticizing the men for their failings and drug use.

For female partners, by contrast, such violent incidents were more likely to be described in the context of patterns of abusive behavior, at the extreme end of which included paranoid, highly coercive control, and brutal violence. Women described experiencing threats and physical abuse as punishment for disagreeing with or challenging their partners’ authority and control. While men were more likely to describe their violence as transactional warranted, women described attacks initiated by male partners who judged them for not making sufficient effort to raise funds and hence defaulting on an unspoken commitment to share money and supplies that were often earned illicitly.

Where both partners used multiple substances, men described using violence and control to protect their partners from “addiction” and from unscrupulous others while women described having to “earn” access to substances, restrictions on who they could use substances with, and using violence themselves to resist male control. In relationships where women were not dependent substance users, economic abuse on the part of male partners was also associated with women’s resistance to male perpetrators attempts to take funds from them and sell their belongings to fund secret use.

Women frequently described these experiences additionally as confusing and psychologically abusive since the rationale for the men’s violence was partially obscured. Access to the narratives of both partners in abusive relationships provides insights into the dynamic of IPV perpetration by men in treatment for substance use. It is in highlighting the differences between how men and women in the same couples tell these stories that our study is unique [40] and has the potential to inform treatment.

Longitudinal qualitative dyad studies are needed to understand how IPV and substance use impact relationships and substance use over time. A core question these findings raise for treatment practitioners is how men who have perpetrated abuse can be helped to recognize that what they see as isolated incidents in which substance use occasionally causes things to get out of control, is part of a different more troubling story from the perspective of women who feel intimidated, dependent, and ashamed. This is a particular challenge in practice where the actual partners are not brought into the room with perpetrators but research and structures of accountability with women’s services can fill this gap.

The findings of this study support the need for interventions for such men that concurrently address the complex interconnections of IPV with substance use [41] and services for women that are informed by an understanding of how dependence and withdrawal frame disputes. The study suggests specific ways in which men’s narratives that rationalize IPV can be reframed and through which tendencies to control and dominate their female partners can be challenged and behavior changed.

As was shown, some men’s desire to protect their female partners from substance use or predatory substance users was, from these women’s perspectives, primed by intoxication, sexual jealousy, and controlling tendencies. Efforts at this controlling protectionism could lead to what the men regarded as accidental violence or outbursts that were, in hindsight, excessive but otherwise regrettable and out of character. Some women omitted accounts of their own violence and substance use from recollections of incidents that led to them being severely assaulted in ways that sounded much more callous and deliberate than their partner’s recognized or were prepared to admit. There is thus a need to provide support to women who are subject to IPV-some of it being life threatening-but who fall short of “ideal” notions of “victimhood” and whose lives are also complicated by adverse childhood experiences, mental health problems, and substance use in much the same ways as their abusers’ lives have been. Trials of integrated interventions for men and women who use substances and perpetrate or experience IPV are needed to test their effectiveness in improving relationships, reducing IPV, and substance use.

Samia, et al. [42] also conducted a study on domestic violence against women. The results of this review emphasized that violence against women has reached epidemic proportions in many societies and suggests that no racial, ethnic, or socio-economic group is immune. However, the author highlighted substantial differences in methodologies, sample sizes, sampling periods, study populations, and the types of violence studied. For all types of violence there was a consistent and a significant heterogeneity between studies, even in studies that appeared to use standardized methods (e.g., WHO multi-country study), population studies, and studies that scored high on our quality criteria. Age, ethnicity, and socioeconomic status were not consistently documented, making comparisons and evaluations of generalizability difficult. However, the WHO Multi-country study was an important attempt to collect internationally comparable statistics through the use of standardized survey methods.

Prevalence of violence has been assumed to be higher in clinical settings than in population samples [43], because it is assumed that health care utilization is higher among victims of abuse [44]. For example, high prevalence rates have been measured in specific patient groups, for example at gynecology clinics in patients with severe Premenstrual Syndrome (PMS) or pelvic pain [45,46].

The present review highlights several important factors involved in the epidemiology of domestic violence against women.

1) Surveys may not measure the actual number of women who have been abused, but rather, the number of women who are willing to disclose abuse. As with all self-reported disclosure, it is possible that results are biased by either over-reporting or under-reporting. In most studies, however, little evidence of over-reporting has been found [47].

2) The meaning of violence varies from culture to culture, and sometimes within the same culture [48]. Women from Asian cultures are brought up in a belief system that stresses the greater need of the family over the needs of individual members [49]. Although women in the poorest of nations are probably most inclined to believe that men are justified in beating their wives, in all settings, in developed and developing countries, abused women tend to hold more beliefs which justify violence against them [50].

Fatoye and Morakinyo [50] pointed out that, in classifying respondents as victims, a particular interpretation is placed on these responses, which may ignore important differences in the interpretation of ‘assault’ and of behaviors which constitute violence. However, not all women who suffer abuse identify with the socially constructed image of a ‘battered woman [51]. It is not only important to learn whether respondents have experienced any of the particular behaviors that we define as violent or abusive, but also to understand to what degree they share these labels with us.

Many important social, political, and economic factors affect women’s lives, other than the cultural practices that receive so much attention in relation to violence. These include poverty, inequalities, new articulations of patriarchies in specific regions, and the legacies of colonialism and racism [52]. In Arab and Islamic countries, domestic violence is not yet considered a major concern, despite its increasing frequency and serious consequences. Domestic violence may be seen as a private matter and a potentially justifiable response to misbehavior on the part of the wife. Selective excerpts from religious tracts have been inappropriately used to endorse violence against women, although abuse is more likely to be a result of culture than of religion [53].

However, issues of power and gender [54], rather than ethnicity and race [55], may be more important in creating and maintaining male dominance and the imbalance of power between husbands and wives [56]. Indeed, definitions of race and ethnicity are themselves problematic in research of this kind. Diverse ethnic groups are often collapsed into a single category, such as Asians, or the patterns of a single group such as Mexican Americans are over generalized to all Hispanics [57]. Because of this, data on partner violence among minority populations are often incomplete, precluding meaningful generalizations.

3) The measurement of domestic violence, and the accuracy of its reporting, are both fraught with problems, and much further work is needed in this area. The choice of measures and the methodology used to establish the prevalence of domestic violence have significant impacts on the prevalence rates there are reported [58]. Face-to-face interview methods yield more disclosures of violence than self-reported or telephone interviews, in accordance with previous research indicating that the use of multiple and opened questions increases accurate reporting [59].

Written screening alone probably underestimates the prevalence of intimate partner violence [60]. The results indicate that prevalence of all types of violence has increased over time, despite the provision of legal services for victims of violence. International law, particularly the Convention on the Elimination of All Forms of Discrimination against Women [61] is a law without sanctions, so that its implementation can easily be avoided, and traditional interpersonal relationships within societies can continue to provide conditions which perpetuate the use of violence [62,63]. While this study has attempted to follow a rigorous protocol in the conduct of this review, it is still subject to a number of limitations. It may be prone to indexing bias, publication bias and reporting bias. The researcher’s ability to assess quality of the studies that were identified was limited by the methodological information provided in the published articles, some of which was incomplete.

Furthermore, Sian [64] explored in his study the prevalence of experiences of domestic violence among psychiatric patients. The review findings suggest a high prevalence of experiences of domestic violence among psychiatric patients. Among female patients, being a victim of lifetime partner violence was reported by about a third of in-patients and out-patients [65]. Only one high-quality paper reported the prevalence of being a victim of domestic violence among male patients. Chang, et al. [66] surveyed patients across a range of psychiatric settings and estimated that 18% had experienced lifetime physical partner violence and 4% had experienced lifetime sexual partner violence.

The review identified only six studies on the prevalence of violence perpetrated by family members, of which only two were of high quality: these two studies reported that 11% of a mixed sample of male and female psychiatric out-patients reported family violence [67], and that 9% and 6% of female in-patients reported adult lifetime physical violence by a father or brother respectively [65]. No study included non-psychiatric controls representative of the general population. Thus, although most of the reviewed studies reported higher estimates of the prevalence of domestic violence than have been reported for general population samples [68], quantifying the extent to which psychiatric populations are at greater risk of domestic violence remains difficult.

Lastly Onyinye, et al. [69] conducted a work on pattern of substance abuse among adolescent secondary school students in Abakaliki. The prevalence rate of substance abuse obtained from this study was 32.9% which is comparable to a previous study done five years prior in same environment that obtained a prevalence of 27.1%. In keeping with previous studies in south eastern Nigeria [70], alcohol was the most commonly abused substance. This finding, may be attributable to the availability of various brands of alcoholic beverages in the study area. However, reports from western [71] Nigeria showed that cigarette was the most commonly abused substance. The difference in finding may be due to cultural differences between the South Eastern, Northern and Western Nigeria.

It is pertinent to note that 47% of substance abusers, abused more than one substance. Substance abuse disorders therefore may be causing significant morbidity amongst our adolescent population. As a result, more efforts need to be exerted to bring the use and abuse of substances to the barest minimum. Substance abuse is more common among male adolescents. This is consistent with observed trend in Nigeria [2,72] and globally [4]. The reason may be attributable to the more adventurous nature of males especially during adolescence [73]. Cigarette and kola nut abuse were more amongst adolescents of lower socioeconomic class. The abuse of other substances did not show any significant association with socioeconomic class. This observation contrasts with the findings of [74] in Ilorin, and [75] in Ibadan, Western Nigeria. They reported that adolescents from upper socioeconomic class abused substances more than those from other socioeconomic classes. Abiodum, et al. [74] as well as Odejide, et al. [75] attributed this to increased availability of these substances to this class of adolescents based on costs.

The reason for the preponderance of cigarettes and kola nut abuse among the adolescents of lower socioeconomic class in Abakaliki may be economic. Kola nuts and cigarettes are cheap and readily available. The practice of giving kolanut as a sign of acceptance of a visitor among the Igbos could also account for a high prevalence of kolanut abuse in Abakaliki. Another possible contributing factor could be parenting style. Adolescents with permissive parents; and those whose parents abuse substance are more likely to abuse substances [73]. Parents of the lower socioeconomic classes have been reported to have less supervision of their adolescent students. This may make them vulnerable to negative peer influences at school [73].

Age of the respondent was found to be significantly associated with the abuse of cigarettes and alcohol. Most of the abusers were older and in the late adolescence. Ngesu, et al. [5] in Kenya and Okike [73] in Nigeria made similar observations. Older students have stayed longer in school, and therefore have been exposed to stronger and sustained peer influences. Adolescents found to be substance abusers were observed to have had their first use of these substances in early adolescence. This is because the use of substance has strong appeal for those beginning their independence as they search for identity [74-76]. Early adolescence is characterized by innate curiosity and thirst for new experiences. They are therefore susceptible to experimentation with drugs at this age [77].

Furthermore, because adolescents at this stage lack the knowledge of consequences of actions and self-will, they may progress from experimentation with substances to addiction in later years [75,77]. Adolescents who were orphaned were more likely to abuse cannabis and cigarettes while the abuse of cigarettes, alcohol, cannabis and kola nuts were more in adolescents from divorced homes. Similar findings of high prevalence of substance use and or abuse among students from dysfunctional homes have been reported severally in the literature [70,73,74]. This may be due to lack of discipline, poor supervision and poor personality development which is often associated with single parenting [74].

Frequent participation in religious activities may be a deterrent to substance abuse since there was a decreased proportion of abusers among those who participated frequently in religious activities. This may be due to the fact that adolescents who participate frequently in religious activities were preoccupied or that the teachings of the religion make it morally wrong for one to use or abuse substances. The objectivity of detecting recent substance use by urine testing in adolescents is undisputed, however this does not provide information about the adolescent’s history of substance use problems. More over some substances require quick assessment in order to detect it in the urine. It therefore supposes that self-report, especially when confidentiality is ensured and no legal contingency is attached, in describing pattern and factors affecting substance use and abuse is reliable. Studies carried out with self-report are cheap, easily accepted and the refusal rate has been found to be minimal.

The high prevalence rates of drug use and domestic violence experienced by people suggests that doctors practicing in all areas of medicine need to recognize and explore the potential relevance of violence issues when considering people’s reasons for presenting with ill health. Sensitization to the problem of domestic violence should be incorporated not only in medical training, but into governmental, legal, and judicial organizations. Inconsistences in methodology identified in the study emphasize the importance of developing clearer definitions so that findings can be compared across settings, to allow more accurate comparisons of prevalence rates over time, and between different population groups.

Future research should seek to recognize cultural differences in family functioning without necessarily viewing such differences as ‘deviant’ or ‘pathological’, and should recognize the complex nature of differences between and within ethnic groups. More concentrated and culturally sensitive research can lead to a clearer understanding of the scope and causes of violence against people, will lead to more effective preventive and intervention efforts. Practitioners and social service systems must continue to develop coordinated, collaborative, or integrated treatments that are gender-responsive, trauma informed, culturally attuned, and specifically designed to address the needs of domestic violence survivors. Finally, practitioners and researchers must consider factors beyond the individual level that will improve policy and practice and ultimately promote domestic violence survivors’ empowerment, healing, and well-being.

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