Domestic Violence in BME Communities

CHAPTER 1: BACKGROUND TO THE REVIEW

1.1 Introduction

This chapter provides an introduction to the review by examining the context of domestic violence and abuse (DVA) within the Black Minority Ethnic (BME) group. In addition, this chapter also outlines the review objectives and the Health Visitors’ (HVs) perception in responding to DVA within the BME communities. Although family is perceived as safe haven historically, this has not been the case for DVA victims facing violence within the home (Office of National Statistics (ONS), 2018). DVA has social costs because incidence of domestic violence can also impact children through co-occurent domestic violence and child abuse (Jouriles, McDonald, Smith Slep, Heyman, & Garrido, 2008). Violence may extend to the children through either abusive or victimised partner (Mahoney, Donnelly, Boxer, & Lewis, 2003). Children who are exposed to DVA may also act with violence towards their peers at school (Drewes, 2008); or grow up to perpetrate domestic violence (Bancroft, Silverman, & Ritchie, 2011). DVA also has economic costs; in 2017 an estimated £66 billion was direct and indirect costs of DVA; £34 014 was the cost per individual victim (Home Office, 2019). DVA can also result in loss of productivity as victims are less likely to maintain stable employment (Home Office, 2019). Therefore, DVA is also a financial burden to society with serious social costs.

1.2 Why is it important to explore DVA disclosure amongst BME women

Women are identified to be at higher risk of DVA compared to men mainly due to cultural gender norms such as patriarchal structures and economic dependency (Refuge, 2019; ONS, 2019; Walby and Towers, 2017; WHO, 2017). DVA has also been identified to have detrimental effects on family. Children who witness DVA may suffer emotional distress, sleep disturbances, exhibit bullying behaviour and demonstrate poor school performance (Das, 2012; Manton, 2015). CAADA (2014) states that 62% of children living in household with DVA were also physically hurt by the perpetrator. The psychological effect of DVA on the mother may have a negative influence on her ability to buffer her children from abuse and affect parenting (Moylan et al, 2010; Litherland, 2012). Although the bond or communication between mother and child is one of the protective factors in children’s response to traumatic stress (Moylan et al, 2010), research indicates that victimised mothers may also show a co-occurrence phenomenon of abuse as an abusive parent (Coohey, 2004). DVA has significant adverse health consequences to the victim and to other family members (Peckover, 2014). These consequences include physical injury, sexually transmitted diseases, premature birth, low birth weight, suicide, depression, death from homicide, unplanned/unwanted pregnancy and abortion (Ogunsiji, Foster and Wilkes, 2016; WHO, 2013). DVA affects 1 in 3 women in the UK; in 2018, 1.3 million women experienced domestic violence in England and Wales (ONS, 2019). Moreover, in 2016 two women were killed each week in England and Wales by their former or current partner (Refuge, 2019). WHO (2013) reports that globally, perpetrators of one-third of female murders are their intimate partners. Government has nevertheless, cut down on services which provide early intervention support in DVA (Siddique, 2018; Ogunsiji, 2016; Sandhu and Stephenson, 2015). This may in part be related to the problem of nondisclosure of DVA as the actual incidence of DVA remains a ‘grey area’ or dark horse (Izzidien, 2008); and the legal and social measures to help victims are not being pressed into action. In the case of BME women, reasons for nondisclosure are also related to cultural factors, which make it important to explore the issue further from a BME context (Izzidien, 2008).

What is Domestic Violence and Abuse?

Home Office (2019) defines DVA as “any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality”. The term may be used in a broad sense to includes the violence perpetrated by other family members as well (Menton, 2015; World Health Organisation (WHO), 2013). There are different forms of DVA which include: psychological, physical, isolation, sexual, financial and emotional abuse, female genital mutilation, forced marriage and child to parent violence (Home Office, 2019). Kenney (2011) warns DVA can be complex to identify as not all DVA has visible signs. Therefore, Public Health workers have a crucial role in recognising and responding to victims of DVA.

Domestic Violence and Abuse trends

Most abusive relationships tend to follow a cyclical pattern and the changes between stages are subtle and vary depending on the nature of the abuse (Dugan and Hock, 2013). This disguises the abusive relationship unless extreme in nature (Dugan and Hock 2013). Walby and Towers (2018) identify DVA as severe form coercion which is influenced by gender inequality. Coercive control is “an act or pattern of acts of assault, threats, humiliation and intimidation or other abuse used to harm, punish or frighten the victim” (Women’s Aid, 2019). It can compromise victims’ well-being because abusers use it to instil fear and compliance (Stark, 2010; Women’s Aid, 2019). DVA perpetrators usually intimidate and destroy their victim’s sense of value utilising a set of behaviourism to form a framework of power and control over their victims (Abramsky, et al., 2011; Woodhouse & Dempsey, 2016). The methods used by perpetrators to lure their victims mainly involve power and control (Duluth, 2017). The Duluth model is identified as an effective DVA intervention but has also attracted criticism because it was developed with the scope of reducing DVA to women perpetrated by male partners and not vice versa and because it was developed without keeping in mind the minorities or their specific social and cultural conditions (Bohall, Bautista and Musson, 2016).

1.3 Health Visitor’s role in recognising and responding to DVA

HVs are registered nurses/midwives with a Specialist Community Public Health Nursing (SCPHN) qualification (Nursing and Midwifery Council (NMC), 2004). HVs’ central role is to ensure that every child and young person has the best start in life through assessing and providing appropriate interventions as per assessment outcome and they work in partnership with the parents/carers, statutory and non-statutory agencies (Institute of Health Visitor (IHV), 2019). Safeguarding and Child Protection are core activities of health visiting, and HVs are well placed to undertake this role (Eynon et al, 2012; Bradbury-Jones 2015; Luker, McHugh and Bryar, 2017). HVs are amongst the frontline staff who have opportunities to identify DVA manifestation when visiting families for routine service provision (NICE, 2016). In 2005, National Health Service (NHS) introduced routine asking of DVA by Health professionals (NICE, 2014). This practice was aimed at enabling healthcare professionals to challenge DVA, empower the victim and simultaneously reduce health inequalities (Bradbury-Jones, 2015). However, this phenomenon is contested due to HVs lack of knowledge and understanding of the link between DVA and the influence of race/culture in uncovering DVA in BME communities (Bradbury-Jones, 2015). Donetto el al, (2013) also criticise health professionals including HVs for failing to identify the nature of DVA among BME women. Another finds that victims are reluctant to engage with the plans and this continues to be challenging to safeguard children (Birmingham City Council, 2009). Hence the rationale for undertaking this review.

1.4 Why DVA amongst BME women should be addressed?

Black Minority Ethnic (BME) is a terminology used in the United Kingdom to describe people from a non-white descent, for example, Black Africans, Asian and Afro-Caribbean’s (Institute of Race Relations (IRR), 2019). BME communities are identified to have higher levels of abuse driven suicide and honour based killings (Siddiqui, 2018). Although BME is not a homogeneous group with the same identity, culture, belief and values, they do share everyday experiences of discrimination in UK (Sandhu and Stephenson, 2015). In the UK, there are a few studies which explore DVA disclosure amongst the BME population (ONS, 2019). Hague et al (2010) and Femi-Ajao, Kendal and Lovell (2018) conclude that there is need for more research to provide insight on the experiences of BME women around DVA. Similarly, Siddiqui and Patel, (2010) and Rehman et al, (2013) demonstrate how national discriminatory policies and practices within statutory agencies often exclude the experiences of BME women. In 2011, an estimated 13% of the UK population was from the BME group and this figure was projected to rise to 30% by 2050 (ONS, 2015). Therefore, a gold standard systematic review was deemed essential in order to ensure that DVA is being identified, responded to by professionals and support services which are tailored to the needs of BME women are provided (ONS, 2015). Furthermore, the findings of this study would aid in identifying and addressing possible hinderances in the way of reporting DVA. Non-disclosure is not only limited to BME community, it is a condition that is found amongst majority of DVA victims (Bradbury-Jones, 2015). Taylor et al (2013) suggest that victims of DVA conceal their abuse to professionals due to fear and confidentiality reasons. Femi-Ajao (2018) and Siddique (2018) suggest that BME women are often subject to intersectional discrimination which may also hinder their ability to seek help as intersection between gender, race, and class can play important roles in how women experience and respond to DVA (Marchetti, 2008 ). Intersectional approach has come to be increasingly adopted by feminists to domestic violence with a focus on social justice and need to explore intervention options (George & Stith, 2014).

HVs may make stereotypical assumptions related to DVA disclosure despite national guidelines to support practitioners’ decision-making in DVA interventions (Taylor et al., 2013). Most HVs appear to struggle with the complexities that dominate BME women’s lives around DVA experience (Siddiqui, 2018). Several studies have highlighted the importance of improving practitioners’ understanding of BME women perceptions around DVA and disclosure (Stockman, Hayashi and Campbell, 2015: Vanda, 2010). National guidelines available on encouraging DVA disclosure may not be appropriate for BME women and increased cultural awareness is vital to supporting BME women (Vanda, 2010). NICE (2014) encourages professionals to tailor their support to meet the needs of the DVA victim but Ruggieri et al. (2013) report that health professionals fail to identify DVA victims because they lack expertise in assessing and psychologically understanding victims of DVA.

1.5 What is the current state of knowledge?

Studies suggest that BME women are disproportionally affected by DVA compared to their white counterparts (Women’s Aid, 2015; Izzidien, 2008). BME communities having a higher number of immigrant women also indicate prevalence of socio-economic factors that make it difficult for women to access help (Menjívar & Salcido, 2002). Immigrant BME women are more vulnerable because there have limited access to resources, limited knowledge of law and may have language barriers (Erez, et al., 2009). Thus, BME women are more likely to face barriers accessing DVA support services (Stockman, Hayashi, Campbell, 2015: Walby and Towers, 2018). ONS (2019) identify DVA as a complex public health concern which makes it challenging to ascertain its actual statistics. The figures of DVA occurrence are grossly underestimated in general; and BME women may only seek support for severe violence (Ogunsiji, 2016). In 2017, total number of reported BME victims was 9.6%, while it was 87.8% for white women (ONS, 2019). Refuge (2019) states that only five out of 100 DV incidents are officially reported. Still, very little is known about the extent and nature of DVA amongst the BME community (Femi-Ajao, 2018). Knowledge of contextual risk factors to DVA such as cultural beliefs and social norms is limited as is our understanding of what constitutes appropriate prevention and intervention strategies for BME victims (Bradbury-Jones, Clark and Taylor, 2017).

1.6 What are the gaps in the current knowledge?

DVA is sometimes a life-long issue for some BME women as they are reluctant to seek help due to higher social acceptance of DVA within their culture (Ogunsiji, 2016). BME women may not report DVA due to their cultural values requiring domestic issues be kept within the private domain, or fear of racist response from professionals (Women’s Aid, 2015; Ogunsiji, 2016; Femi-Ajao 2018). Some BME women may not understand what constitutes DVA (Das, 2012; Hague et al, 2010; Women’s Aid, 2015). The Ending Violence Against Women and Girls Strategy (2016-2020) identifies raising awareness of DVA through educating women and girls as a preventative measure to combat DVA (HM Government, 2016). Most BME DVA victims are dependent on their partners for income and may experience social exclusion such as inadequate housing, poverty, lack of access to education and unemployment (Vanda and Wellock, 2010). Walby and Towers (2018) write that economy has a significant impact on DVA, as evident in the 2008 economic crisis when the numbers of domestic violence crime escalated. ONS (2019) notes that women whose immigration status is dependent on their marriage are predicted to be most likely to experience DVA. The Domestic Violence Concession Rule 289A (2002) enables victims of DVA who entered the UK on a spousal visa to apply for Indefinite Leave to Remain (ILR) if they can prove that DVA is the reason for their relationship breakdown (Anitha, 2011). Furthermore, Destitution Domestic Violence (DDV) concession allows victims of DVA to apply for access to public funds (Home Office, 2019). Even though these policies are in place, not every BME woman is aware of how to access the support (Haque et al, 2010; Wellock, 2010, Burchill, 2011). NICE (2016) has introduced quality standard with key recommendations and guidance for frontline staff to improve their care provision to DVA victims (NICE, 2016).

1.7 Aim and objectives

In order to conduct a well-focussed literature review, it was essential to start with a clear research question (Aveyard 2019). The PICo (Population Interest Context) framework was utilised to guide the question formulation as it enables a more exploratory analysis of the phenomenon compared to PICO (Population Intervention Comparison Outcome) which is mainly used for quantitative questions (Wakefield, 2014). The aim of this integrated review was to conduct a structured comprehensive literature review on BME women’s experiences around DVA and disclosure. The review gave insight in this area and provided knowledge base of DVA amongst BME women. The objectives of the review were to explore:

Factors which influence the majority of BME women experiencing DVA to not seek help;

DVA impact on BME women and children;

Methods through which HVs can encourage help seeking.

1.8 Chapter summary

BME victims’ experiences may be different due to cultural factors and problems of accessing services. These factors are likely to make disclosure by BME women difficult. Given the complexities around DVA disclosure amongst BME women, exploring and understanding their perceptions around their experience is intrinsic for development of support services for BME communities.

1.9 Conclusion

DVA is a violation of the victims’ human rights and depicts gender inequality. DVA undermines health, dignity and autonomy of victims, yet it remains masked in a culture of silence. Most DVA against BME women is deeply rooted in traditions that value men more than women.

Chapter 2: THE INTEGRATED LITERATURE REVIEW

2.1 Introduction

This chapter examines the available literature on DVA amongst BME women. The factors which hinder DVA disclosure among BME women were discussed in Chapter 1. In order to provide a comprehensive understanding of the study topic, a qualitative systematic approach has been utilised to identify available literature. Qualitative approach provides exploratory analysis of human behaviour and it is also an important evidence base for nursing research (Lipp and Fothergill, 2015). An integrated literature review is a comprehensive methodological approach of reviews that provides synthesis of knowledge and allows inclusion of experimental and non-experimental studies to fully understand a phenomenon (Aveyard, 2014; Tavared de Sauza, Dias de Silva and de Carvalho, 2010). It enables the reviewer to create new knowledge and identify gaps in research (Torraco, 2016). Moreover, it allows us to “collate all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question” (Green, et al., 2011, p. 6). Conversely, literature reviews are criticised for yielding misleading information and missing literature (Moule,2018). Therefore, literature searching skills need to be robust in order to identify all relevant literature (Bettany-Saltikov and McSherry, 2016). Literature reviews can be highly credible when process is followed for identification, selection, appraisal and synthesis of high quality literature (Bettany-Saltikov, 2012, p. 5).

2.2 Search strategy

The search strategy is a predefined plan for literature searching which enhances rigour of literature review by minimising incomplete and biased searches which result in potentially inaccurate outcomes (Whittemore and Knafl, 2005; Aveyard, 2014). An extensive systematic search yields up to date evidence and minimises publication bias (Parahoo, 2014). Bettany-Saltikov and McSherry (2016) warn that negative results are not always published as much as positive results in journals therefore wide literature search strategy is pivotal in yielding unbiased results. The databases used to identify relevant literature included: CINAHL, University Liabrary Search, Medline, SocIndex and Nursing and Allied Health Service. These databases were deemed appropriate as they are relevant for nursing research (Halcomb and Fernandez, 2015). Computer databases are criticised due to indexing problems which may only yield 50% of the eligible studies (Knafl, 2005). This problem was somewhat addressed in this research by using multiple databases so that missed studies in one may be yielded in the others. Systematic search strategy was performed utilising keywords and Boolean operators (see table 1). The use of appropriate search terms is key to identification of relevant literature (Parahoo, 2014). Boolean operator OR was used to expand the search (Wakefield, 2014). A more focused search was undertaken using the keywords and Boolean operator ‘AND’ to narrow the search (Wakefield, 2014). Comprehensive search of literature included hand searching of journals (Aveyard, 2019; Halcomb and Fernandez, 2015). English papers worldwide including studies conducted in America were analysed to ascertain if there were similar themes as identified in the UK. Furthermore, the search did not limit to full text only. In addition, researchers who conducted research on the similar topic were contacted to ascertain if were any other unpublished studies.

Inclusion and Exclusion criteria

Rigorous and transparently reported inclusion and exclusion criteria were utilised (Togerson, 2003 in Bettany-Saltikov and McSherry, 2016). This enabled the author to conduct a more focused literature search (Halcomb and Fernandez, 2015; Aveyard, 2014).

Inclusion Criteria:

All studies published in English.

Published during years 2009 to 2019.

Involving adult BME women who have experienced or are experiencing DVA.

Exclusion Criteria:

Studies not identifyig BME women experience around DVA.

Non-English language studies, editorials, historical studies and narrative reviews.

2.3 Search outcome and Study selection

To ensure transparency and complete reporting of the systematic review, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flowchart was utilised to document the process of identifying literature (Liberati et al, 2009). The PRISMA model is a widely accepted gold standard as it is transparent and enables an audit trail (Aveyard, 2019; Halcomb and Fernandez, 2015). The initial search from the databases using keywords ‘domestic violence’ yielded 9264 articles. 8841 articles were excluded after application of BME keywords. The second search yielded 423 studies published between 2010 and 2019. 372 articles where excluded for not meeting inclusion criteria. Three articles emerged through hand searching the reference lists of the included studies. The journal titles and abstracts of the 54 identified studies were reviewed. 48 articles were excluded as they did not meet the inclusion criteria. 3 of the articles excluded were duplicates. Majority of studies did not relate to BME women, hence were excluded. A total of 6 qualitative studies were finally selected based on the inclusion and exclusion criteria. See figure 1 for the literature screening process. This strategy minimised the risk of cherry picking literature (Aveyard, 2019). See appendix 1 for the description of included studies.

2.4 Quality Appraisal

Critiquing research enables feedback and improvement (Polit and Beck, 2017). Therefore, reviewing study quality is a vital component in evidence-based practice (Windle, Bennett and Noyes, 2011). A sifting process is recommended for selecting the most relevant articles based on quality and credibility of the articles (Bettany-Saltikov, 2012). Nevertheless, understanding the risk of bias on study results is challenging, because the compiled outcome is only a substitute of the actual study conduct (Leberati et al, 2009). Whittemore and Knafl (2005) claim that in an integrated review there is no gold standard for evaluating methodological quality. The quality of each study was assessed utilising the Critical Appraisal Skills Programme (CASP) tool, utilised as part of the qualitative systematic review process (Bettany-Saltikov and McSherry, 2016). CASP enables critical analyses of studies and is widely used in development of systematic reviews for evidence-based practice (Aveyard, 2019). Furthermore, CASP checklist has a specific tool for most studies (CASP, 2018; Aveyard, 2019). The CASP tool comprises ten questions which were used to appraise the qualitative studies, (see table 1).

2.5 Data extraction and synthesis

Data extraction process identified by Whittmore and Knofl (2005) was adapted. Data was extracted in an attempt to answer the review question (Bettany-Saltikov and McSherry, 2016). The process of data extraction included identification of key words and identification of factors influencing BME women experiencing DVA. The articles were read by the researcher in order to extract and synthesise data, and summarise the main points (Parandeh et al, 2016). As having one researcher analysing and synthesising data could diminish validity of the study (Parandeh et al, 2016), the researcher meticulously analysed the studies a few times in order to enhance rigour and ensure that important pieces of information were not missed during synthesis (Wakefield, 2014). In order to improve results’ validity, data extraction form was used (Bettany-Saltikov and McSherry, 2016). The study utilised thematic analysis recommended by Aveyard (2019) which involves breaking down relevant data into different modules and discussing how they relate with each other. The outcomes from data extracted from the studies were analysed in order to identify emerging themes (Aveyard, 2019).

2.6 Results

Themes identified from each study where collated with themes from other papers to identify common themes (Aveyard and Bradbury-Jones, 2019). Table 2 demonstrates the initial identification of themes from the data, including subordinate and emerging themes (Kiernan, Moran and Hill, 2016). One superordinate theme was identified: Barriers to DVA disclosure and three subordinate themes were: Acculturation; Social implications; and BME women perception of DVA.

2.6.1 Acculturation

All studies reported significance of cultural values to how BME women experience DVA (Hague et al, 2010; Wellock, 2010; Anitha, 2011; Burchill, 2011; Das, 2012; Femi-Ajao, 2018). Acculturation is a process of learning a new culture on migration (Organista, Marin and Chun, 2010). Changes following migration increase vulnerability which may lead to acculturation stress that may in turn result to increased risk of DVA (Millett, Seay and Kohl, 2015). Nagaraj et al, (2018) identify that acculturation is linked to both protective and risky health behaviours though further research is needed in this area for more clarity. Four of the studies identified acculturation as one of the barriers contributing to BME women’s help seeking behaviour. Hague et al, (2010) note that BME women struggle with DVA due to lack of information regarding their rights. Many BME women do not speak English and have difficulty trying to understand the social and legal system in the UK. In addition, Hague et al (2010) mention that BME women who have migrated to the UK felt isolated and depended on the husband’s or family’s support. Anitha (2011) noted experiences of recent migrant BME women of being ridiculed for not adapting to the English culture; this acted as a barrier to reach out to authorities or services. Burchill (2011) found that participants identified with prior family experience with DVA in country of origin and found it difficult to make cultural adjustments once in the UK with the notion that DVA was unacceptable. Femi-Ajao (2018) did not link acculturation to negative affect in help-seeking behaviour. However, prolonged acculturation process may affect women’s ability to secure employment and develop friendships making them more vulnerable and financially reliant on perpetrators (Femi-Ajao, 2018). In conclusion, learning a new culture can be challenging for BME women because prior family experience may normalise DVA and instil barriers for reporting it. Cultural backgrounds may affect BME women’s beliefs and attitudes towards their decision making around their DVA experience as demonstrated in 83% of the studies included (Hague et al, 2010; Wellock, 2011; Anitha, 2011; Burchill, 2012; Femi-Ajao, 2018).

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2.7.2 Social Implications

Social implication is a result of an action, beneficial or detrimental to individual (Ahmad, et al., 2013). Studies suggest that DVA disclosure was affected by a combination of overlapping issues triggered by the sociological impact of DVA encountered by BME women. Immigration is one of the factors which was found pivotal in inability to disclose DVA or seek help. The fear of being deported and losing children once marriage is over is a relevant factor (Haque et al, 2010). Women’s immigration status and lack of information regarding their rights exacerbate their fear and vulnerability which consequentially hinder their help seeking (Hague et al, 2010). Furthermore, inability to secure employment may hinder ability to leave abusive relationships when the victim is financially reliant on the perpetrator. Wellock (2010) identifies that family has influence in relationships and familial expectations regarding commitment to marriage even though it exposed them to abuse. Wellock (2010) further mentioned that familial expectation contributed to women’s vulnerability and also influenced ability to seek help. Moreover, most perpetrators utilise a mixture of controlling behaviours which might include isolation to instil fear in their victims (Bradbury-Jones, Taylor, Kroll and Duncan, 2014). Burchill (2011) states HVs’ experience with DVA victims that fear of losing home is an important factor. BME women who are trapped in the cycle of abuse due to their immigration status may have fear of losing home adding to problems of lack of resources and access to public funds (Burchill, 2011). Femi-Ajao (2018) asserts that lack of finances is exacerbated by the immigration status and race. Therefore, intersectionality of race, class and immigration status for the BME women is an important context that differentiates their experience of abuse from white British women making it important for professionals to be able to identify signs of DVA, ask about DVA routinely, offer advice and give information on local DVA support groups (Burchill, 2011; Bradbury-Jones, Taylor, Kroll and Duncan, 2014).

2.7.3 BME women perception of DVA

Historically, the father was seen as the head of the family within a patriarchal hierarchy and this cultural practice is evident in BME communities (Femi-Ajao, 2018 and Haque et al, 2011). Burchill (2011) mentions that immigrant BME women struggle to make cultural adjustments due to prior family experience of DVA and normalisation of wife battering. Furthermore, shame and embarrassment for leaving husbands is also a factor (Burchill, 2011). However, some participants sought help after changing their perception of what constitutes abuse following intervention (NICE, 2014).

2.8 Chapter Summary

In summary, the main factors which hinder disclosure include social implications are linked to economic and cultural values. Immigration status was identified to be a common factor amongst BME women who settle in UK on a spousal visa. In contrast for BME women who have settled status, cultural values affect the way DVA is experienced and whether or not it is reported. In the next chapter the overarching themes will be discussed at greater length.