Program Profile: Routine Inquiry About Violence Victimization and Follow-Up Support (Sweden)

This is a program for young women in nonemergency health centers in Sweden. It involves routine inquiry about their experiences with violence victimization and offers empowerment strategies for victimized women. The program is rated Ineffective. There were no statistically significant differences between the intervention and control groups in self-reported measures of physical violence, sexual violence (touch or penetration), and emotional violence at the 12-month follow-up.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Youths victimized by violence are at risk for numerous adverse health outcomes, but previous research has found that young people rarely reveal violence victimization to health professionals if not directly asked (Ashley and Foshee 2005; Black et al. 2008; Crisma et al. 2004). Because of the prevalence of violence victimization among youth and its association with poor health, regular inquiry and subsequent interventions for victimized youth in healthcare settings have been recommended (Palm et al. 2020).

In Sweden, almost all municipalities have youth health centers staffed by midwives, social workers, and physicians that offer 15- to 23-year-olds counseling on sexual and reproductive health and for social, psychological, and physical problems. Young women account for about 90 percent of the visits (Palm et al. 2020). These health centers serve as the setting for routine inquiry about violence victimization, with interventions for those who report victimization. The goal of the program is to routinely ask youths structured questions about violence victimization and offer them subsequent support to improve health outcomes and reduce revictimization.

Program Components

Youths who visit the health centers are asked structured questions about prior experiences of violence victimization. For youths who report victimization, a midwife or social worker employs empowerment strategies (Chang et al. 2005; Feder et al. 2006; Tiwari et al. 2005). Empowerment strategies include listening to the participant’s story, taking in and accepting the participant’s perceptions and feelings in a nonjudgmental way, and emphasizing that violence is never the victim’s fault (Tiwari et al. 2005). The midwife or social worker also addresses safety issues and contacts social authorities when considered necessary. All participants who experience violence victimization are also offered further counseling.

Key Personnel

Midwives and social workers at youth health centers conduct the routine inquiry and deliver subsequent empowerment strategies and counseling. All personnel at the health centers participate in education sessions on violence against youths and women. Action plans for personnel on how to handle victimized youth are well established at all youth health centers.

Study

Palm and colleagues (2020) conducted a randomized parallel controlled design to assess the effectiveness of routine inquiry about violence victimization and follow-up support on self-reported physical, sexual, and emotional violence in young women in health centers in the county of Västernorrland, Sweden, at the 12-month follow-up.

All youths ages 15 to 22 coming for their first visit to one of the four youth health centers during the period of Jan. 1, 2012, to Dec. 31, 2012, were asked to participate. In one of the youth health centers, participants were included until June 10, 2013, because of a lack of staff at the beginning of the study period. Possible participants were privately informed about the study orally and in writing by a midwife or social worker, and oral informed consent was obtained. In Sweden, consent from parents or guardians is not needed for a youth older than 15 to participate in a study, as long as the youth is considered able to fully comprehend the information. Exclusion criteria included severe mental disease, intellectual mental impairment, and inability to understand written Swedish. The eligible youths who agreed to participate were randomized into the intervention group or the control group through a random allocation sequence procedure. A total of 1,051 young women consented and were enrolled; of these, 565 young women answered the 12-month follow-up questionnaire (n = 280 in the intervention group, n = 285 in the control group) and were the focus of the analysis. A very small number of young men participated in this study (n = 86); therefore, only the young women’s results were reported on.

The participants assigned to the intervention group were asked structured questions about violence victimization by the midwife or social worker during their regular visits. For the participants in the intervention group who had been violence victimized, the midwife or social worker employed empowerment strategies. The participants in the control group had a regular visit with a midwife or social worker who attended to the specific reason for the visit. Violence victimization was not generally addressed, but these participants answered the same questions about violence victimization in a questionnaire after the visit. A questionnaire including the questions on violence victimization was then administered to the participants in both the intervention and control groups by mail, email, or cellphone text message, at 3 months and 12 months after the baseline.

To assess lifetime violence victimization, five structured questions were used in the health dialogue interview for the intervention group and in the questionnaire for the control group. Four questions were modeled on the NorVold Abuse Questionnaire: 1) “Have you ever experienced being repressed, humiliated, or threatened?” 2) “Have you ever experienced physical abuse (e.g., been slapped in the face, hit with fists or kicked, or had a weapon used against you)?” 3) “Have you ever experienced being touched against your will on your body or genitals, or been forced to touch someone else’s body or genitals, or has anybody used your body to satisfy himself or herself?” and 4) “Have you ever experienced someone, against your will, putting or trying to put his penis, or something else, into your (vagina), mouth, or rectum?” A fifth question was added about witnessing family violence: “Have you ever seen or heard an adult in your family hurting someone in your family?” with three options on the individual: a) “parent,” b) “stepparent or mother’s or father’s partner,” and c) “another adult in the family.” After each question, the participant, if victimized, was asked to mark on a Visual Analogue Scale of 0 to 10 to what extent they were still adversely affected by the violence (0 = not at all, to 10 = very much). In the 3-month and 12-month follow-ups, a question about the person who perpetrated the crime was added for each of the five questions on violence, worded as “By whom, mark all answers that apply to you” with the options: a) “parent, sibling, or other relative”; b) “stepparent or mother’s or father’s partner”; c) “partner or ex-partner”; d) “friend, schoolmate, or acquaintance”; and e) “unknown.”

The full sample of young women who completed the 12-month follow-up questionnaires were on average 18.2 years of age. Of the young women in the intervention group, 53 percent reported any lifetime violence victimization at baseline (“violence-victimized”), versus 60 percent in the control group. This difference was not statistically significant. Forty-five percent of the violence-victimized intervention group reported two or more types of violence victimization (emotional, physical, sexual-touch or sexual-penetration violence), compared with 55 percent of the control group. The most commonly reported type of violence was emotional violence (78 percent of the violence-victimized intervention group, and 82 percent of the violence-victimized control group) perpetrated by a friend or acquaintance (60 percent of the violence-victimized intervention group, and 65 percent of the violence-victimized control group). There were no statistically significant differences between the violence-victimized intervention and control groups at baseline on any of the outcomes of interest.

To determine differences in the outcomes of physical violence, sexual violence—touch, sexual violence—penetration, and emotional violence victimization over the 12-month follow-up period between the intervention group and the control group, generalized estimating equations were performed. Subgroup analyses were conducted with the 147 young women in the intervention group and the 171 in the control group who reported experiences of violence victimization at baseline.

Two of the study researchers visited all four youth health centers every second month during the study period, to ensure the interventions were consistently carried out (Palm et al. 2020).

Subgroup Analysis

Palm and colleagues (2020) conducted subgroup analyses with young women who reported violence victimization at baseline in the intervention group (n = 147) and subsequently received empowerment strategies from health center staff, and those who reported violence victimization at baseline in the control group (n = 171). There were no statistically significant differences at the 12-month follow-up for young women in the violence-victimized intervention or control subgroups on emotional, physical, and sexual violence (touch or penetration) victimization.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Ashley, Olivia Silber, and Vangie Ann Foshee. 2005. “Adolescent Help-Seeking for Dating Violence: Prevalence, Sociodemographic Correlates, and Sources of Help.” Journal of Adolescent Health 36:25–31.

Black, Beverly M., Richard M. Tolman, Michelle R. Callahan, Daniel G. Saunders, and Arlene N. Weisz. 2008. “When Will Adolescents Tell Someone About Dating Violence Victimization?” Violence Against Women 14(7):741–58.

Chang, Judy C., Patricia A. Cluss, LeeAnn Ranieri, Lynn Hawker, Raquel Buranosky, Diane Dado, Melissa McNeil, and Sarah H. Scholle. 2005. “Healthcare Interventions for Intimate Partner Violence: What Women Want.” Women’s Health Issues 15(1):21–30.

Crisma, Micaela, Elisabetta Bascelli, Daniela Paci, and Patrizia Romito. 2004. “Adolescents Who Experienced Sexual Abuse: Fears, Needs, and Impediments to Disclosure.” Child Abuse and Neglect 28(10):1035–48.

Feder, Gene S., Madeleine Hutson, Jean Ramsay, and Ann R. Taket. 2006. “Women Exposed to Intimate-Partner Violence: Expectations and Experiences When They Encounter Healthcare Professionals: A Meta-Analysis of Qualitative Studies.” Archives of Internal Medicine 166(1): 22–37.

Tiwari, Agnes, Wing Cheung Leung, Tak Yeung Leung, Janice Humphreys, Barbara Parker, and Pak Chung Ho. 2005. “A Randomised Controlled Trial of Empowerment Training for Chinese Abused Pregnant Women in Hong Kong.” BJOG: An International Journal of Obstetrics and Gynaecology 112(9):1249–56.

Following are CrimeSolutions-rated programs that are related to this practice:

Advocacy Interventions for Women Who Experience Intimate Partner Violence

This practice uses advocacy interventions to empower women who have experienced intimate partner violence. The goals of advocacy interventions include helping abused women to access necessary services, reducing or preventing incidents of abuse, and improving women’s physical and psychological health. The practice is rated Ineffective for reducing physical abuse. (This Practice was originally rated Promising. See “Other Information” in the practice profile for further discussion of that change).

Evidence Ratings for Outcomes

Victimization - Domestic/intimate partner/family violence

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?