Introduction

Intimate partner violence (IPV) defined as “behaviour by an intimate partner that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviours” [1] remains a prevalent global health problem. Globally, an estimated 1 in 3 women will experience IPV and/or sexual violence [1]. Despite the growing recognition of violence against women, evidence to support best practices for responding to violence against women remains lacking [2, 3]. Further, questions remain as to whether sub-populations can access evidence-based IPV interventions and whether such interventions are effective in addressing IPV among these populations. In 2014, the 67^th World Health Assembly [4] called for health services to have a more impactful response to secondary prevention of IPV; however to meet this goal the gaps in understanding best practices for secondary prevention of IPV must be addressed.

High-income countries such as the United States (US) remain challenged with meeting health care needs of many of its underserved sub-populations, such as the Latina population. Latinas in the U.S, particularly immigrant Latinas, continue to have limited access to formal resources for IPV intervention. Examining which elements of interventions have demonstrated to decrease IPV among Latina women could inform health service responses in resource-constrained areas or high-income countries with growing immigrant populations, particularly Latina diaspora.

The Latino population is not only one of the fastest growing populations in the US (now constituting 18% of the US) but is also growing in Canada (National Household Survey, 2011), and increasingly Europe [5, 6]. The rapid growth of a young Latino population–particularly in the US [7] has drawn greater attention to IPV among Latina women. In the US, approximately a third of Latina women report a history of IPV [8]. Compared to non-Latina whites, Latina women are more likely to experience more severe adverse effects from IPV, such as depression low self-esteem, and physical ailments [9–11]. Not only the largest and fastest growing minority group in the US, the Latino population is also the youngest. Young adult Latinos comprise almost 20% of the general population of the 18–25 year age group–a historic proportion[7]. Further, compared to the majority white population, Latinos experience higher rates of adverse health outcomes often related to risk behaviors including unplanned pregnancy, sexually transmitted infections, and HIV infection—all of which have been shown to have IPV as a contributing factor [12]. Thus, this growing and vulnerable population warrants attention regarding interventions to promote healthy relationships and mitigate IPV.

Increasing women’s ability to plan for their safety in any setting—by assessing their risk and prioritizing safety strategies to reduce repeat victimization in violent intimate relationships—is important to increase safety and improve health outcomes.

Suggested contributors to IPV among Latinos include the following: immigration status, lower socioeconomic status, acculturation stress, and machismo—a cultural term used in Latin America to describe male domination in the relationship[13, 14]. These factors not only serve as risk factors for IPV, but also as barriers for women safely leaving their abusive partners. For example, qualitative studies have revealed that some Latinas hesitate leaving their abusers in keeping with traditional norms of staying in a marriage [13–15] and, among undocumented women, for fear that reporting their abuser would result in their own deportation [14]. In cases when women were ready to report the IPV to an authority or leave the relationship, English literacy and understanding the social, health, and legal systems can serve as significant barriers for safety. Researchers also suggest that Latinas who are less acculturated to the United States may be more likely to internalize negative emotions related to their abuse because of the cultural expectation to not express anger [10]. As such, Latinas (especially monolingual Spanish speakers) are more likely to negate the severity of abuse, less likely to use formal services to address IPV, and when they do eventually use formal services, it is after extended periods of experiencing abuse [11, 16].

Developing linguistically and culturally appropriate interventions geared towards empowering Latinas in decision-making about their safety as well as seeking help from informal and formal systems is a high priority. In an effort to develop an appropriate intervention for Latina survivors of IPV, Davila and colleagues learned from participants what the ideal intervention would entail [17]. Their suggestions include: (1) having an intervention that increased their knowledge about women’s health as well as IPV, (2) using talking circles and interactive activities to enhance learning and keep participants engaged, and (3) hosting sessions in locations that would not make their partners suspicious (i.e., participants suggested that hosting the interventions at churches or schools would be preferred over a clinic).

The aim of this review was to identify elements of successful interventions to address IPV among Latina women. This review highlights promising and best practices for IPV interventions among Latinas, and identifies critical areas for further research.

Method

Results

The literature largely addresses exploratory studies and predictors of IPV among Latino populations. A total of 1,132 articles were identified (Fig 1), while 4 met the study inclusion criteria [20–23]. The majority of the articles were excluded because there was no intervention and no measure of IPV. The selected study characteristics are presented in Table 1.

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Fig 1. PRISMA Flowchart for selection of eligible research articles for this systematic review of effective interventions for decreasing intimate partner violence (IPV) among Latina survivors.

https://doi.org/10.1371/journal.pone.0160518.g001

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Table 1. Overview of Interventions in Systematic Review of Effective Interventions for Decreasing Intimate Partner Violence among Latina Women.

https://doi.org/10.1371/journal.pone.0160518.t001

Discussion

This review has identified that in spite of the magnitude of IPV as a public health problem and documentation of the problem within the diverse Latino population, prevention and response interventions are sparse. Our systematic review for effective interventions for Latinos retrieved only four interventions. Only one study focused exclusively on a Latina population [22], one study targeted survivors of IPV [20], and one focused on the couple dyad involved in the IPV [23]. We did not identify any interventions with positive outcomes for IPV prevention specifically targeting Latina survivors of IPV.

Among the four studies, there was heterogeneity in the quality of the studies, setting, content, and delivery of the intervention precluding meta-analysis. Given such variation, it is challenging to make comparisons related to essential elements for promising or best practices for IPV prevention and response interventions with Latinos. Nonetheless, there were some commonalities in the three interventions that reported reduced IPV in the intervention groups compared to control group. These three studies were all grounded in a theoretical framework [21–23], and involved multiple sessions; for example, two of the studies delivered the intervention in a group setting [22, 23]. Indeed, group sessions have been shown to increase self-awareness, feelings of empowerment, and also create a form of peer support [24, 25]. According to social cognitive theory, improvements in self-awareness, empowerment, peer support, and self-efficacy are all critical elements for behavior modification [26, 27].

Another commonality between the interventions was a focus on improving relationships with one’s partner and/or family members [21–23]. The SEPA intervention in particular focused on increasing sexual communication between couples[22]. The researchers of SEPA recently conducted analyses to evaluate whether partner communication contributes to reductions in IPV [28]. Their findings revealed that greater partner communication was associated with less male-to-female IPV. In other words, the potential “mechanism of action” of the intervention was the emphasis on healthy communication strategies. Participants in the other study interventions [21, 23] may have also learned about healthy communication and strategies to reduce conflict and thereby IPV.

Even though McFarlane and colleagues (2006) found that the 20-minute nurse intervention was almost as effective as providing a referral card, this finding is still useful. In this study both the control and intervention group received information about community resources. In a study that explored differences between women who sought formal services and those who did not, the main finding among the Latina women who did seek services was that they were informed about the available bilingual services for survivors of IPV [16]. Some of these women remarked that if no one had ever told them about such social services they never would have known and perhaps never have left the abusive relationship. In essence, in some cases, merely informing survivors of IPV about available resources can be an intervention.

Only one study was explicit about the effects of the intervention on different types of IPV [20]. Of the studies that used the CTS to measure IPV, one used the physical abuse items only [22] and the other two did not parse out how the interventions may have affected different types of IPV. When considering safety and psychological well-being of the participants, it would be important to know whether an intervention has an effect on diverse forms of IPV, including physical and sexual IPV and psychological abuse. Such a finding would have important implications for modifying the intervention as appropriate. For example, psychological abuse not only has adverse mental health effects, this type of IPV is also less likely to be reported [29] and may be more difficult to address through safety planning and other intervention strategies [30].

Although all of these studies included large proportions of Latinos, none of the investigators discussed how the intervention was tailored for the population. Only two studies described how they accommodated non-English-speaking participants [20, 22]; this included providing written materials in Spanish; however, there was no mention of including specific cultural values/practices in the intervention; for example, familismo (the belief of loyalty and respect for the family, and considering the family when making decisions about one’s life) [31]. This concept has been shown to influence how survivors of IPV make decisions about their relationship and safety, such as help-seeking behavior and confiding in family or friends [16]. Including such cultural values may have furthered our understanding about how including these values could yield more positive outcomes.

The level of acculturation in relation to effects of the intervention was also not explored in these studies. Acculturation was measured in two of the studies only to describe the sample [20, 22]. Given that the evidence that the level of acculturation is associated with IPV perpetration and safety strategies used by survivors [10, 32], it would be useful to know whether certain elements of an intervention are more appropriate with high or low-acculturated Latinas. The studies that included both Latinos and non-Latinos did not disaggregate the data to show whether there were any interaction effects of treatment and acculturation on IPV outcomes, such as reduction in physical or sexual violence.

None of these studies included bystanders or family members in the intervention. Although the study by Olds allowed for involvement of family members, the consistency of family inclusion and effect on IPV was not addressed [21]. Women’s perception of how family and community respond to IPV influences their help-seeking behaviors. At the same time, community members and family sometimes opt to “not get involved” in helping survivors out of concern for their own safety, belief that the survivor is at fault, and also because they are unaware of how to help [33]. Influencing social norms about IPV will be a critical component of primary and secondary prevention of IPV within the Latina community.

Despite the growing body of literature documenting the predictors, complexity, and survivor experiences of IPV among Latinos [10], evidence on how to address the problem is lacking. There are likely many challenges both researchers and community members may need to overcome in order to develop effective prevention and response interventions with Latinos. For example, in developing a culturally tailored intervention for sexual risk behavior, researchers encountered myths about why Latinos would not participate in such interventions, such as “Latinos won’t wear condoms because they are too macho” [34]. Similarly, when community members and service providers were interviewed about barriers to IPV interventions, they also reported “cultural barriers,” such as acceptance of IPV and desire to keep the family together [33]. At the same time, studies have demonstrated that these factors need not be considered as barriers but rather “cultural values” to include in intervention content [25, 34].

Using expert recommendations [35], the development of effective interventions for Latina IPV survivors will require a collaborative process. Coproduction of interventions by researchers with community members and survivors will facilitate better understanding of the problem, as well as how to work with “cultural barriers.” Building on Davila’s work [17] and others who have explored survivors’ suggestions for IPV interventions [29, 36], collaborative intervention development, implementation, and evaluation will most likely result in a community-driven, culturally, and linguistically appropriate intervention for the target population.

While this review focused on a Latina population in the US, our findings remain relevant for other immigrant populations across the globe. Developing interventions for IPV survivors that facilitate overcoming barriers such as language, culture, and family values are relevant to the many migrant populations seeking services for any health issue, including one as complex as IPV. Theory-driven and evidence-based solutions are critical to developing sustainable programs and long-term impacts for secondary prevention of IPV regardless of the setting in which it occurs.

Regardless of the target population, interventions guided by theory have been demonstrated to be more effective than those without a theoretical foundation [27]. Theoretical frameworks are tested models that can help the researcher understand antecedent and moderating factors and consider concepts that may be relevant to the phenomenon of interest. The use of theoretical frameworks can help researchers approach a problem with a more comprehensive perspective and best identify points of intervention. Interventions are more likely to be successful if they are developed in partnership with the target population, those who understand the context of the problem, and use behavioral change strategies that align with the norms of the target population [27, 35]. In other words, tailored and culturally appropriate interventions are most successful for changing health behaviors [37].

Conclusion

In spite of the documentation of the burden of IPV in Latino populations, solutions are less apparent and, as this diaspora increases in the US, effective interventions are critically needed. This review emphasizes the importance of developing and implementing interventions that are tailored and targeted to the needs of the Latino population. Targeting theoretically derived interventions that are gender specific, culturally appropriate, enhance mutual support through group dynamics, and that are developed collaboratively with the target population are likely to be most effective.

Supporting Information