In Australia, every 1 in 4 persons are affected by domestic violence, with Mildura ranking the second highest place for family violence in Victoria (Domestic violence resource centre Victoria, 2016). Domestic violence is a pattern of abusive behaviour through which a person seeks to control and dominate another person, in which they may have relations with. It is not only physical, but can take on many other forms including sexual, emotional, social, spiritual and economic abuse that can be equally harmful. Violence against women is far greater with 17 per cent of all women and 5 per cent of men experiencing violence by a partner since the age of 15 (Phillips, 2017). 85-90% of incidents of domestic violence occur with children present, and impacts over one million Australian children a year (Sutherland, 2015).

Victims suffer long term physical and psychological harm that can lead to negative behaviours such as drug and alcohol use, inherited grief and trauma, poverty and loss of traditional male and female role models within the community. Research has shown that the biggest contributor to domestic violence in regional Australia is the negative attitudes of men towards women, within a community that values traditional “patriarchal gender roles”, combined with increase alcohol consumption and the vulnerability of women and children (Sutherland, 2015). This essay will explore potential and past health promotion strategies for domestic violence that would be beneficial to implement within Mildura, how they align with the Ottawa charter, health promotion values and principles, and the contribution of occupational therapists.

Health promotion strategies

Mandatory school-based health programs

School-based programs provide the strongest “evidence of effectiveness” in relation to violence prevention programs (Flood, Fergus, & Heenan, 2009).  As a primary prevention plan, mandatory school based programs that take on a holistic approach through educating and advocating against domestic violence within both school and communities has demonstrated effectiveness in reducing family violence. Student-oriented activities including creation of DVD’s, rap songs and other forms of media that raise awareness of domestic violence can be presented at different community events. Students are not only educated about negative effects of domestic violence, but they are influenced to feel responsible to advocate against it through community displays of their school work. The Victorian Health Promotion Foundation identified two programs in particular that were successful in influencing and empowering students to reshape their attitudes about this issue (Flood et al., 2009).  “Positive Relationships and successful lives” ran by Mallee sexual assault unit, was conducted within a mainstream secondary college, a specialist school for students who have an intellectual disability, and a local Indigenous KODE school. Students participated in a range of media based activities, in which they presented at community forums. Flood, Fergus and Heenan (2009) depicted that this program was successful due to: allowing students and the community to work together to advocate against domestic violence, the inclusion of indigenous and specialist schools, and being “student-driven content” that could be used in other prevention programs across the states.

In addition, “solving the Jigsaw”, a program ran within schools of Loddon Mallee region educated children to ‘understand the role of power and control over others to the culture of violence.’ They were to identify types of power, abuse and violence and acknowledge how violence should not be kept a secret. Milne (2006) stated in her clinical review that it challenged society’s ideology e.g. gender issues, self-regard, culture of violence and providing confronting material that children can relate to. Children felt connected within the group, and at ease showing care to one another. It encouraged them to identify what actions were portrayed as “violent”, how to respond to situations and to speak out about their experiences. Both programs were successful in influencing students to view violence as unacceptable, and motivated them to seek help if needed.

Behaviour change programs

A behaviour change program that aims to change men’s patriarchal ideology that men can take control over women, through teaching them to respond differently to ‘trigger’ situations as well as counselling for alcohol driven domestic violence should be implemented in Mildura. Education and training can help perpetrators recognise their behaviour is abusive, and explore the use of non-violent strategies that promote intimate relationships built on respect, trust, and equality. A program in regional NSW called “Taking Responsibility”, has proven to have successful outcomes for men who wish to be better their relationships with partners and/or children. The program was evaluated using follow up interviews of men and partners of the men attending the program. Intended positive outcomes were achieved and expressed through quotations of the participants, and benefits included that men had learnt to change their attitudes towards women, and new ways to express their feelings instead of violence. Men felt they were accepted back by their partners which restored intimate partner relationships and strengthened family bonds. In addition, implementing cognitive-behavioural approaches has also proven successful in reducing alcohol related domestic violence. 53% per cent of women that have been physically assaulted by a male (in the past twenty years) reported that alcohol or drugs had been involved in their most recent incident (Phillips, 2017). Satyanarayana et al (2016) found that teaching cognitive-behavioral techniques including relaxation, anger management, assertiveness training and cognitive restructuring, is able to decrease alcohol consumption amongst men, and resulted in their partners having less depression, anxiety and stress from the DASS scores following intervention

Mixed gender community sports programs

A strategy that takes on a socio-environmental approach, is the use of well-known sports players to advocate against domestic violence through promoting positive relationships between girls and boys during mixed gender sports programs within the community. AFL football players can volunteer to participate within local football clubs to educate children about domestic violence, teaching them about what it is and why it is not acceptable, how to respond or avoid potential situations that could lead to violence, and access to help such as websites or phone lines. As children may view these players as role models, they will be more influenced to listen to them when out on the field.  An 8 week trial program called “Equal Playing Field” ran by the Rugby League used sport to minimise violence and assaults in less advantaged communities. This was first implemented for children in Papua New Guinea, and due to the high success rates, a school in Wollongong called Berkeley’s Illawarra Sports High decided to also run the program. As a result, there were many positive reviews from both students, parents and the community when the well- known rugby players volunteered to educate the boys and girls during games of rugby. The mixed gender teams were encouraged to show good sportsmanship and positive behaviour and actions towards each-other, and acknowledge that violence between men and women within the home is not acceptable (Huntsdale, 2017). A similar program called “Kicking goals for Healthy Relationships,” created through the partnership of VicHealth and the Australian football league also depicted to be successful in engaging local rural communities and football clubs to promote respectful relationships between men and women (Loxton, Hosking, Williams, Brookes, & Byles, 2008). Activities advocated and supported change in football club practises and policies to ensure safe, supportive and inclusive environments for women Both programs demonstrated the importance of using primary prevention interventions in highly masculinised environments (in this case sporting clubs), as boy’s attitudes are often shaped by other men they view as role models.

The Ottawa charter and related health promotion values and principles

The ability to ‘

create supportive environments’

and simultaneously ‘

strengthen community action’

is greatly shown in both Mandatory school based programs and community sports programs. These programs encourage people to care for each other through educating both students and the community to build healthy and respectful relationships with each other, and encourages change in attitudes towards domestic violence. This also strengthens the community actions as they are

’empowered

‘ to take ownership of these strategies such as advocating against domestic violence through displaying school work, or gathering at community sports events to advocate against domestic violence (The world health organisation, 2017). Through using methods such as education to empower youth to view domestic violence as unacceptable, both strategies align with Ottawa charter

‘reorient health services’

as they focus strongly on primary promotion and preventative measures rather than secondary/tertiary.

Establishing a policy where school based programs for domestic violence are made mandatory for all schools also aligns with

‘building healthy public policy’

. It also greatly ‘

respects cultural diversity’

as students and/or schools from different culturally backgrounds i.g the local indigenous KODE school can implement the program. The community sports program

‘mediates’

the ability for ‘

capacity building’

through collaboration and coordination of multiple parties within the community including local sports clubs and their teams, parents and AFL members. Therefore using pre-existing skills and resources within the community, not only encourages their

‘participation’,

but also ’empowers’ them to feel responsible for this program which will help it remain

‘sustainable’

in the long run.

The behaviour change program supports Ottawa charter

‘development of personal skills’

as it provides education and training for perpetrators of violence to develop skills, which

‘enable’

them to have more control over their actions, so that they can respond appropriately to triggers that in the past would result in violence. This program takes on a

‘holistic health’

approach through targeting perpetrators rather than the victims of domestic violence, in which far more programs for victims exist. Therefore, rather than focusing on treating consequences of domestic violence (i.e illness/injury) it takes into account the broader determinants of the people involved, such as their motivation for violence

Occupational Therapy and health promotion

Occupational therapists in Australia and worldwide can play a huge role in contributing to health promotion. They have the potential to raise awareness of domestic violence due to first- hand experience, however as there is little research available in occupational therapy literature, it is very difficult to single out ‘well-known’ health promotion strategies. Some researchers have realised this, and conducted a systematic review of past programs/interventions implemented by occupational therapists who worked with victims of domestic violence. Carlson and Streit (2010) found that O.T’s have worked in more secondary/tertiary prevention settings, and key areas where they have ‘added value’ in addressing domestic violence included advocating the importance of social support systems, providing training for emotional and financial troubles, as well as education on safety.

Ramsay et al (2009) and Gutman et al (2004) depicted the important of occupational therapists using advocacy to connect those who were experiencing or had experienced domestic violence with social supports around the community and giving them resources that can help them become independent. It was found that women who were able to use community resources to find shelters or programs where other women in similar situations were found, was beneficial in stopping or preventing domestic violence. Through providing a range of support systems women learn to become re-engaged within their daily occupations and increase community participation.

A stress management program for abused women promoted improvement in emotional well-being (Gutman et al, 2004). Women experience stress due to emotional issues surrounding the violence including feelings of helplessness and believing they deserved. Through learning strategies to manage stress, many participants were able to generalise learnt strategies outside the clinic, and increased their participation in previous activities that they were not able to do beforehand. Gutman et al (2004) also illustrated the importance of safety education, to decrease risk of partners’ becoming victim to domestic violence. Occupational therapists worked with woman to develop a safety plan: identifying a safe place to escape and connections to support systems so they could safety escape violent situations.

Employment skills were the focus of an intervention designed by Helfrich and Rivera (2006), which supported women who had left their violent partners. Group sessions taught victims how to search for, apply for, and maintain a job, including how to write resumes, where and how to apply, completing mock interviews, and ways to advance in a job. Feedback given by participants were mostly positive and felt that they had learnt necessary skills to obtain a job within their community.

Common challenges for occupational therapists

It is somewhat difficult for occupational therapists to take particular health promotion approaches to address domestic violence. More than half of occupational therapists work in hospitals or outpatient settings where they fill secondary or tertiary health promoting roles through empowering people through education, training and equipment. Their aim being that their clients can develop the necessary skills to manage their chronic disease or injury and prevent further deterioration and potential secondary conditions. If occupational therapists turned to a more upstream primary prevention approach, it would be difficult to maintain the quality of services in the traditional downstream approach, and thus time constraints is also a pressure to adopt preventative health promotion role alongside their current remit (Scriven, & Atwal, 2004).

Occupational therapists, like any health profession, need to work with not only the health conditions of the community, but also their attitudes and social/cultural norms which can be barriers to implementing new programs. Communities that support or encourage the use of violence will make it very difficult for occupational therapist to implement a program advocates against domestic violence. For example intimate partner violence is accepted across India, Nigeria and China, where men have the right to discipline female behaviour. “Sub groups” of communities, can also have differing views of family violence, for example the indigenous communities or isolated rural areas within Australia may accept violence as a part of their culture, compared to the majority of the population who condone it (World Health Organisation, 2009).

Lack of partnerships to establish a health promotion strategy is also a limitation for occupational therapists. Evidence has shown that occupational therapists often use concepts and medical terminology that can be misunderstood and possibly misconstrued in health promotion partnership arenas (Wilcock 1999, Townsend 1999). It is also found that it is easier for an occupational therapist to implement secondary health promotion such as cognitive behavioural training for perpetrators of violence rather than working towards implementing primary preventative approaches that rely on other organisations.

In conclusion, with domestic violence being a significant issue in Mildura, health promotion strategies such as mandatory school based programs, behaviour change programs for perpetrators and community sports programs can influence members of the community to construct or change their attitudes towards domestic violence, to foster for healthy and respectful relationships. Occupational therapists face many challenges in the area of health promotion, as it’s harder for them to adopt an upstream primary preventative approach, due to time constraints and demands for secondary/tertiary care, as well as difficulty building partnerships and working with the differing cultural and social attitudes of specific communities. Furthermore, for occupational therapists wanting to become more engaged with health promotion, they need to be prepared to go extra lengths to gain power and respect from others, and have specific skills and resources to be able to facilitate for an ‘upstream’ approach, to preventing domestic violence in Mildura.