Violence, Gender, and Health Research Agenda 2010-2015

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Table of Contents

• Introduction
  • Purpose and Objectives
  • Definition of Violence
• Research Topics
  • Criteria for Selection
  • Topic Summaries
  • Topic 1: Violence and Health: Pathways and Processes of Change
  • Topic 2: Contexts of Vulnerabilities, Resiliencies, and Care among Understudied Groups
  • Topic 3: Ecological Approaches to Understanding and Addressing Violence — from Societies to Cells and Back Again
  • Topic 4: Structural and Systemic Violence
  • Topic 5: Evaluating Knowledge Translation and Exchange in Violence, Gender, and Health
  • Topic 6: Approaches and Interventions to Prevent and Reduce Violence and Improve Health Outcomes across the Lifespan
• Principles for Knowledge Translation & Exchange
• Conclusion
• Appendices
  • Appendix 1: Roundtable Agenda
  • Appendix 2: List of Participants

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Introduction

Violence is a significant health issue facing individuals, families, and societies today. Injury and violence contribute to an estimated 15 percent of the burden of disease in the world, and violence is overtaking infectious diseases as a main cause of premature death.

Violence is gendered and sexed. It has many manifestations and affects women, men, girls, and boys. By identifying violence as one of six strategic research directions in its 2009-2012 strategic plan the Institute of Gender and Health (IGH) is building on its legacy of supporting research that conceptualizes violence as a gendered phenomenon with implications for health.

As a next step in this effort, the IGH held a national Roundtable on Violence, Gender and Health in Ottawa on January 28 and 29, 2010, to help shape a research agenda in this area for April 2010 to April 2015. Collaborators in this initiative included other institutes and branches of the Canadian Institutes of Health Research (CIHR) and the Public Health Agency of Canada.¹

Purpose and Objectives

The primary purpose of the roundtable was to continue building capacity for multi-disciplinary research on violence, gender, and health. The meeting brought together leading experts representing diverse disciplines and research areas and examined violence, gender, and health in both national and global contexts. To serve as a background for discussion, participants and partners were asked to complete a survey on the subject in advance of the meeting (results are available on request).

The specific objectives of the roundtable were to:

• discuss the current state of evidence, identify gaps in our knowledge, and identify promising areas for the development of policies and interventions (including knowledge translation opportunities) related to violence, gender and health;
• identify priority areas for multi-disciplinary research on violence, gender, and health;
• gather the research community's input on which resources are needed to advance research on violence, gender, and health; and
• facilitate multi-disciplinary linkages and exchanges among violence, gender, and health researchers.

Definition of Violence

The IGH adopted the following World Health Organization definition of violence for the purposes of the roundtable:

The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.²

This definition encompasses a range of types of violence, including self-directed, interpersonal, and collective, and their multi-dimensional impacts.

Research Topics

Criteria for Selection

Five criteria were used by participants to identify priority topics for research on violence, gender, and health:

1. Addresses critical violence, gender, and health-related issues – including interventions and knowledge translation – that have been identified by stakeholders. In this context, "critical" means (i) of highest importance and (ii) where there is a crisis or turning point.
2. Reflects, supports, and build on Canada's violence, gender, and health-related research strengths.
3. Has strong potential for significant impact on the health of Canadians through research, policy development, interventions, and knowledge translation activities.
4. Helps to address gaps related to the current violence, gender, and health research situation.
5. Has strong potential for partnerships where individuals, groups, CIHR institutes, and other organizations can work together collaboratively to leverage each others' intellectual capital and resources.

These criteria were originally developed by IGH's Institute Advisory Board for its strategic planning process and were subsequently customized by the roundtable working group to support the identification of priority areas for research on violence, gender, and health.

Topic Summaries

After a facilitator-led discussion process, the following six topics were identified:

1. Approaches and interventions to prevent and reduce violence and improve health outcomes across the lifespan
2. Contexts of vulnerabilities, resiliencies, and care in understudied groups
3. Ecological approaches to understanding and addressing violence
4. Evaluating knowledge translation and exchange (KTE) in violence, gender, and health
5. Pathways and processes of change in violence, gender, and health
6. Structural and systemic violence

Cross-cutting themes that apply across all topic areas include KTE and building research capacity. Systemic and contextual issues and a lifespan trajectory were also noted as important considerations.

Participants also raised two overarching theoretical and methodological issues: the need for a national, consensus-driven research framework, and the need to develop a surveillance system for violence and health in Canada.

Those who advocated for the development of a framework emphasized the need to define violence in such a way that encompasses structures, organizations, systems, individuals, cumulative violence over the lifecourse, other contextual or situational factors, and synergies and tensions across levels, times, and sectors. They recommended that research in this field should be multi-method, integrative, intersectional, interdisciplinary, intersectoral, and multi-level. It should also include understudied/specific populations; consideration of the dynamic and reciprocal relationships among research, knowledge sharing, and action; and evaluation of research to action.

While the development of a surveillance system for violence and health in Canada is not within the IGH's mission or capacity, the Institute will take steps to raise the issue with relevant parties, such as Statistics Canada and Health Canada.

Topic 1: Violence and Health: Pathways and Processes of Change

The effects of violence can be cumulative, and exposure to violence affects health trajectories. This topic focuses on change over time (along the continuum from preconception to death) in health status, risk, and protective factors for violence; violence itself; health-relevant consequences of violence; and transactions between them. Research in this area will provide a foundation for the development of evidence-based interventions and improve researchers' abilities to identify causes and mechanisms related to violence and health, examine the factors that mediate health outcomes, and test relevant theories.

Research on this topic might seek to understand the linear and non-linear moderators and mediators of health trajectories following violence exposure. It might examine how risks and protective factors at the levels of biological, psychological, interpersonal, and societal environments interact over time in human risk for and responses to violence, or how violence interacts with physical and mental health.

Pathways and processes research could investigate how to restructure health and related systems (including but not limited to criminal justice and policing, social services, educational systems, and immigration systems) in order to incorporate a lifecourse perspective with regard to violence, gender, and health. There is also a need to explore the best methods for capturing pathways and processes over time with respect to violence, gender, and health.

Topic 2: Contexts of Vulnerabilities, Resiliencies, and Care among Understudied Groups

Individuals do not develop in isolation but within and across contexts. We are all members of families, social circles, and workplaces: we live in communities where formal and informal, and tailored and universal services are provided; and we are incorporated into broader social, political, and economic fabrics. Health inequities develop as an outgrowth of contexts of vulnerabilities, yet, even within consistent contextual adversity, individuals, families, subgroups, and populations can be also supported by contexts of resilience. The term "contexts" is used in an attempt to avoid stereotyping, marginalizing, and stigmatizing individuals and groups, and to accommodate the complexities inherent in human development and health outcomes.

This topic is specifically focused on understanding contexts of vulnerabilities, resiliencies, and care among populations that have historically been understudied in research on violence, including Aboriginal peoples, immigrants, refugees and trafficked people, sex workers, people with disabilities, lesbian, gay, bisexual, and transgendered people, homeless or street-involved people, and people involved in systems such as justice, mental health, or child welfare. Individuals are often members of multiple groups. While it is recognized that making lists opens the door to inadvertent exclusion, the list is included in order to highlight several research gaps and to exemplify this concept.

Topic 3: Ecological Approaches to Understanding and Addressing Violence — from Societies to Cells and Back Again

This topic focuses on the use of ecological approaches to understand and address violence. Such approaches explore complex adaptive systems related to violence and multi-level interactions between levels in the same study. Research in this area could focus on an individual's life course, societal transitions, or both. It might explore how exposure to violence "gets under our skin" – for example, how different levels of violence (e.g., societal, familial, intrauterine) influence our responses, including epigenetic (e.g., hypothalamic-pituitary-adrenal axis), cognitive, stress, mental health, pain, physiological, sexual (e.g., arousal).

Ecological approaches might investigate the interplay among various systems (e.g., biological, psychological, social, spiritual, cultural, legal, and economic) and aggression, aggressive behaviour, and the perpetration of violence. Studies related to this topic may examine how victimization is influenced by the dynamic interplay of multi-level influences over time and the social structures that reinforce or impede positive changes between system levels. They might take advantage of "natural" experiments offered by policy or structural changes as a means to understand multi- (i.e., micro-, meso-, macro-) level responses to violence.

Topic 4: Structural and Systemic Violence

Violence should not only be considered the act of an individual. This topic examines how social systems and institutions perpetuate and reproduce violence and impact various dimensions of health, as well as seeks to understand how intervention should take place at a structural and systemic level to prevent violence. It includes an exploration of the social culture of violence (e.g., the normalization of violence), the intended and unintended consequences of violence (including who benefits from it), and the intersections among forms of inequity and power differentials (e.g., discrimination, stereotyping, racism, poverty, homophobia). This topic seeks to situate violence within a historical context and investigate how globalization contributes to structural and systemic violence.

Topic 5: Evaluating Knowledge Translation and Exchange in Violence, Gender, and Health

KTE is a cyclical process, incorporating synthesis, dissemination, exchange, and the ethically-sound application of knowledge. The needs of stakeholders, such as policy makers, health practitioners, or consumers, must be incorporated directly into the selection and development of the knowledge to translate/exchange. KTE in the area of violence, gender, and health is informed by specific and sometimes diverging values and the multiple contexts of different stakeholders (e.g., policymakers, practitioners, community groups, advocacy groups, women) within and outside the health care system.

This complexity underscores the imperative to understand and apply KTE processes in an ethically appropriate way. Research is needed to understand the measures and ethical considerations of uptake and use of knowledge in the area of violence, gender, and health. There is also a need to explore the ethical dimensions of KTE audiences (e.g., are some more privileged than others, perhaps perpetuating existing imbalances?), definitions of evidence (e.g., do some forms of evidence count more than others?), and processes (e.g., what are the potential intended and unintended consequences of KTE processes?).

Research on this topic might explore the impact of new knowledge in the area of violence, gender, and health, as well as the development of best practices for KTE in this domain. There is a need to investigate which KTE methods and models are most effective for which audiences and to devise strategies for addressing known knowledge gaps through specific dissemination methods.

Topic 6: Approaches and Interventions to Prevent and Reduce Violence and Improve Health Outcomes across the Lifespan

Interventions related to violence, gender, and health must be theoretically informed and extend beyond documenting health outcomes to understanding the processes and mechanisms of change. Roundtable participants encouraged researchers to use a multi-dimensional framework that includes an ecological perspective (e.g., individual, family, community, population, policy), primary, secondary, and tertiary interventions, and a lifespan approach. There is a need to consider the acceptability, feasibility, portability, and cost of prevention and intervention approaches.

Research on this topic seeks to answer the question: "Which interventions work for which individuals, in which context, and why?" It might examine the effectiveness of current best evidence to address violence in the Canadian context (i.e., to evaluate effectiveness of an intervention established in another country and its applicability to the Canadian population). There is a need to identify leading practices for addressing symptoms/conditions of those experiencing and exposed to violence and to determine what works with respect to the prevention and treatment of chronic mental and physical health problems associated with experiencing and/or being exposed to violence (e.g., gastrointestinal, post-traumatic stress disorder, chronic pain, depression).

Intervention research might investigate the effectiveness of interventions that target specific transitions and turning points in preventing violence, reducing symptoms, and improving functioning and health. It may examine the processes and mechanisms of change underlying the effectiveness of efforts to prevent violence, reduce symptoms, and enhance health as a stage-based process. There is also a need to determine how best to evaluate interventions as they are rolled out and tailored to new populations.

Principles for Knowledge Translation & Exchange

Roundtable participants developed a list of KTE principles for research on violence, gender, and health:

• Engage with stakeholders early and often in a spirit of reciprocity, exchange, and respect.
• Use new, innovative, and creative methods to engage stakeholders and share messages (e.g., arts-based, multi-media, technology).
• Make strategies tailored and flexible. Match them to stakeholders and their desired outcomes.
• Partner at all required levels to ensure implementation and sustainability (e.g., engage provinces/territories that fund service delivery in interventions).
• Remove barriers or "black box" structures (e.g., templates or frameworks for KTE) that limit creativity and flexibility.
• Use an ethical lens to inform all KTE work, especially in considering unintended consequences and potential harms.
• Encourage or require research teams to share lessons learned from KTE practices.

Conclusion

The roundtable closed with a reflection on the two-day discussion and what participants thought a culture of intervention would look like in 2015. They described a future in which research on violence was more solution- and intervention-oriented, and where program evaluation was recognized as research and as a fundamental consideration for funding. They envisioned the study of processes and mechanisms changing fundamental assumptions about the development and repercussions of violence, and hoped for a greater uptake of policies at the provincial level.

Final thoughts focused on what would be needed to accomplish this vision. There was overwhelming agreement that better communication and connections were needed among researchers, policy makers, funders, communities, and those implementing interventions (e.g., sociologists, psychologists, social workers). Other key needs identified by the group included to be more creative in testing interventions, to address ethics issues, to foster public and political will to put evidence into practice, to distribute funding more equitably among all four research pillars, and to provide more strategic funding for trainees.

Appendices

Appendix 1: Roundtable Agenda
 

	Thursday, January 28, 2010	Friday, January 29, 2010
0900	Welcome and Opening Remarks Dr. Joy Johnson, Scientific Director, Institute of Gender and Health Part I: The Context Welcome! People and Process: Dorothy Strachan, Facilitator Funding Announcement Experts in Action: Survey Results	Agenda: Review, Preview Feedback summary Small group work: Review of draft report on Part III Plenary discussions: Refining topics
	Part II: Criteria and Priorities Criteria for Priority Setting: discussion and confirmation Identification of priority research topics	Part IV: Knowledge Translation and Exchange Small Group Work: Leading practices Regional, national and international approaches A culture of intervention Plenary Discussion
1300	Part III: Research Topics and Funding Opportunities Small group work: Topic description Related challenges, gaps, opportunities Potential research questions: Supportive funding opportunities Knowledge translation and exchange Plenary: Presentations and discussions: refining small group work	Closing Remarks Feedback on the Roundtable
1700	Closing Free Evening

Appendix 2: List of Participants
 

Name	Title	Affiliation
Dr. Farah Ahmad	Assistant Professor	Dalla Lana School of Public Health, University of Toronto
Kristiann Allen	Senior Ethics Policy Advisor	CIHR Ethics Office
Dr. Neil Andersson	Executive Director Principal Investigator	CIET Canada CIHR Centre for intercultural research on prevention of gender violence
Dr. Pat Armstrong	Professor CIHR/CHSRF Chair in Applied Health Services and Nursing Research	Department of Sociology, York University
Dr. Raymond Henri Baillargeon	Assistant Professor	Faculty of Health Sciences, University of Ottawa
Dr. Helene Berman	Associate Professor, Scotiabank Chair in Research and Education on Violence Against Women and Children	School of Nursing, University of Western Ontario
Dr. Wanda Thomas Bernard	Professor and Director	School of Social Work, Dalhousie University
Dr. Michael J. Chandler	Professor Emeritus	School of Psychology, University of British Columbia
Ruth Code	Research Analyst	PHAC Family Violence Prevention Unit
Dr. Wendy Craig	Professor	Department of Psychology, Queen's University
Dr. Myrna F. Dawson	Associate Professor Canada Research Chair in Public Policy in Criminal Justice	Department of Sociology and Anthropology, University of Guelph
Dr. Anne-Cecile Desfaits	Assistant Director	CIHR Institute of Human Development, Child and Youth Health
Dr. Kevin S. Douglas	Associate Professor	School of Psychology, Simon Fraser University
Dr. Janice Du Mont	Assistant Professor	Department of Public Health Sciences, University of Toronto
Dr. Nancy Edwards	Scientific Director Professor	CIHR Institute of Population and Public Health, School of Nursing, University of Ottawa
Dr. Marilyn Ford-Gilboe	Professor	School of Nursing, University of Western Ontario
Abigail Forson	Assistant Director	CIHR Institute of Gender and Health
Jennifer Gunning	Associate Director	CIHR HIV/AIDS Research Initiative
Dr. Sepali Guruge	Associate Professor	School of Nursing, Ryerson University
Dr. Kathy Hegadoren	Professor Canada Research Chair in Stress-related Disorders in Women	Faculty of Nursing, University of Alberta
Dr. Susan Jack	Assistant Professor	School of Nursing, McMaster University
Dr. Lois Jackson	Professor	School of Health and Human Performance, Dalhousie University
Dr. Patti Janssen	Associate Professor	School of Population and Public Health, University of British Columbia
Dr. Joy Johnson	Scientific Director Professor	CIHR Institute of Gender and Health School of Nursing, University of British Columbia
Leah Jurkovic	Assistant Director	CIHR Institute of Health Services and Policy Research
Dr. Malcolm King	Scientific Director Professor	CIHR Institute of Aboriginal Peoples' Health Department of Medicine, University of Alberta
Joanne Lacroix	Manager	PHAC Family Violence Prevention Unit
Dr. Barbara Lent	Associate Professor	Department of Family Medicine, University of Western Ontario
Dr. Angeline Letendre	Assistant Director	CIHR Institute of Aboriginal Peoples' Health
Dr. Nicole Letourneau	Professor Canada Research Chair in Healthy Child Development	Faculty of Nursing, University of New Brunswick
Dr. Harriet MacMillan	Professor Principal Investigator	Department of Psychiatry and Behavioural Neurosciences and Pediatrics, McMaster University CIHR Centre for Research Development in Gender, Mental Health and Violence Across the Lifespan
Dr. Marlene Moretti	Professor	Department of Psychology, Simon Fraser University
Adrian Mota	Senior Knowledge Synthesis and Exchange Specialist	CIHR Knowledge Synthesis and Exchange Branch
Ashley Page	Administrative Coordinator	CIHR Institute of Population and Public Health
Dr. Debra J. Pepler	Distinguished Research Professor	Department of Psychology, York University
Melissa Phypers	Assistant Director	CIHR Institute of Neurosciences, Mental Health and Addictions
Dr. Charlotte Loppie Reading	Associate Professor Research Affiliate	School of Public Health and Social Policy, University of Victoria Centre for Aboriginal Health Research
Dr. Maryse Rinfret-Raynor	Professeure émérite	École de service social, Université de Montréal
Dr. Chantal Robillard	CIHR Global Health Initiative Postdoctoral Fellow Research Associate	Institute of Population Health, University of Ottawa Trauma and Global Health Program, McGill University
Dr. Elizabeth Saewyc	Professor	School of Nursing, University of British Columbia
Dr. Kate Shannon	Assistant Professor	Division of AIDS, Department of Medicine, University of British Columbia
Zena Sharman	Assistant Director	CIHR Institute of Gender and Health
Dr. Raven Sinclair	Assistant Professor	Faculty of Social Work, University of Regina
Dr. Donna E. Stewart	Lillian Love Chair in Women's Health	University Health Network and University of Toronto
Dr. Wilfreda E. Thurston	Professor	Department of Community Health Sciences, University of Calgary
Dr. Leslie M. Tutty	Professor	Faculty of Social Work, University of Calgary
Dr. Tracy Vaillancourt	Associate Professor Canada Research Chair in Children's Mental Health and Violence Prevention	Department of Psychology, Neuroscience, and Behaviour, McMaster University
Dr. Colleen Varcoe	Associate Professor	School of Nursing, University of British Columbia
Dr. Bilkis Vissandjée	Professor	School of Nursing, Université de Montréal
Dr. Nadine Wathen	Assistant Professor	Faculty of Information and Media Studies, University of Western Ontario
Dr. Christine Wekerle	Associate Professor	Faculty of Education, University of Western Ontario
Dr. Samantha L. Wells	Assistant Professor	Department of Epidemiology and Biostatics, University of Western Ontario
Dr. Judith Wuest	Professor	Faculty of Nursing, University of New Brunswick

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1. The roundtable partners were CIHR's Ethics Office, HIV/AIDS Research Initiative, Institute of Aboriginal Peoples' Health, Institute of Health Services and Policy Research, Institute of Human Development, Child and Youth Health, Institute of Neurosciences, Mental Health and Addictions, Institute of Population and Public Health, and the Family Violence Prevention Unit of the Public Health Agency of Canada.
2. World Health Organization (2002). World report on violence and health: summary, p. 4. Geneva: author.