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Running head: HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

Health Education for Survivors of Domestic Violence


Danielle Cole, Adair Flynt, & Abigail P. Wetzel
Nell Hodgson Woodruff School of Nursing
Emory University

This paper represents our own work in accordance with the School and University regulations.

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

Health Education for Survivors of Domestic Violence


Meditation
Meditation is the practice in which you exercise your brain in mindfulness. The goals of
mindfulness and meditation are to encourage an attitude of love and compassion with a
nonjudgmental awareness of the present experience (Hoffman, Sawyer, Witt, & Oh, 2010). This
process encompasses emotions, thoughts, sensations, and the internal and external environment
of the persons current state (Hoffman et al., 2010).
Many of the mental health and personal health benefits of meditative practice are widely
researched and understood. Studies suggest that the neurophysiological effects of mindfulness
and meditation include decreases in central nervous system activation, resulting in decreases in
blood pressure, heart rate, breathing rate, and excitation (Sedlmeier et al., 2012). These benefits
are crucial to female trauma survivors who are more likely to experience mental health disorders,
including post-traumatic stress disorder and panic attacks (Lee & Akers, 2015; Sedlmeier et al.,
2012). It has also been found that among female survivors of trauma, women who meditate
experience less anxiety and improve in depressive symptoms (Lee & Akers, 2015).
Meditation and mindfulness can be used by survivors of intimate partner violence in
addition to spirituality to increase resiliency, understanding, and coping with where they are in
their current journey (Lee & Akers, 2015). The benefits of mindfulness and meditation are
accessible as they are easy and are not time consuming. Research suggests that even meditating
for two minutes a day has health benefits and can relax a stressed person (Hoffman et al., 2010).
Meditation and mindfulness can be individualized and practiced differently according to
each persons preferences. In general, mindfulness meditation involves being in a quiet state and
focusing on breathing while allowing thoughts to run through the mind and exploring them.

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

Some people prefer a quiet place to sit, while others might meditate while exercising
(Puddicombe, 2015). For women who would like to start meditating, there are plenty of
resources available. Headspace.com has a free 10-day course for beginners and plenty of mantras
and meditations to experience. YouTube also has many channels dedicated to meditative
sessions and instructions on how to enhance the practice and experience.
Sleep
Sleep, though innately human, may be viewed as a disposable commodity for many
people. People do not regularly think about the quantity and quality of their sleep unless it begins
to negatively impact their health. Women exposed to intimate partner violence experience many
mental health consequences, which include sleep disturbances (Pigeon et al., 2011). The
consequences of restricted sleep are twofold: 1) sleep deprivation may be utilized as a form of
abuse; and 2) as sleep disturbances are seen as the hallmark of posttraumatic stress disorder,
women with posttraumatic stress disorder related to intimate partner violence may not be able to
sleep (Ross, Ball, Sullivan, & Caroff, 1989).
In a focus group study, Lowe, Humphreys, and Williams (2007) noted that women were
aware of their sleeping patterns in relation to reducing the threat of the violence they endured on
a day-to-day basis. In the same study, it was noted that being asleep while their perpetrator was
awake was extremely risky and losing sleep was a chance at avoiding violence (Lowe et al.,
2007). According to a population-based health survey, 53% of women reporting intimate partner
violence had experienced problems with sleeping compared to 28% of women who did not report
violence (Hathaway et al., 2000).
As a provider, it is important to be diligent when a female patient comes in with sleep
problems. Given all of the evidence related to the impact of intimate partner violence on sleep

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

disturbance, providers must evaluate the root cause of the sleep disturbance before being quick to
provide medication for sleeping. A patient may be experiencing sleep problems due to daily life
stressors, but for some these stressors may include a domestic violence situation at home.
Treatment for the sleep disturbance should consider both the violence and mental health
symptoms that the patient may be experiencing (Pigeon et al., 2011).
Nutrition
Balanced nutrition is an important element of wellness throughout the lifespan and can
contribute to flourishing in individuals of all backgrounds. Nutrition is an especially important
focus area as those in homes where intimate partner violence occurs are at risk for altered
nutritional status (Yount, DiGirolamo, & Ramakrishnana, 2011). Providers should be aware not
only of the impact of intimate partner violence on the nutritional status of individuals and
families, but also of easy-to-implement strategies for optimizing nutritional status in their
patients.
Throughout the world, research on intimate partner violence and its impact on nutrition
has revealed a strong connection between exposure to partner violence and malnutrition. In a
study of households in India, women reporting more than one instance of domestic violence over
the preceding year were significantly more likely to be underweight or severely underweight and
had significantly higher rates of anemia and severe anemia (Ackerson & Subramanian, 2008).
Beyond individuals directly impacted by domestic violence, exposure to domestic violence has
been shown to have impacts on children in the home. In a review exploring the effects of
exposure to domestic violence on the growth and nutrition of children, Yount et al. (2011) found
that exposure to chronic domestic violence in the home was associated with an increased risk for

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

malnutrition, whether manifested as obesity, non-organic failure to thrive, wasting, insufficient


weight gain, or short stature.
Given the increased risk to nutritional status in individuals exposed to intimate partner
violence, it is important for providers to understand the best ways to approach nutritional
education with their patients. Many accessible, patient-ready resources already exist, such as the
United States Department of Agricultures website, ChooseMyPlate.gov (2015), which includes
recipes, meal plans, food and exercise trackers, tips for eating healthy in a variety of situations,
and advice on how to eat healthy even with a busy schedule or a limited budget.
ChooseMyPlate.gov and similar resources emphasize prioritizing balance, the importance of
variety in food choices, choosing whole grains, drinking water, adding exercise to the daily
routine, and learning what is in foods to ensure healthy choices. Providers can use these
guidelines to work with their patients on individualized plans, setting nutrition-based goals that
take into account each individuals or each familys specific circumstances.
Self-Esteem
Self-esteem is a frequently overlooked but critical element of wellness, whether related to
relationship health, physical health, or mental and emotional health. Self-esteem is especially
complex in the context of domestic violence, as low self-esteem can emerge as a result of
intimate partner violence, can be a risk factor for power asymmetry in relationships, can be a risk
factor for intimate partner violence, or can be a combination of the above (Papadaki,
Tzamalouka, Chatzifotiou, & Chliaoutakis, 2009). Providers working with survivors of intimate
partner violence should be prepared to work with patients on improving perception of self-worth;
such effort may seem extraneous, but the impact on self-care and safety can be significant.

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

The role of self-esteem in the onset, manifestations, and perpetuation of intimate partner
violence is complex, with the self-esteem of both the perpetrator and the victim or survivor
playing a role. A cross-sectional study of men and women in Greece found that low self-esteem
was significantly associated with physical violence victimization and perpetration (Papadaki et
al, 2009). These findings resonate with a body of literature confirming the link between low selfesteem and intimate partner violence, both as a precursor to violence and a consequence. Further,
in addition to direct impacts of low self-esteem on both victims and perpetrators, interparental
violence has been shown to significantly predict low self-esteem in adolescents that persists into
adulthood (Shen, 2009).
Given the vast role of self-esteem in intimate partner violence, it is important for
providers to understand strategies to suggest to patients struggling with low self-esteem.
Providers may utilize resources from a variety of sources, such as the Substance Abuse and
Mental Health Services Administrations ([SAMHSA], n.d.) toolkit for building self-esteem.
SAMHSA strategies include prioritizing self-care, including hygiene, nutrition and exercise;
taking time for relaxation and hobbies; learning new skills; journaling with a positive focus,
whether through self-affirming journaling or gratitude journals; and changing negative thoughts
about self to positive ones. It is important to screen for and, if identified, refer to treatment for
depression in patients with low self-esteem, as the two phenomena often occur in the same
individuals.
Ultimately, spending the time to work on self-esteem with individuals experiencing
domestic violence once a safety plan has been established and pressing physical needs have
been addressed is a worthwhile investment of time. As each individuals circumstances vary,
and remembering that perpetrating partners may exert significant control over an individual

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

experiencing intimate partner violence, ensure that care plans are uniquely tailored to the
patients goals and motivations.
Spirituality
Spirituality cannot be exactly defined because it involves a different experience and
process for each person. Overall, it encompasses the aspects of life that make a human feel whole
or centered. Spirituality is an important process in mental health wellness and therefore can
contribute to flourishing for a domestic violence survivor. Spirituality includes processes such as
gratitude, positive thinking, and reflection, all of which can enable a survivor to feel powerful
and gain self-acceptance. (Fowler & Rountree, 2009).
Research shows that benefits of spirituality include improving self-care, enhancing
connections with others, lowering the central nervous systems response to stress, and giving the
individual a meaning to life (Fowler & Rountree, 2009). The literature also suggests that
spirituality provides a protective barrier in trauma survivors that promotes resiliency and
forgiveness (Fowler & Rountree, 2009).
In a qualitative study done with women survivors, Fowler and Rountree (2009) found that
spirituality correlated with guidance, improved outcomes, resiliency, and positive behavioral
response. When women believe in something higher than themselves they believe in something
bigger and a purpose for life. This can contribute to positive mental states, forgiveness, and
increased self-confidence. (Fowler & Rountree, 2009).
As stated previously, there is no correct way to practice spirituality. Some spiritual
practices that can positively influence self-actualization include journaling, positive thinking and
motivation, and meditation (Fowler & Rountree, 2009). These practices promote self-reflection,
mental and event processing, and gratitude. Given the overlap between spiritual practices and

HEALTH EDUCATION FOR SURVIVORS OF DOMESTIC VIOLENCE

meditation for many people, the summary section above on meditation also contains relevant
information on the effects of meditation on the mind and body.
Exercise
Depression and anxiety are mental health consequences of intimate partner violence
(Pigeon et al., 2011). Depression is characterized by mood changes, fatigue, guilt, weight gain or
loss, and difficulty concentrating, and it is associated with decreased physical activity over time.
Studies have shown that exercise is beneficial in the treatment in prevention of psychiatric
diseases, which include depressive and anxiety disorders (Peluso & Guerra de Andrade, 2005).
The benefits of exercise are not limited to mood but include various other aspects of wellness,
such as general well-being, self-esteem, and satisfaction with physical appearance (Peluso &
Guerra de Andrade, 2005).
The effects of exercise on mental health and mood have been studied primarily using
aerobic exercise, but there is evidence that anaerobic activity such as muscle strengthening can
also reduce depressive symptoms (Paluska & Schwenk, 2000). The Centers for Disease Control
and Prevention ([CDC], 2015) recommend doing aerobic along with muscle strengthening
activities three to five times a week for 30 to 60 minutes to improve mental health and mood, but
lower levels of exercise may also be beneficial.
Based on the well-established findings that exercise decreases symptoms of depression, if
a patient is experiencing symptoms of depression and anxiety, it may be beneficial for providers
to recommend that the patient begin an exercise regimen. The regimen does not need to be
strenuous but should be something that gets the patient moving more frequently. Once exercise
has been recommended, it is important to follow-up with the patient in order to provide support,
as well as to see how the adoption of exercise has benefitted the patient (Craft & Perna, 2004).

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