Literature reviews

Vol.:(0123456789)1 3

https://doi.org/10.1007/s10896-021-00298-x

ORIGINAL ARTICLE

Examining the Impact of Duration, Connection, and Dosage of Domestic Violence Services on Survivor Well‑Being

Leila Wood1  · Bethany Backes2 · Elizabeth Baumler3 · Maggy McGiffert1

Accepted: 17 June 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract Survivors of domestic violence (DV) have a wide range of needs when they seek help from DV programs. While there is growing evidence that advocacy and other supportive services for DV survivors are helpful for increasing wellbeing, little is known about the mechanisms that best promote these goals. This study sought to further understand the role of survivor advocacy and service duration on survivors’ physical and mental health, safety, and needs. Structured interviews were con- ducted with a sample of 150 women recruited from 16 DV programs across seven regions in a southwestern state. Independ- ent variables included overall service duration, time with advocate, and feelings of connection with advocate. Bivariate and regression analyses were conducted to test associations of the advocate-survivor relationship and length of time in services with physical, social, and psychological outcomes. The majority (75.8%) of survivors indicated decreases in abuse since obtaining services. Frequent needs included housing, counseling, and safety planning. Regression analysis indicates longer service duration and increased connection with an advocate were significantly associated with a greater number of survi- vor needs being met. No other independent variables were significant in regression models, but several covariates reached significance. This study adds to the growing and needed body of literature on survivors’ experiences with DV services and associated outcomes. Advocates should prioritize connecting with clients in favor of a priori service goals based on time limits. Further study can be used to better understand health outcomes for survivors.

Keywords Intimate partner violence · Trauma · Mental health · Housing · Counseling · Advocacy

Over 37% of women and 30% of men have experienced domestic violence (DV) during their lifetime (Smith et al., 2017), with 27% of survivors who identify as women and 11% of survivors who identify as men experiencing physical injury, chronic health problems, and mental health impacts (Breiding, et al., 2014; Campbell, 2002; Smith et al., 2017). To address these impacts, a network of DV-focused pro- grams were created in the last 50 years to offer material and emotional support to survivors and their children (Nichols, 2014). The goal of community-based DV programs are typi- cally to increase safety, decrease abuse, and improve the social and emotional well-being of survivors and their fami- lies by addressing mental, physical, and economic challenges created or exacerbated by abuse and traumatic experiences (Sullivan, 2018). Community-based DV programs offer a variety of services, including crisis hotline, advocacy, case management, counseling, shelter, short and long-term hous- ing, support with criminal and civil legal systems, and help with basic needs (Allen et al., 2004; Baker et al., 2009; Lyon et al., 2012; Wathen et al., 2015). While a growing body of

* Leila Wood [email protected]

Bethany Backes [email protected]

Elizabeth Baumler [email protected]

Maggy McGiffert [email protected]

1 Center for Violence Prevention, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0587, USA

2 Violence Against Women Faculty Cluster, Department of Criminal Justice | School of Social Work, University of Central Florida, Classroom Building I, 302N, 12494 University Blvd, Orlando, FL 32816, USA

3 Center for Violence Prevention, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, University Blvd, Galveston, TX 77555-0587, USA

/ Published online: 26 June 2021

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evidence indicates that DV programs may be successful in increasing resource access and improving safety (Kulkarni et al., 2012; Nichols, 2014; Rivas et al., 2019), there is a lack of evidence on time and service model features that best facilitate improved well-being for survivors, limiting DV programs’ ability to enhance outcomes and better meet survivor needs. To further our knowledge of the mechanisms underlying improved outcomes for survivors, this study uses a diverse cross-sectional sample of 150 female-identified survivors using services in DV community programs. The study aims were to understand how service model features, survivors’ feelings of connection with staff, and their dura- tion of services are related to core DV service goals includ- ing enhancing physical and mental health, reducing abuse (and increasing safety), as well as increasing social support, and resource access.

Literature Review

Domestic Violence Community Service Response

The pernicious impacts of DV on the physical and mental health, economic and housing stability, and social needs of survivors and their children necessitate a strong service response to enhance DV survivors’ well-being (Bennett et al., 2004; Bybee & Sullivan, 2002; Constantino et al., 2005; Kulkarni et al., 2012; McNamara et al., 2008). Ser- vices have specialized over time beyond emergency shelters and hotlines to encompass comprehensive residential and non-residential advocacy (supportive services), counseling centers, legal support, and short and long-term housing programs (Davies & Lyon, 2014; Nichols, 2014). Notably, most DV survivors do not seek services. Estimates from the National Crime Victimization Survey indicate that between 1993 and 2015, a little more than 20% of survivors sought assistance from at least one survivor services program (Warnken & Lauritsen, 2019), though the type of program accessed and the survivor’s experience with the program is largely unknown.

Survivors have a wide range of needs when they engage in support after DV. The National Intimate Partner and Sex- ual Violence Survey (NISVS) found that 22.1% of female survivors needed medical care, 21.2% needed legal services, 7.5% needed victim advocacy services, 6.9% needed hous- ing services, and 6.1% needed community services after experiencing abuse (Breiding et al., 2014). Despite seeing only a small percentage of survivors, most DV programs are extended beyond capacity related to the needs of survivors (Iyengar & Sabik, 2009; National Network to End Domes- tic Violence, 2020). In 2019, the National Network to End Domestic Violence (NNEDV) reported that 77,226 survivors were helped in a single day in 1,887 DV programs – 42,964

of whom were provided shelter or transitional housing, and 34,262 provided non-residential care (NNEDV, 2020). Domestic violence programs work with diverse groups of survivors, many with experiences of previous marginaliza- tion, including those who identify as women, often serving disproportionate numbers of Black, Indigenous and People of Color (BIPOC), especially in shelter and housing ser- vices, in part because of disproportionate impact for these populations of homelessness and poverty (Gillum, 2019). Additionally, immigrant survivors can face barriers when accessing DV services such as language barriers, fear of deportation, and lack of knowledge of community resources (Eisenman et al, 2009).

The community service response to DV has historically relied on shelter as an entry point for accessing other com- prehensive services, such as case management or advocacy. Shelter services are typically time limited to 30–60 days (Sullivan & Virden, 2017), though some may extend to 90 days or longer. Recent research indicates duration in shel- ter may be impacted by previous shelter stays, immigration issues, severe emotional abuse, first attempts at separation from abusive partner, and entry to shelter due to child wel- fare involvement (Ben-Porat & Sror-Bondarevsky, 2018). While shelter remains a primary vehicle for survivors to obtain comprehensive services, there is a broad range of non-shelter residential and non-residential services that many DV programs provide including legal help, counseling, housing, and economic or financial assistance (Lyon et al., 2012; Macy et al, 2009).

How Domestic Violence Programs Help: Practice Frameworks

Domestic violence services use advocacy and other sup- portive mechanisms to address diminished resources and well-being after violence or trauma. Domestic violence ser- vices goals include changes in the intrapersonal (increased skills, hope), interpersonal (reduction of abuse, increased safety, and social support) and societal changes (resource access and navigating systems) (Sullivan, 2018). Conser- vation of Resources (COR) provides a theoretical base for services, explaining that after trauma or loss (such as DV), individual, interpersonal, and social resource loss occurs (Hobfoll, 2001, 2011; Sullivan, 2018). Resource loss can be mitigated by resource gain, which minimizes long-term trauma impacts. Resource loss or gain contributes to spirals of further resource loss or gain, thus addressing resource loss with additional gain immediately can prevent further loss (Hobfoll, 2011). The Five Domains of Wellbeing for people experiencing poverty and/or violence (Full Frame Initiative, 2020) provide an additional framework for DV program goals. The five domains are social connectedness, stability, safety, mastery (control), and access to relevant

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resources. Based on survivor needs, DV programs aim to increase social connections, safety, economic stabil- ity, access to resources, and mental, physical and spiritual health (Full Frame Initiative, 2020; Sullivan, 2018) through individualized, that respect participant cultural background (Ragavan et al., 2018; Serrata et al., 2019).

In residential and non-residential setting, supportive, voluntary services are often offered through advocacy, one of the primary non-clinical practice modalities with survi- vors in DV programs. Advocacy, along with counseling and legal support, are some of the most frequently requested services from survivors in DV programs (Grossman et al., 2010). Advocacy services are frequently conflated with case management, but while the two may share common tasks (referrals, goal setting, active listening) they are distinctly different philosophically (Sullivan & Goodman, 2019). The advocacy model of service represents a departure from traditional case management in social services towards an approach that emphasizes collaborative work to individu- alized goals rather than providing a prescriptive, one-size- fits-all approach (Wood, 2014; Goodman et al., 2016a, b; Sullivan, 2018; Sullivan & Goodman, 2019). Advocacy ser- vices, based on the assertion that everyone has rights and self-determination in individual and macro systems, focus on offering support to survivors to gain resources and improve well-being (Davies & Lyon, 2014; Sullivan & Goodman, 2019). These services are provided to both survivors of vio- lence who have left their abusive partners and those who have not, as well as to many survivors who are in contact with their abusive partners due to child custody and visita- tion arrangements.

Domestic violence advocacy and other supportive services are typically oriented in feminist, empowerment and strengths perspec- tives (Wood, 2014, Nichols, 2014; Cattaneo & Goodman, 2015), using the survivor-centered (Cattaneo & Goodman, 2015) or sometimes called victim-defined (Davies & Lyon, 2014) framework to orient services to the expressed needs of indi- vidual survivors and their families. The survivor-centered approach emphasizes autonomy, choice, and collaboration (Cattaneo & Goodman, 2015; Davies & Lyon, 2014). Fur- ther contributing to this service approach, DV programs with federal funding must provide advocacy and other services on a voluntary basis in compliance with the 2010 update to the Family Violence Prevention and Services Act (FVPSA), a policy that prevents programs from mandating program participation as a condition of services (FVPSA, 2016). Vol- untary and low barrier DV services are significantly associ- ated with increased survivor autonomy and empowerment (Nnawulezi et al., 2018), and empowerment is empirically linked in previous studies to more positive mental health outcomes (Perez et al., 2012). Advocates work with DV survivors to help increase safety, meet social and economic goals, access resources, advocate for their rights within

systems, and heal from trauma (Goodman et al., 2016a, b; Rivas et al., 2019; Sullivan, 2018).

Domestic Violence Advocacy Service Efficacy

Emerging evidence over the last twenty years indicates the efficacy of DV advocacy services for improving survivor well-being (Rivas et al., 2019; Sullivan & Goodman, 2019). Seminal work from Sullivan and Bybee (1999) demonstrated the positive effects of advocacy intervention, including increased access to needed resources, and higher measures of social support and quality of life. A meta-analysis of 13 studies with over 2000 participants indicated that advocacy may improve quality of life and reduce physical violence (Rivas et al., 2019). In other studies, DV advocacy has been shown to decrease negative outcomes such as subsequent experiences of violence and negative mental health symptoms (Bybee & Sullivan, 2002; Perez et al., 2012; Ramsey et al., 2009 Sullivan & Bybee, 1999; Wathen & MacMillian, 2003). Evidence is growing that advocacy and other supportive ser- vices for survivors is effective in meeting DV program goals of promoting increased resources gain, connection, reduc- tion of abuse, increased safety, and improved well-being of survivors. However, little is known about the association of time (service duration) and advocacy service model features (connection and dosage) related to DV program goals of increased wellbeing. To expand the current research base, we tested the impact of service duration, connection with advocate (or primary staff member), amount of time with advocate, and use of external (non-DV program) mental health services on survivor well-bring, decreased abuse, and material/resource need. Our research question was: What is the association of service duration, connection and time with an advocate, and use of external mental health services, on DV survivors’ physical and mental health, abuse experi- ences, and met needs?

Method

Procedure

Data were collected from seven regions of a southwestern state for a statewide project focused on DV services and needs of survivors in collaboration with the state coalition. The state coalition worked with the research team to estab- lish initial staff contact with the DV programs, and once programs agreed to participate, the study was advertised to residential and non-residential adult clients through staff, print fliers, and word of mouth. The research team con- ducted site visits to provide information to potential par- ticipants about the study and conduct structured interviews with those that consented. Structured interviews were

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conducted in English and Spanish by a research project member and were held at a private location within the DV program. All questions were voluntary, and interviewers followed the survey logic/skip patterns thus not all ques- tions were administered to all participants. Participants received $20 for participation. Interviews were recorded with participant permission. All members of the research team conducting interviews were from the university and state coalition group, including the authors, had experi- ence working with DV survivors in practice, and were trained in procedures for the protection of human subjects. The study was approved by the first authors’ previous insti- tution (The University of Texas at Austin). For additional details on methods, please see (Author citation, 2019c).

Participants

Participants were recruited from 16 different community based DV programs and were eligible for the interview if they were 18 or older and were currently using or had pre- viously used DV services, residential or non-residential, at the program where data were collected. All recruited participants identified as female, though recruitment was open to all gender identities. Almost 60% (n = 85) of participants resided in either emergency shelter or transitional housing during the time of study and 43.3% (n = 65) engaged in non-residential services. The average age was 35.13 and the age range was 19–67. Of partici- pants with minor children, 53.2% (n = 58) had a child aged 5 or younger. Forty percent of the sample identified as Hispanic/Latina (n = 60) and almost a quarter (n = 36) of the sample identified as Black or African American. See Table 1 for participant demographics.

Measures

Structured interviews administered by research team mem- bers to meet study aims were conducted in English and Spanish and each interview took 40–75 min. The interview protocol had established and study-modified measurement tools, covering demographics; housing and homelessness; abuse disclosure and service access; economic and reproduc- tive coercion; and safety needs and risks. A portion of the interview was dedicated to service experiences, including needs, connection and interactions with an advocate or other primary staff member, use of other mental health services in the community external to the DV program, and goals. The interview also focused on physical and mental health, including established measures of social support and post- traumatic stress disorder symptoms. For the current study, to test the association of service duration and connection on DV program goals, the following measures were used:

Demographics

Demographic questions included race/ethnicity, age, gender/ gender identity, sexual orientation and employment status. Participants were asked if they had children, and about their current housing status. For this analysis, participants were considered living in residential DV services if they were currently living in shelter or DV transitional housing at the program in which they sought services. All other partici- pants were considered non-residential, and lived in their own homes, apartment or other housing situations. Aligned with previous studies (Ben-Porat & Sror-Bondarevsky, 2018; Grossman et al., 2010; Lyon et al., 2008), race/ethnicity, employment and housing status, and age of children were used as correlate variables in multivariate modeling.

Independent Variables

These independent variables represent DV program goals of improved physical and mental health, decreased abuse/ increased safety, resource access, and connection.

Service duration

Participants were asked length of time in services at the DV program they were currently engaged in services. Partici- pants reported time in services from 1-week or less to 5 or more years. Due to the wide distribution, a scale was created to assess monthly increments in time from 1 week or less (1) to 60 or more months (10) in service thus creating a proxy of the time in service as intervals that may be meaningful with regard to impacts.

Table 1 DV Survivor Demographics (n = 150)

Variable n %

Race/Ethnicity   Black 36 24.0%   Hispanic/Latinx 60 40.0%   White 30 20.0%   Multiracial/Other 24 16.0%

Employment   Employed 65 43.0%   Not Employed 85 57.0%

Children   Has Minor Child 109 72.7%

Residential Status   Shelter/Transitional   Housing 85 56.7%   Non-residential client 65 43.3%

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Time with Advocate

Questions related to the experience with advocacy services were adapted from previous advocacy evaluations (Sullivan, 2016). Participants were first asked to identify a primary advocate or support person they have worked with in the DV program. One question about the amount of time they spent with their advocate, Time periods are expressed in weekly amounts by hour and ranged from 0 to16 hours spent with an advocate.

Connection with Advocate

Participants were asked one question about connection with their identified advocate. The question was How connected do you feel to (name of identified advocate)? By connected, I mean feeling there was bond between the two of you. Answers ranged from not at all, a little, somewhat, or a lot and were coded on a scale of 1–4 respectively.

External Mental Health Services Used

To assess other potential facilitators of mental health changes, participants were asked if they had used psychiatric, counseling and/or substance abuse counseling services at an agency outside of the DV program in the previous 6 months. Answer options were yes, no, and decline to answer.

Respect for Cultural Background

Participants were asked about their perception of the pro- gram’s climate regarding cultural background. For analysis, a single question was used from Trauma‐Informed Practice Scale (TIPS) (Goodman et al, 2016a, b), “Peoples’ cultural backgrounds are respected in this program.” The item stemmed from the cultural responsiveness and inclusivity subscale from TIPS (α = 0.96). Items from TIPS can be examined individu- ally or within subscales. This was measured with a four-point scale from “not at all true” to “very true” and coded 0–3.

Outcome Variables

Needs Met by Domestic Violence Program

The Index of Services Needed and Received (Sullivan et al., 2008) was modified with additional categories and used for the current study. Participants were asked about a range of

fifteen common needs of people using DV services (such as help with housing; childcare; employment; or safety plan- ning) and asked if they a). had that need and had it met by the DV program, at least in part; b) had the need and were referred to another program; c) had that need and received no assistance and/or referral or d) did not have that need. For the current study, we considered the need met by the DV program if the participant indicated they needed help and got it or if they were referred out, and considered the need unmet by the DV program if they reported a need but that it was unmet. See Table 3 for an overview of needs endorsed.

Changes in Abuse and Safety

Perceptions of abuse experience was assessed using a ques- tion from the 131-item New Jersey Assessment of Domes- tic Violence Risk and Impact (Postmus et al., 2017). DV service-related changes in abuse were assessed with the question “In your time at this program so far, has the abuse against you…decreased, increased, stayed the same?” We coded this as a dichotomous variable with 1 = abuse had decreased (75.8%) or never happened (10.6%) and 0 = is abuse had increased (4%) or stayed the same (9.6%). The individual item of continued abuse was of particular interest in this study and almost 76% of those responding reported a decrease in abuse since starting services. To further under- stand safety concerns, participants were asked to answer an additional question about whether they had had any contact with their current/former partner who had used violence (coded as yes/1 and no/0).

Physical Health

Participant physical health was assessed with a single item from the Patient-Reported Outcomes Measurement Infor- mation System (PROMIS) global health items (single item α = 0.52) with “In general, how would you rate your over- all physical health?” with five answer options ranging from “poor” to “excellent” (Hays et al., 2015). Responses were coded on a scale from 0–4 respectively. The one item ques- tion is used frequently in social science research as a brief assessment of physical health (Hays et al., 2015).

Social Support

Social support was assessed with the MOS Social Support Survey 6-item (MOS-SSS-6, α = 0.70, 0.81) measure scale, with has six questions assessing different dimensions of social support. Participants are asked: “How much of the

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time would you say you currently have someone in your life who could…Help if confined to bed…and Do something enjoyable with.” Answer options include: none of the time, a little of the time, some of the time, most of the time, or all of the time (Holden, et al., 2014). Responses were coded on a scale of 1 to 5 respectively with higher scores indicating higher levels of social support.

Post‑Traumatic Stress Disorder (PTSD) Symptoms

PTSD symptoms were assessed with the Primary Care PTSD Screen for DSM-5 (Prins et al., 2016; r = 0.83). The scale asks about experiences in the past month and includes five questions, including “In the past month, have you had nightmares about the event(s) or thought about the event(s) when you did not want to?”, with answer choices of “yes” or “no”. Participants answering yes to four or more ques- tions are considered to have probable PTSD for this analysis and responses dichotomously coded into probable PTSD (1) and no PTSD (0). Using the 4 or more threshold minimizes the possibility of false positives or false negatives (Prins, et al, 2016). For further psychometric information, please see Prins et al., 2016.

Data Analysis

Descriptive analyses were used to provide a profile of the sample with regard to each of the study measures. Sam- ple sizes, means, and prevalence estimates were presented. Regression modeling was used to investigate the relation- ship of the key program measures of service duration, con- nection and time with advocate, and use of other services with each of the desired study outcomes. Logistic models were used for the dichotomous outcomes of continued abuse, contact with partner, and PTSD. Linear models were used for overall physical health, needs met, and social support. While overall physical heath was measured on a five-point categorical scale rather than a continuous measure, sample size limitations did not allow estimation of a multinomial model. Linear regression was our best available choice given our interest in magnitude of change, and application of such models to scales such as this have been shown to provide unbiased estimates (Johnson & Creech, 1983). Separate regression models were fit for each of the study outcomes. All models included race/ethnicity, employment, housing status and if the participant had a minor child. Inclusion of these covariates into the models allowed for the investigation of the relationship between the independent and dependent measures adjusted for any confounding that may be observed

by differences in the included covariates. Linear regression models produced regression estimates showing the aver- age change in the dependent variable per unit change in the independent variable controlling for covariates in the model. Similarly, logistic regression models provided estimates of odd ratios showing changes in relative likelihood, control- ling for all other covariates in the model. Statistical signifi- cance was determined using the Wald test of the ratio of the regression parameter to its standard error. Type I error rate was set at 0.05 to test significance.

Results

Participants on average had 72% of expressed needs met, either directly from the DV program or by referral (see Table 2). Just over 29% of participants still had contact with the partner who used violence and the vast majority, 75.8% reported that abuse had decreased since engaging with DV services. The slight majority, over 56%, of participants reported 4 or more PTSD symptoms, indicating probable PTSD at a conservative threshold. Social support averages were mid-range, with an average of 3.04, indicating moder- ate levels among participants. Physical health was average with a mean of 1.85. Feelings of connection with advocate were overall high, with an average of 3.32 out of 4. Par- ticipants spent, on average, just over two hours a week with their advocate. Forty percent of participants reported engag- ing in external mental health services in a non-DV program in the previous 6 months.

Needs varied across participants and although many needs were met by the DV agency, participants were referred out for services (see Table 3). Agencies met the needs of participants consistently for emergency shelter (94.3%), counseling (85.7%), and safety planning (82.9%). Services frequently referred out included employment assistance (17.8%), legal assistance (14.7%), healthcare (14.7%), and immigration support (17.5%). Less than half of partici- pants that requested educational assistance and/or financial assistance had that need met by the DV agency or referral (Table 4).

Regression modeling indicate longer service duration (B = 0.025, p 0.031) and increased connection with advo- cate (B = 0.064, p. 004) are significantly and positively associated with getting needs met. Having a minor child also was significantly associated with having more needs met (B = -0.091, p 0.044). None of the other variables were significantly associated with increased needs met. None of the independent measures were significantly associated with abuse and safety, represented by perception of abuse and/or contact with former/current partner, though several covari- ates reached significance. Those who are currently employed (OR = 2.56, p < 0.05) and those with minor children were

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nearly significant (OR = 2.70, p 0.054) as more likely to have contact with their partner, representing potential for safety

concerns from post-separation violence. Participants iden- tifying as Black (OR = 0.26, p < 0.05), Hispanic (OR = 0.16,

Table 2 Overview of Outcome Measures for DV Survivors

† Scale is as follows (in months): 1 = .25 or less; 2 = .26-.5; 3 = .51–1; 4 = 1:01–3:00; 5 = 3:01–6:00; 6 = 6:01–12:00; 7 = 12:01–24:00; 8 = 24:01–36:00; 9 = 36:01–60:00; 10 = 60:01 +

Outcome measures n %/Mean (SD) Range

Needs met .11%-100%   Mean percentage of reported needs met 150 .72 (0.25)

Contact with partner   (1 = contact with partner) 148 29.1%

Abuse Experiences    (1 = decrease in abuse/never happened) 124 86.4%

Probable PTSD    (1 = cutoff of 4 or higher on PTSD-DSM5) 144 56.3%

Physical Health    (0 = poor to 4 = Excellent) 141 1.85 (1.08) 0–4

Social Support    (scale, lower = less support) 144 3.04 (1.25) 1–5

Independent measures n %/Mean (SD) Range Service Duration†

   (scale, lower score indicates less duration) 149 4.47 (1.94) 1–10 Feeling of Connection

   (scale, lower score indicates less connection) 141 3.32 (1.07) 1–4 Time

   (hours per week spent with advocate) 139 2.11 (2.25) 0–16 Non-DV program mental health services

   (1 = used non DV MH services) 150 40.0% Respect for cultural background

  (scale, higher indicates more culture respect) 132 2.78 0–3

Table 3 DV Survivors’ Service Needs and Needs Met

Participant Need Total n Reporting Need (%)

Need Met by Agency (%)

Need Referred Out (%)

Need not Met

Looking for Housing 116 (77.3%) 67 (57.8%) 9 (7.8%) 40 (34.4%) Emergency Shelter 106 (70.7) 100 (94.3) 0 (0.0) 6 (5.7%) Counseling 105 (70.0) 90 (85.7) 6 (5.7) 9 (8.6%) Safety Planning 105 (70.0) 87 (82.9) 0 (0.0) 9 (8.6%) Transportation 78 (52.0) 49 (62.8) 7 (9.0) 22 (28.2%) Legal Assistance 75 (50.0) 35 (46.7) 11 (14.7) 27 (38.6%) Employment Assistance 73 (48.7) 33 (45.2) 13 (17.8) 27 (37%) Healthcare 68 (45.3) 34 (50.0) 10 (14.7) 24 (35.3%) Government Benefit Assistance 65 (43.3) 36 (55.4) 7 (10.8) 21 (33.8%) Issues for Children 64 (42.7) 44 (68.8) 5 (7.8) 15 (23.4%) Help with Financial Barriers 63 (42.0) 23 (36.5) 5 (7.9) 35 (55.6%) Educational Assistance 61 (40.7) 23 (37.7) 8 (13.1) 34 (75.4%) Keeping Current Housing 53 (35.3) 31 (58.5) 4(7.5) 18 (33.7%) Childcare 46 (30.7) 26 (56.5) 2 (4.3) 18 (39.2%) Help with CPS 43 (28.7) 25 (58.1) 2 (4.3) 16 (37.6%) Immigration Support 40 (26.7) 22 (55.0) 7 (17.5) 11 (27.5%)

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p < 0.01) or Other race/ethnicity (OR = 0.20, p < 0.05) were less likely to have contact with their partner. None of the independent measures or co-variates were significantly associated with decreased abuse, probable PTSD, physi- cal health, or social support. Participants who identified as Black (B = 0.71, p < 0.05) or Hispanic (B = 0.60, p < 0.05) had significantly higher levels of social support. Partici- pants not living in transitional housing or shelter (B = 0.58, p < 0.05) had significantly higher levels of social support.

Since over 86% of participants indicate abuse had decreased or not happened, an exploratory analysis was con- ducted to understand more about the 13% of participants (n = 17) that indicated their abuse experiences had gotten worse or stayed the same. Exploratory analyses showed a similar percentage (44%) of participants indicating increased and decreased abuse had active protective orders, though, among those with protective orders, those that had their orders violated in the last 6 months were more likely to indicate increase abuse (75%) than those with no violation (19%). Participants indicating their former partner had a DV conviction were significantly more likely to report decreased abuse than those without a conviction.

Discussion

The present study examined use of DV services to under- stand the association of service duration, amount of time spent with advocate (or primary staff member), and feelings of connection with advocate on the core goals of DV programs including: improved mental and physical health, decreased abuse/increase safety, social support, and increased resources

in the form of needs met. Regression analysis revealed that increased service duration and connection with advocate were associated with more needs met (resource increase), but were not predictive of improved safety, social support, mental or physical health. Study findings suggest that DV programs are contributing to resource access gains, aligned with some aspects of COR theory (Hobfoll, 2011) and the Five Domains of Wellbeing (Full Frame Initiative, 2020). Further, connec- tion with advocates or primary staff members is a vehicle by which survivors increase resources, also aligned with the wellbeing domains. However, our findings did not offer fur- ther support that DV program service duration and connection with advocate were directly related to the Full Frame domain of safety or social connection. Resource gain could enhance these domains, as posited by COR theory. Other aspects of DV programming and survivor actions beyond connection with advocate and service duration are likely associated with other aspects of COR and the Five Domains of Wellbeing. Positive impacts from longer service durations have been found in previous studies (Ben-Porat & Sror-Bondarevsky, 2018; Goodman et al., 2016a, b). However, McFarlane et al. (2014), found improvements in functioning and resiliency in survivors and a decrease in abuse in those used shelter ser- vices, regardless of the length of time in shelter. For mental and physical health, none of the program practice indicators or covariates were predictive of improved outcomes. Participants in non-residential DV services had higher levels of social sup- port. Our study indicates that duration of services and connec- tion with advocate are important for resource acquisition and needs met, and type of services (residential vs. non-residen- tial), family, and community are important factors in safety and social support.

Table 4 Linear and Logistic Regression Results

* p < .05, **p < .01 †White is referent category for Race/Ethnicity

Linear Regression Logistic Regression

% Needs Met (n = 131)

Physical Health (n = 133)

Social Sup- port (n = 134)

Partner Contact (n = 134)

Abuse Experiences (n = 110)

PTSD (n = 135)

B SE B SE B SE OR 95% CI OR 95% CI OR 95% CI

Service Duration .025* .012 -.05 .06 -.09 .06 1.13 .88, 1.45 .94 .65, 1.35 1.05 .85, 1.30 Connection with Advocate .064** .022 .01 .10 .03 .11 1.00 .64, 1.56 .63 .30, 1.36 1.00 .67, 1.49 Time with Advocate .012 .009 .01 .05 .04 .05 1.05 .87, 1.26 1.41 .88, 2.26 .95 .81, 1.12 Use of Other Services .001 .040 .19 .20 .35 .22 1.33 .58, 3.06 .63 .18, 2.15 1.13 .54, 2.36 Black/† -.009 .061 .28 .29 .71* .32 .26* .08, .87 1.06 .18, 6.27 .59 .19, 1.86 Hispanic/Latinx† .099 .056 .03 .28 .60* .30 .16** .05, .52 1.84 .33, 10.17 .55 .19, 1.58 Other Race† .084 .068 .35 .35 .27 .37 .20* .05, .86 .29 .05, 1.58 .61 .17, 2.17 Employment .015 .041 .13 .21 -.37 .22 2.56* 1.08, 6.02 1.55 .44, 5.40 .76 .36, 1.62 Housing -.064 .047 .03 .23 .58* .25 1.18 .47, 2.95 1.52 .36, 6.43 .63 .27, 1.48 Minor Child -.091* .044 -.04 .22 .32 .24 2.70* .98, 7.44 .68 .18, 2.62 1.59 .71, 3.58 Culture respect .027 .034 -.05 .06 -.09 .06

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Covariates also significantly predicted some program out- comes. Having a minor child predicted more needs met, and potential for increased safety concerns in the form of part- ner contact, possibly due to nearly significant more contact with the former partner. The latter is potentially explained by child custody exchange, which is a documented safety risk for DV survivors (Saunders & Oglesby, 2016), even when protective orders are in place (Fleury-Steiner et al., 2016). Participants identifying as Black, Hispanic or another non- white race/ethnicity had less contact with the former partner and had increased social support. Yet, it could be possible that less contact with the former partner for BIPOC partici- pants is associated with historical criminal justice responses in these communities that typically arrest and incarcerate Black and Hispanic men at higher levels than White commu- nities (Stark, 2004). Additionally, increased social support within these populations may explain the reduced contact with partner in part, with increased support systems poten- tially decreasing reliance on the abusive partner. Increased levels of social support among Black women is unsurprising based on the extant literature that Black women typically prefer informal support, and social support is considered a key cultural-level protective factor within the Black com- munity enhancing resiliency and mitigating negative health impacts (Catabay et. al, 2019; Dale & Safren, 2018; Howell et. al, 2018; Mitchell et. al, 2006; Raj et. al, 1999). Yet, the topic of social support among women with DV histo- ries merits more exploration and may provide guidance for advocates in broadening social support for survivors. Recent research indicates survivors’ needs for more economic sup- ports focused on employment, housing, flexible funding and childcare, as well as needs for more culturally specific services which can highlight the protective strengths of cul- ture identities and address systemic forms of discrimination (Burman et al., 2004; Gillum, 2009; Ragavan et al, 2018). In addition, for marginalized groups, DV occurs in tandem with structural oppression that often limits access to needed resources after violence (Ghanbarpour et al., 2018). While increased perception of respect for cultural background was not significantly associated with needs met, social support or physical health, future studies should explore the impact of microaggressions, racial injustice, white privilege, and staff diversity in DV program outcomes (Donnelly, et al., 2005; Nnawulezi & Sullivan, 2014).

Participants overwhelmingly indicated that their safety had increased, or improved, since working with the DV program. Over 75% of participants reported a decrease in abuse since engaging in services. Common safety-related participant needs met by the DV program included a safe place to live (emergency shelter or housing), emotional support (counseling), and safety planning. DV programs were less successful in helping survivors with education, employment, and other economic barriers. Experimental

analysis from this study indicates that survivors with a pro- tective order violation reported more abuse experiences. High levels of social support for those in non-residential services is supported by findings from previous studies indicating that survivors may build better social networks in housing opportunities outside of shelter and on-site transitional housing (Clark et al., 2018). Non-residential DV services have been previously found to be effective. Lyon et al. (2012) surveyed over 1400 survivors in four states from over 90 programs and found that DV survivors reported high rates of satisfaction with non-residential DV services and significant positive change in their lives, including knowing more ways to plan for safety, increased knowledge about community resources, and feeling more confident in making decisions (Lyon et al., 2012). These findings indicate that DV programs help facilitate increase safety and decrease abuse, but other relational and com- munity factors are more contributive to social support.

Perhaps most critically, this study provides additional support for the need for connection, or what Goodman and colleagues (2016a) call “alliance” in DV services. Strong alliance, or partnership, between survivors and advocates have been associated with positive outcomes, such as increased safety, needs met and decreased depression (Wood et al., 2020; Goodman et al., 2016a, b; Ham-Rowbottom, et al., 2005; Lyon et al., 2008; Sullivan & Bybee, 1999). Amount of time spent with an advocate was not signifi- cantly associated with needs being met or other improved wellness outcomes, but connection with the advocate and overall service duration were associated with needs met. Prior work in this area has also found that connection is less about time and more about whether the survivor is receiv- ing the support they need (Sullivan & Virden, 2017). This indicates that DV survivors should be able to dictate their pace through services and are able to assert their needs with an advocate with whom they feel aligned with and trust. Previous studies indicate that when survivors perceive this relationship with an advocate is a stable partnership and that the advocate is nonjudgmental and knowledgeable about community resources, the connection and trust can grow stronger over time (Wood et al., 2020).

Limitations

Study limitations to note include that this is a cross-sec- tional study with a sample that was actively help-seeking and had recent service experiences, with a wide-range of service duration. It is not clear how DV survivors that had not sought help at all may present across physical and psy- chological health measures. We also are unable to know how service experience may have changed, for better or worse, over time, and given the wide service duration, we lack precision on the optimum duration. Although PTSD

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was measured, a depression scale was not included which could have provided additional context related to psycho- logical well-being. While unintentional, no male or trans survivors were recruited for the study, limiting our ability to comment on the experiences of non-female survivors. Some constructs included small sample sizes, for example those who rated abuse experiences as being worse, which would benefit from qualitative analyses to better understand the context behind changes in perception of safety. We lacked a separate measure to assess perception of safety, relying on contact with partner was used to understand some aspects of safety. Finally, our study lacked a comprehensive assessment of types, frequency and severity of DV experienced by the sample, limiting our ability to look at associations of DV and other trauma with health and mental health.

Recommendations

Despite limitations, this study adds to the growing and needed body of literature on experiences with DV services and associated outcomes (O’Doherty et al., 2014), exploring the extent to which organizational factors such as duration and program context like time and connection with advo- cate or other staff member help meet DV program goals. A key recommendation from this study is, to the extent DV programs are able, time limits on services should be recon- sidered in favor of a survivor-guided timeline that acknowl- edges the individual and environmental restraints DV survi- vors face in getting their needs met, which may be shorter or longer than what agencies typically offer based on individual needs. Removal or easing of time limit policies would neces- sitate additional staffing and resources to extend organiza- tion capacity. Findings from this study indicate additional areas of research, including an urgent need for longitudi- nal evaluation of core DV services that would help to bet- ter understand what factors impact survivor mental health and changes for survivors who vacillate between residential and non-residential services. The lack of significant findings related to health and mental health merits more exploration. While previous studies (Bybee & Sullivan, 2002; Perez et al., 2012) indicate positive program impacts on mental health, we found no significant relationship between time, connec- tion, or dosage on PTSD symptoms. More research is needed to see what specific program factors and interventions help to “move the needle” on improve survivor mental health. While some specialized, culturally-specific DV services and agen- cies have arisen from communities’ organizing efforts around culture and identity, there is a need for more such programs (Burman et al., 2004; Serrata et. al, 2019). Evaluation of culturally specific stand-alone or embedded services could improve understanding about how DV program goals can be more inclusive of cultural needs and improve outcomes and the experiences of survivors.

Given the importance of the advocate role, and the con- nection between survivors and staff to having needs met, more training and supports are needed for advocates to do their jobs. Domestic violence advocates face high levels of occupational stress, burnout, staff turnover, and secondary traumatic stress which can greatly impact their own wellbe- ing, as well as their ability to stay connected to the survi- vors they serve (Kulkarni, et al., 2013; Slattery & Goodman, 2009; Voth Schrag et al., 2021). Comprehensive wellness programs, giving advocates self-autonomy, addressing microaggressions in the workplace, providing adequate pay and intentionally focusing on building resilience and shared power within organizations can lead to better outcomes for both advocates, and thus for survivors seeking their services (Wood et al., 2019; Choi, 2017; Frey et al., 2017; Slattery & Goodman, 2009). Also important is deconstructing what safety and decreased abuse means to survivors, how percep- tions of safety are complex, can change day to day for some and are connected not only to safety from the abusive partner but also safety within social systems (Davies & Lyon, 2014). In this study, a small group of survivors reported the same or worsening abuse. More context gleaned through qualita- tive analyses is warranted to understand what it means to “decrease” abuse and how such safety relates to civil and criminal justice interventions like orders of protection, arrest, and prosecution. Services typically do not occur in silos, as evidenced by the survivors in this and other studies reporting having their needs met across a vast array of services not nec- essarily tied to a DV program. Thus, we also need to better understand how such services and experiences with multiple staff across multiple programs and systems also impact sur- vivor safety, social support networks, and health. Further, the variations in social support for residential and non-residential clients need to be explored further to understand how pro- gram structure impacts survivors in their environments.

Conclusion

Domestic violence services strive to improve survivor well- being by increasing resources and connection, improving health and decreasing or stopping violence. Although little is known about the key factors to improved DV programs’ outcomes for survivors, this study provides some additional evidence to a growing base suggesting that duration of ser- vices and quality of the connection with an advocate are both important to meeting survivors’ needs. The ability to connect with social networks is influenced by personal and program factors. A reconsideration of service time limits to be survivor-defined, in addition to support for advocates to do this challenging work, will help to better meet pro- gram goals. Additional research is needed to assess the role of cultural respect and inclusivity on program outcomes.

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Domestic violence programs merit further rigorous study and resources to provide support to survivors and prevent future violence.

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