A Network Model for Providing Culturally Competent Services for Intimate Partner Violence and Sexual...

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Violence Against Women

DOI: 10.1177/1077801206296984 2007; 13; 190 VIOLENCE AGAINST WOMEN

Carlene Pavlos, Beth Jacklin Nagy and Jay Silverman Daniel J. Whitaker, Charlene K. Baker, Carter Pratt, Elizabeth Reed, Sonia Suri,

Intimate Partner Violence and Sexual ViolenceA Network Model for Providing Culturally Competent Services for

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190

Violence Against WomenVolume 13 Number 2

February 2007 190-209© 2007 Sage Publications

10.1177/1077801206296984http://vaw.sagepub.com

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A Network Model for Providing Culturally Competent Services for Intimate Partner Violence and Sexual ViolenceDaniel J. WhitakerCharlene K. BakerCenters for Disease Control and Prevention, Atlanta, GACarter PrattElizabeth ReedSonia SuriCarlene PavlosBeth Jacklin NagyMassachusetts Department of Public Health, BostonJay SilvermanHarvard School of Public Health, Boston

The Massachusetts Department of Public Health implemented the Collaborative for AbusePrevention in Racial and Ethnic Communities (CARE) project in two Latino communities,in the city of Chelsea and in Berkshire County, Massachusetts. One goal of CARE was tobuild collaborative networks of service providers to provide culturally competent services.Networks of existing community-based agencies that provide a variety of different ser-vices regarding violence against women were established in both locales. This articledescribes the CARE model, network formation, initial attempts to build collaboration andcultural competence, outreach and education activities, and organizational-level changesresulting from the establishment of the networks. The challenges, successes, and lessonslearned in implementing this network model are also discussed.

Keywords: cultural competence; Latinos; violence against women

Background and Rationale

Research regarding the incidence and prevalence of intimate partner violence (IPV)in Latino households is often inconsistent. One national study found that 23.4% ofLatinas report abuse by intimate partners in their lifetime (Tjaden & Thoennes, 2000a).Although this is comparable to the 25.6% prevalence rate among all women in the

Authors’ Note: The article’s contents are solely the responsibility of the authors and do not necessarilyrepresent the official views of the CDC.



Whitaker et al. / Culturally Competent Services for IPV 191

United States (Tjaden & Thoennes, 2000b), some studies have suggested that IPV rates among U.S.-born Latinos are higher than U.S.-born non-Latinos (Sorenson &Telles, 1991). There is also evidence to suggest that, for undocumented and recentlydocumented Latinas, the prevalence of IPV may be as high as 49% (Hass, Dutton, &Orloff, 2000).

Evidence also suggests that Latino women may experience poorer health com-pared to non-Latino women because of IPV. In addition to Latinas’ relative lowerlevels of income, employment, and education (U.S. Department of Commerce,Bureau of the Census, 2002), a lack of resources and cultural isolation may pose spe-cific impediments to Latinas’ awareness of and access to services (West, Kantor, &Jasinski, 1998), and serious health problems may result from underutilization ofhealth care services (Lown & Vega, 2001). Services from social service agencies,hospitals, or the criminal justice system may not be adequate for Latina womenbecause of language barriers or because of differences in the cultural norms (per-ceived or actual) in the way in which services are provided. For example, Latinasmay avoid battered women’s shelters because shelters often require separation fromtheir partner and family, which may be incongruent with the strong value placed onfamily in the Latino culture (Marin & Marin, 1991).

Issues related to lack of resources and cultural isolation may be even more salientfor undocumented Latinas who are abused by their partners. Undocumented womenalso live with fear of deportation (Bauer, Rodriguez, Quiroga, & Flores-Ortiz, 1999;Raj & Silverman, 2002) for themselves or their partner and thus may be unlikely tocontact the criminal justice system in response to partner abuse. Such women mayface a choice between abuse and the economic instability of losing the partner’sincome. In addition, Latina women may fear the response from their family, friends,or community if they contact the criminal justice system. This concern is likelyshared by most women, but it may be exacerbated by the isolation and marginaliza-tion of undocumented and immigrant women (Bauer et al., 1999; Dutton, Orloff, &Haas, 2000).

Programs that offer a set of services based on a single philosophy may not behelpful for all Latino families. Instead, services that are culturally appropriate andaddress the specific issues faced by Latino families may be needed (Gondolf &Fisher, 1988; O’Keefe, 1994; West et al., 1998). But all programs are unlikely tohave the expertise or the capacity to tailor their services to the range of ethnic pop-ulations in need of those services; thus, coordination between agencies may beneeded to best serve Latino families.

This article describes the implementation of a network model involving existingorganizations that serve victims and perpetrators of violence against women (VAW)in two Latino communities to promote the provision of culturally competent servicesand service utilization by Latino families. We describe the network model and its development, activities to promote cultural competence and collaboration, spe-cific education and outreach activities, and agency-level changes in procedures andpolicies to facilitate more culturally competent services for Latino families.



192 Violence Against Women

A Conceptual Network Model for Providing VAW Services toEthnic Minority Communities

The goal of the network model is to increase culturally competent services for aspecific racial or ethnic minority group. Because definitions of culturally competentservices exist at many levels, from individual behavior to institutional practices(Mason, 1995), here we use a broad definition of cultural competence: individualsand organizations having the values, skills, knowledge, attitudes, and attributes towork effectively in cross-cultural situations. The network model is based on thepremise that collaboration and cultural competence are each essential to provideappropriate services to racial/ethnic minorities and that these concepts are related.

Our model is based on the assumption that greater collaboration among existingVAW service organizations will increase the provision of culturally competent ser-vices for specific racial/ethnic minority populations in several ways. Collaborationallows organizations that are more culturally competent to share their expertise withorganizations that are less so. A formal collaboration also allows an organization toutilize the linguistic capacity of a different organization to communicate with non-English-speaking clients. Formal collaborations among organizations enhance orga-nizations’ learning of each other’s service philosophies and procedures, and thisallows for better integration of services for clients and families who must accessmultiple agencies. It may also reduce the need for clients and families to access mul-tiple agencies. Finally, collaborations among agencies dealing with different familymembers (e.g., victims, children, batterers) may result in a more coordinated effortbetween agencies resulting in better services for the entire family. This may be moreconsistent with cultural aspects of many racial/ethnic minorities that are highlyfamily focused, such as Latinos (Marin & Marin, 1991).

The idea of coordinating VAW organizations is not new. One popular approach, thecoordinated community response (CCR), aims to provide a community-wide responseto VAW and to promote cooperation among service agencies. There are various mod-els by which a CCR can be implemented (e.g., coordinating councils, communityinterventions; see Shepard & Pence, 1999), but all have the common goal of promot-ing interagency coordination that will lead to a more consistent response by serviceagencies to improve women’s safety and increase accountability for male perpetrators.The CCR approach has been influential but may not be ideal for the specific goal ofimproving VAW services for racial and ethnic minorities. The CCR approach is typi-cally very broad, involving many agencies, and does not place specific emphasis onproviding services to ethnic or racial minorities that may be underserved. In addition,the CCR approach typically includes significant involvement from criminal justiceagencies (police, prosecutors, courts), and this may reduce the willingness ofracial/ethnic minority families to utilize services because of general suspicion, per-ceived or real discrimination against minorities, or fear of deportation for immigrantwomen (Bauer et al., 1999; Dutton et al., 2000; Raj & Silverman, 2002). The current



approach focuses more on a smaller set of community-based agencies, taking a moregrassroots approach to develop a shared identity between those agencies. By shiftingto a community-based approach and away from a criminal justice approach, the net-work model attempts to address some of the barriers to services for women of racialand ethnic minorities. In this way, the network model may lead to the development ofmore culturally competent VAW service coordination.

Development of the Networks

In 2000, the Massachusetts Department of Public Health (MDPH), with fundingfrom the Centers for Disease Control and Prevention (CDC), initiated the Collabora-tive for Abuse Prevention in Racial and Ethnic Minority Communities (CARE) pro-ject. The goals of CARE were to increase collaboration among VAW serviceagencies regarding services for specified racial and ethnic minorities and to promotemore culturally competent services for those communities. The structure and activi-ties of the networks were determined partly by MDPH and partly by the networksthemselves.

MDPH mandated that (a) a “lead agency” would coordinate and establish formalrelationships, including provision of subcontracts, among a network of agencies thatserved families affected by VAW in specified geographic or cultural communities; (b) the lead agency would hire a bilingual and bicultural network coordinator to orga-nize the activities of the network (at least half-time); and (c) each network would con-sist of at least five types of agencies to cover a range of services. The five agency typeswere a domestic violence prevention and shelter program, a rape crisis center, aprogram for child witnesses to domestic violence, a batterer intervention program, anda program that served refugee and immigrant families affected by VAW. InMassachusetts, the RISE (Refugee and Immigrant Safety and Empowerment) programis a state-funded program whose mission is to provide VAW services to specific lin-guistic and cultural communities. The inclusion of the RISE program was seen as acritical component for promoting cultural competence and sensitivity and, in somecases, to ensure the linguistic capacity to serve the specified community. Because theseagencies already receive funding to provide direct service, the CARE funding was topromote outreach and education, collaboration, and cultural competence.

In addition to mandating the network’s structure, MDPH compiled a list of empir-ically supported activities for networks designed to promote collaboration and cul-tural competence. For example, previous research on group functioning suggestedthat cross-trainings of staff across agencies, competent leadership, frequent commu-nication and cohesion among group members, and egalitarian decision making(Butterfoss, Goodman, & Wandersman, 1996; Fawcett et al., 1995; Kegler, Steckler,Malek, & McLeory, 1998; Kegler, Steckler, McLeory, & Malek, 1998) were impor-tant in building a strong collaborative. Based in part on this literature, lead agencies




were directed to coordinate regular meetings and to hire a bilingual or bicultural net-work coordinator with provided funds to lead and oversee the network’s efforts.Network member agencies were funded to dedicate staff to the network who wouldparticipate in meetings, cross-trainings, collaboration, and cultural competencetrainings; develop referral protocols among agencies; and develop and implementjoint outreach and education activities. It was assumed that the implementation ofother specific activities to build collaboration and cultural competence would varyby network and would depend on the target population, staff involved, location, orspecifics around the organizations involved in the network.

Initial Implementation of the Network Model

MDPH awarded funds to networks serving African Americans (in Boston),Cambodians (in Lowell), and Latinos (in Berkshire County and in the city ofChelsea). This article focuses on the two networks that serve Latino communities:one in Berkshire county (referred to as CARE Berkshire) in the western part ofMassachusetts and the other in the city of Chelsea (referred to as CARE Chelsea) inthe greater Boston area. These two settings provide contrasting contexts in which thenetwork model was implemented.

Berkshire County is a rural county in Massachusetts. It is the second largestcounty in area in the state, but its population of 134,953 represents only 2% of stateresidents (Community Development Corporation of South Berkshire, 2002). A size-able portion of the county’s residents (50,000) live in the city of Pittsfield. Censusdata (U.S. Department of Commerce, Bureau of the Census, 2000) suggest a smallpercentage of Latinos in Berkshire County (1.7%), but other data suggest thenumbers may be far greater, possibly because of an influx of Latinos that the censusdata may not reflect. Specifically, data from the Pittsfield School District showed an18% enrollment of Latino children. More than 30% of Latinos in Berkshire Countyreport incomes below the poverty level (U.S. Department of Commerce, Bureau ofthe Census, 2000). CARE Berkshire initially consisted of nine representatives fromthree different agencies (some provided multiple services), all located in Pittsfieldand all within walking distance from one another. Of those members, only two wereSpanish-speaking Latinos.

The city of Chelsea is part of the greater Boston metro area and has a populationof 35,080 (U.S. Department of Commerce, Bureau of the Census, 2000). Latinosrepresent 48.4% of the population, and there is considerable diversity within theLatino population, with about one third from Puerto Rico, one fourth from CentralAmerica, and smaller proportions from Mexico, the Dominican Republic, Cuba,Colombia, and other countries in South America (U.S. Department of Commerce,Bureau of the Census, 2000). More than one fourth live below the poverty level, andamong Latino households, almost one fourth are single female-headed households





(U.S. Department of Commerce, Bureau of the Census, 2000). CARE Chelsea beganwith six individuals from five different agencies, all of which were within 1 mile ofeach other, with one exception located approximately 10 miles away. Five of the sixCARE Chelsea members were Latina and Spanish speaking.

Data Collection

Data are being collected to document how the broad guidelines of the CARE modelare implemented by each network for the specified cultural community, along with thebarriers, challenges, and solutions related to implementation. Data are collected fromvarious sources, including each network coordinator, all network members, and theMDPH program director charged with oversight of the project. Methods for collectingthe data include monthly reports, service utilization reports, interviews, surveys andparticipant observation of meetings of the lead agencies, meetings of each network,and network-sponsored events. Because the focus of this article is on documenting theinitial activities of the networks, the data used here are taken primarily from themonthly reports completed by the network coordinator, the semiannual interviews withthe network coordinators and program director, and participant observations from net-work meetings and events. Network coordinator monthly reports document activities,such as attendance at meetings, trainings, outreach activities, educational materialsdeveloped, contacts, and products generated and distributed. Semiannual interviews ofthe network coordinator assess various aspects of network functioning, including net-work goals and progress toward those goals; working relationships including decisionmaking, conflict, and division of labor; network activities, accomplishments, and suc-cesses; linkages made with the community; and outreach and education activities.Participant observations of network meetings and events documented what occurredand the issues that were raised.

Network Building, Outreach and Education,and Agency Change

Network-Building Activities

For each network, much of the first 2 years was spent building the network byestablishing collaborative relationships, understanding each agency’s services, anddeveloping a mission and goals for the network. Table 1 includes some of the majornetwork-building activities for each network, including MDPH-mandated activities.To help build each network, MDPH required that networks develop memoranda ofagreement among agencies, hold regular network meetings, establish mission state-ments and goals, conduct cross-trainings between member agencies, and receive




trainings from external experts on coalition building and cultural competence. Thecoalition-building training focused on the formation of a collaborative effort and theimportance of pooling resources to more successfully serve the community. It alsoincluded training on creating work plans, documenting activities, and communicat-ing more effectively with each other. The cultural competence training included dis-cussions about the importance of defining cultural competence; understanding that a

Table 1Network-Building and Outreach and Education Activities by Network

Chelsea

Coalition-building traininga

Cultural competence traininga

Monthly meetingsa

Cross-trainingsa

Chelsea

Meetings with Domestic ViolenceUnit in the Chelsea PoliceDepartment

Undoing Racism workshopCommunity breakfastNetwork coordinator–facilitated

12-week program for fathers onprobation

Present CARE information to teenmothers

Peace in the Family dayMen’s initiative eventCollaboration with Chelsea DVTF to

sponsor giveaways (e.g., Mother’sDay and Father’s Day cards)

Provided police with CARE cards todistribute on VAW calls

Weekly radio call-in show

Network-Building ActivitiesBerkshire

Coalition-building traininga

Cultural competence traininga

Monthly meetingsa

Cross-trainingsa

Trainings: diversity, language, culture, immigration, workingwith Latino men

Outreach and Education ActivitiesBerkshire

Establish linkages, networking, and building relationships with outside agencies: presentations on CARE toDepartment of Social Services, homeless shelter, localemployment programs, SANE (Sexual Assault NurseExaminer) program, police

Annual conference for service providers about the need forculturally competent services for Latinos

Resource booklet and map of CARE agencies distributed tosocial service agencies and businesses

Radio showCable TV showImmigrant DayNumerous professional education trainings to a variety of local

agencies

Note: CARE = Collaborative for Abuse Prevention in Racial and Ethnic Communities; DVTF = DomesticViolence Task Force; VAW = violence against women.a. Massachusetts Department of Public Health mandated activity.



competent response may differ depending on the cultural group; reducing culturalmisinformation based on stereotyping and generalizing; and how political, social,and economic contexts shape the work on VAW. It also emphasized the need foragencies serving minority communities to institutionalize culturally competent out-reach into their mission statement and practice.

In CARE Berkshire, because the initial CARE membership included only twoLatina network members, additional educative trainings were held to increase thecultural sensitivity of network members and other staff from the network agencies.The first was conducted by a local legal services organization and provided infor-mation about the rights of VAW victims who did not have legal status. Two othertrainings focused on providing information about Latino culture, diversity withinLatino populations, and working with Latinos where a language barrier may exist. Afourth training focused on working with Latino families and was conducted by anexpert in that area. This training included a discussion about barriers to reachingabused women in immigrant and refugee communities (i.e., cultural and languagebarriers, fear of deportation, fear of the police, fear of economic survival) and theneed to understand the importance of family and community in the Latino cultureand adapting the agency’s framework to these values.

CARE Chelsea’s membership was made up primarily of Latina members (5 of 6members). CARE Chelsea was slower to implement network-building activitiesbecause of initial staff turnover and internal management difficulties within networkmember agencies that led to inconsistent representation of agencies at CAREChelsea’s monthly meetings. (Such experiences are typical of underfunded, nonprofit,community-based organizations.) The member agencies of CARE Chelsea each werea part of the Chelsea Domestic Violence Task Force (DVTF), which had been in placefor more than 10 years. Thus, although some of CARE Chelsea members may havebeen accustomed to working with one another, it took some time for members to growaccustomed to the differing structure, roles, and responsibilities of the CARE project.Once staffing stabilized and roles in CARE Chelsea appeared to become clearer, net-work members chose to focus on developing a mission statement, conducting cross-trainings to educate clients and each other about agency services and client needs, andcreating a new interagency referral policy. CARE Chelsea also focused on planningoutreach and education activities, many of which were cosponsored with the DVTF.

Education and Outreach Activities

Each network created a work plan for conducting education and outreach activi-ties in their respective Latino communities. Although there was not a formal needsassessment conducted, the selection of education and outreach activities was basedon the members’ collective experiences providing direct crisis intervention servicesin the community. The work plans developed by each agency that would determinethe specific activities to be conducted were planned during the first several months




of work for the networks and continued to evolve over time. The purposes of theeducation and outreach activities were to provide information to non-CARE agen-cies and the Latino community about the nature and scope of the problem of VAW(education) and to provide culturally and linguistically accessible information aboutavailable services to referral sources and potential clients in the Latino community(outreach). Although MDPH required that networks conduct education and outreachactivities, the specific types of activities were left up to each network (see Table 1for a partial list of these activities).

CARE Berkshire’s primary education and outreach activities had several aims: toincrease the awareness of members and providers in the community of CARE ser-vices and educate them about VAW issues; to educate providers on the provision ofculturally competent services; and to provide education and services beyond thescope of VAW to community members to attract a broader audience.

Efforts at raising awareness about CARE services to non-CARE agencies focusedprimarily on meetings and trainings. For example, the network coordinator met with theDepartment of Social Services (DSS; the state child protection agency) to try toincrease referrals of Latina families from DSS to CARE agencies with the goal of orga-nizing a support group for Latina victims of VAW involved with DSS. Additional pre-sentations were made to a local homeless shelter, a training and employment program,the SANE (Sexual Assault Nurse Examiner) program, and local law enforcement.

Outreach and education directly to the Berkshire Latino community took severalforms. CARE Berkshire created a resource booklet for all social service agencies inBerkshire County (e.g., schools, clinics, hospitals, adult learning centers) to distrib-ute to their Latino clients. The booklet was printed in Spanish, identified CARE net-work agencies and other resources, and provided information about health, housing,child care, employment, counseling and support, English as a second language(ESL) and legal services, and food pantries in the community. In addition, a mapshowing the location of these services and the CARE Berkshire agencies was dis-tributed. CARE Berkshire also hosted a morning radio show and a cable access tele-vision program. Program content included a discussion with children regarding theirperceptions of violence in their lives, a conversation among Latino women aboutdomestic violence in their community, information about obtaining a restrainingorder and the limitations of restraining orders, an information session on the batter-ers’ intervention program, and a segment on sexual assault prevention and services.Importantly, to attract a broader audience, discussion of these issues was embeddedin programming not specifically focused on VAW (e.g., music, dancing).

To promote the provision of culturally competent services among both their ownnetwork agencies and other local providers, the network hosted an annual conferenceaimed at educating social workers, counselors, teachers, attorneys, and others about theprovision of culturally competent services to Latino communities. Conference atten-dees were also given basic information on immigration law, sexual abuse in Latino cul-ture, cultural competence, and social issues and traditions in Latino families. For





instance, presentations focused on the importance and role of family unity, loyalty, andcooperation in Latino culture; machismo and its role in VAW; nontraditional healingmethods in Spanish culture; and information about Latino culture and Immigration andNaturalization Services, the police, and racism.

CARE Berkshire also increased their exposure to the community by sponsoringan event not specifically addressing VAW but addressing one of the primary needsof the community. CARE Berkshire achieved this by sponsoring an Immigrant Dayat which Latinos from the community could receive a free consult from 1 of 4 attor-neys present. The event also included speakers from several immigrant advocacycoalitions who discussed community services for citizenship assistance, ESLclasses, and visas and current state and federal legislation about immigration. Closeto 100 people attended, with about half seeking legal consultation from an attorney.Most had questions about the Violence Against Women Act (e.g., political asylum,deportation), family-based issues (e.g., green cards), and employment-based issues(e.g., sponsorship). This turnout exceeded expectations and was noted as a great suc-cess by CARE Berkshire.

CARE Chelsea’s education and outreach activities also had several aims: to inte-grate their services with other services, to educate providers on the provision of cul-turally competent services and about CARE Chelsea, and to conduct communityoutreach and education. CARE Chelsea held a series of meetings with detectives inthe Domestic Violence Unit of the Chelsea Police Department to provide informa-tion about the batterers’ intervention program and to discuss how CARE Chelsea andthe police could work together on VAW prevention. Results of these meetingsincluded the distribution of IPV palm cards and brochures by officers responding todomestic violence calls.

To promote more culturally competent services among providers in the commu-nity and educate providers about CARE, CARE Chelsea focused attention on racismin the community by sponsoring a large workshop, titled Undoing Racism, con-ducted by a national training organization. The workshop discussion focused on thestructural, political, social, and economic underpinnings of racism and the interac-tion of racism with issues related to VAW. CARE Chelsea also hosted an annualcommunity breakfast for service providers, business owners, and local officials todiscuss service needs of the Latino community, issues of VAW, and CARE services.These events led to opportunities to work directly with the community. For example,the CARE Chelsea network coordinator was asked to facilitate parts of a 12-weekvoluntary program for fathers currently on probation (half of whom were Latino),which included information about signs of VAW, child safety, first aid and CPR, cus-tody issues, social support, and the impact of violence on children. The network wasalso asked by an agency that served teen mothers to present information about VAWand sexual violence to their clients.

CARE Chelsea’s outreach and education activities to the Latino communityincluded health fairs with giveaways, community events, and a radio call-in show.



For example, CARE Chelsea hosted a Peace in the Family Day, at which refresh-ments were provided and information on the DVTF and services offered by CAREagencies were distributed. The network also hosted a Men’s Initiative Event, inwhich group discussions were held on how to better promote men’s involvement inthe prevention of VAW. The event was attended by professionals (e.g., probation offi-cers, child protection service workers, men who worked at various social serviceagencies) and by men from the community.

CARE Chelsea cosponsored and participated in other community-based events inwhich information was distributed about the network in various ways. For Valentine’sDay, CARE Chelsea distributed heart-shaped key chains with anti-VAW messages andthe network member shelter hotline number on them. Similarly, CARE Chelsea dis-tributed Mother’s and Father’s Day cards with token gifts included.

As with Berkshire, CARE Chelsea hosted a weekly call-in radio show. Topicsincluded family life, health and stress, abuse and controlling behavior in relationships,restraining orders, safety planning, myths and facts about VAW, Chelsea CARE ser-vices, renewing temporary work permits, and child protection services. Although theimpact of the radio program was not formally evaluated, the network coordinatorreported receiving several calls to her agency that referred to the radio show and tele-phone requests to reinstate the show when it was temporarily suspended.

Policy and Procedural Changes That Grew Out of Network Activities

Implementation of the network model in Berkshire and Chelsea led to a number ofchanges in policy and procedures among the CARE member agencies to improve ser-vices for Latino families. Table 2 shows the major changes observed at each network.At CARE Berkshire, for example, individual agencies’ ability to support culturallyappropriate services for Latinos has increased, as evidenced by the fact that all networkmembers completed a Spanish-language class and that staff at all CARE agencies arenow able to have a simple conversation with Spanish-speaking clients. This basicchange is a necessary (but not sufficient) condition for providing culturally competentservices. In addition, agency materials referring to CARE activities are translated intoSpanish to accommodate non-English speakers, and all public materials from eachagency are being translated to Spanish (e.g., the batterer intervention program pur-chased a curriculum in Spanish and now offers services in Spanish).

Several other changes in practices and policies have been made to accommodateLatino clients. Staff from the domestic violence shelter now conduct home visitswith Latina victims when it is safe to do so (e.g., when victims do not report dan-ger). This is important as domestic violence is often a private issue for Latinas, andthey may not seek help by going to a shelter. The shelter has also changed its poli-cies regarding duration of shelter stay and victim privacy so that women with immi-gration issues no longer have a restriction on the duration of their stay. This is





important because women who are not legal residents may have few other optionswith regard to housing. In addition, Latina shelter residents are now able to requestthat their extended families be told where they are (or the advocate can contact thewomen’s family to tell them they are safe). These new policies are meant to addressthe frequent lack of follow-up on services by Latina clients noted by agency staff.Such policy changes have been received positively by other local service providerswho have responded with an increase in referrals of Latino families. Because thesepolicy and practice changes are changing service provision and referrals, they mayalso affect service utilization of CARE agencies by Latino families.

Among CARE Chelsea agencies, concrete changes to policy and practice that directly affect clients have also been observed. One important change is greater

Table 2Concrete Changes Seen in Agency Policy and Lessons

Learned by Network

Chelsea

Greater coordination between battered women’sprogram and Batterer Intervention Program(BIP). BIP staff now accompany victims tobattered women’s program

HarborCov staff conduct home visitsIncreased length of shelter stay for Latina clients

facing immigration issuesEstablish referral system

Berkshire

Members are conversational in SpanishAgency materials translated into SpanishBIP purchased Spanish curriculumNo limit on length of stay for women with

immigration issues at DV shelterFamily or friends now allowed to accompany

victims to initial visit at DV shelterLatina residents at DV shelter able to inform

families of where they are and thatthey are safe

Bilingual, bicultural community-basedstaff are critical

Agency policies may need to be adapted toprovide culturally competent services

Involve men in education and outreach activitiesAddress VAW in the context of other servicesIntegration of services are important in keeping

Latino families engaged in servicesVAW service delivery should include the entire

family

Note: DV = domestic violence; VAW = violence against women.

Lessons Learned in Implementing CARE

Concrete Changes in Agencies’ Policies and Interactions by Network



coordination between the batterer intervention program and battered women’sprogram. Staff from the batterer intervention program routinely conduct initial part-ner contacts over the phone to provide victims with information about available ser-vices. An important addition to this protocol is that staff from the batterer programare now often accompanying the woman (on request) to the battered women’sprogram to provide support. Many women have expressed an appreciation of thisnew policy. This method of referral may be particularly important for Latina clients,who may be unwilling to seek services without assistance because of language orother barriers (West et al., 1998). The referral system also allowed staff from differ-ent agencies—even staff who did not directly participate in CARE—to communicateand share information about working with culturally diverse populations. A secondchange is that, as in CARE Berkshire, the battered women’s program in CAREChelsea has increased the length of shelter stay for undocumented clients.

Challenges in Implementing the Network Model

Challenges in implementation were reported in network coordinator interviewsconducted in the second and third years of funding. For CARE Berkshire, barriers inthe second year were primarily tied to staffing issues and the lack of Latina serviceproviders in the CARE network. With only two Latinas in the network, it was diffi-cult to conduct outreach in the community. Furthermore, for safety reasons, the iden-tity of staff members who acted as victim advocates had to be protected, and thusoutreach and education activities often fell solely on the network coordinator.Because of the lack of bicultural advocates, the Berkshire network coordinator wasforced to balance providing direct crisis intervention services with coordinatingCARE and conducting CARE activities.

In Chelsea, one of the initial major barriers to implementation was the unstablenature of the staffing of the network. As noted, during the first 2 years, there wasconsiderable staff turnover among network members, and this resulted in inconsis-tent meeting attendance that made it very difficult to develop a cohesive network andto coordinate work efforts. Another challenge was that one agency (the rape crisiscenter) is not physically located in the city of Chelsea. This caused networkmembers from that agency to feel somewhat isolated from the other members, andit caused difficulty in coordinating their participation in monthly meetings and com-munity events.

Both Berkshire and Chelsea faced a similar challenge in the third year, when statefunding was cut for several agencies involved in the CARE network.1 In Berkshire,the funding cuts led to staff reductions, and the network retained only 4 of the orig-inal 9 members. This made completing network activities difficult. As stated by thenetwork coordinator,




The loss of all these personnel led to a breakdown of the system. Some people whoknew they were leaving stopped working on CARE tasks. Before these changes, wehad adopted a good system of sharing responsibility; now things have sort of fallenapart, and we need to regroup and redelegate responsibilities.

In Chelsea, the budget cuts compounded an existing problem of an unequal distrib-ution of work, with work to be divided among even fewer individuals. The CAREChelsea network coordinator described the impact:

There was a loss of morale associated with the cuts. People are not as motivated. It isdifficult to plan stuff because people are not sure if they will be able to keep their jobs.This has limited network activities tremendously.

Discussion

Efforts such as CARE are important because of structural and programmaticinadequacies in addressing the specific needs of racial and ethnic minority familiesand because of the great service needs of those families concerning VAW. From theinitial implementation of the CARE model in Latino communities, there are severalimportant lessons that can inform future VAW work with Latino communities. Thesefall into three broad categories: organizational policy and staffing, outreach and edu-cation, and delivery of services. The major lessons learned are bulleted in Table 2and discussed in some depth below.

Several organizational issues were noted as important in providing culturally sensi-tive VAW services to Latino families. A first is the importance of community-basedorganizations and Latina staff within those organizations and, in particular, the bilin-gual or bicultural network coordinator. The CARE Chelsea network coordinatordescribed the importance of being Latina when conducting education and outreachactivities: “It helps to understand the cultural differences within the Latino communityas a whole but also for specific cultural traits of people from different parts of LatinAmerica.” This illustrates the need for Latino staff who understand Latino history andnorms to attain a more advanced level of cultural competence (Mason, 1995).

Another organizational issue is that agency policies must be adapted to provideculturally competent services for Latino families. Agency policies directing shelterstays were altered in both Berkshire and Chelsea, and policies directing immigrationstatus and confidentiality were changed to better meet the needs of Latino families inChelsea. In describing the importance of this issue, the CARE Chelsea network coor-dinator stated that Latino women may be “afraid that immigration is going to get bat-terers” and that “victims need to be assured that confidentiality will be kept and thattheir legal status is not a factor.” Some of these changes contradict the established, tra-ditional framework for providing VAW services, and there was conflict around the





decision to allow some Latinas to contact their families, thereby revealing the shelterlocation. This conflict centered around the tension of serving a more diverse set ofclientele in a culturally competent manner while maintaining a confidential shelter toassure the safety of all shelter clients and staff. Changes in policies and proceduresthat are made to provide culturally competent services for Latino families may needto be balanced with policies and procedures for ensuring victim safety.

The experiences of the CARE networks also offer lessons on conducting outreachand education. One of these was the importance of including men in outreach andeducation for prevention activities. Several of the CARE activities were specificallytargeted to men. Although the issue of machismo in Latino and other cultures hasbeen characterized as contributing to the domination of women by men, there arealso positive aspects associated with machismo, including being a good provider forone’s family (Marin & Marin, 1991). Involving men in prevention activities isimportant for promoting the positive aspects of machismo, along with other positiveaspects of the Latino culture, to change the norm so that taking care of one’s familymust exclude violent acts and thereby eliminate the toleration of violence.

Another lesson learned that can be used to improve outreach, education, anddelivery of VAW services—a lesson noted by other authors (Perilla & Perez,2002)—is that VAW may best be addressed in the context of other services or out-reach and education activities. This is important because of the difficulty of dis-cussing VAW issues directly in Latino cultures. As the Berkshire networkcoordinator stated,

There is a shared understanding that Latinas cannot talk about sex. . . . I have to becareful in talking about domestic violence and sexual assault. Having the cultural con-nection and the references allows me to work in the community without the womenhaving to own up and talk about specifics.

Latinos’ avoidance of discussing sexual activity is illustrated by changes in thenumber of responses to CARE Chelsea’s radio show; relatively few calls werereceived when the discussion topic was sexual abuse, but more calls were receivedwhen the discussion of sexual violence was integrated with other topics, such as dis-cussions on child protection services or immigration and employment issues

Integration of VAW services with other service needs is also important because ofthe limited funding relative to the many services needed. Agencies that can providean array of services may be able to reach VAW victims who would not have soughthelp specifically for violence because of lack of awareness or stigma. They also havethe opportunity to offer nonvictims who may be at risk for VAW and are seeking helpfor other issues (e.g., homelessness, immigration) preventive services for VAW.Other authors have argued for the importance of focusing on larger social issuesrather than only on violence (Perilla & Perez, 2002).



Another lesson learned concerning VAW service delivery to Latino families is theimportance of integrating services so that Latino clients, who may be hesitant to accessservices (West et al., 1998), are not forced to weave their way through a complex webof social systems. The formal and informal connections that now exist between CAREagencies (and other agencies with whom they have connected) have facilitated thereferral process and Latino families’ willingness to follow up with referrals. This islikely because of increased trust at both the agency level and the client level. At theagency level, the collaboration and cross-trainings may have increased staff members’understanding of other agencies’ services, their philosophy, the service providers, andhow their services can help, which would contribute to increased referrals betweenagencies. At the client level, if a client trusts a staff member at one agency who thenrecommends contacting a specific staff member from another agency, then the clientmay be more likely to follow up with the referral.

Finally, VAW service delivery to Latino families should emphasize the impor-tance of working with all family members. This theme was prominent in severalaspects of the network activities: the training on working with Latino men, efforts toorganize a support group for Latina VAW victims involved with child protection ser-vices, and efforts to alter policies at shelters to be more inclusive of Latino families.This theme may be a direct result of the collaborative nature of CARE as networkmembers whose focus was on individual family members (i.e., female victim, maleabuser, and the children) came to understand the service needs of other familymembers.

Sustainability of the CARE Model

One of the critical questions about the CARE model is whether it can and will besustained beyond the funding period and what factors are important for sustainabil-ity. Currently, funds are used to employ the network coordinator, to partially reim-burse agencies for staff time to conduct network activities, to conduct networktrainings, and to obtain some materials and transportation. Although ongoing fundsmay be needed for some specific network activities, the hope and goal of the CAREproject is that funds provided to initiate the network will result in many activities thatcan and will be sustained and in the lasting impact of altered policies and proceduresand stronger relationships. For instance, the collaborative working relationships thatwere established between staff members and agencies will ideally continue beyondfunding. This may be seen at the individual level, as indicated by informal workingrelationships between colleagues, or at the agency level, as indicated by changes inreferral processes, memoranda of understanding, or informal collaborative arrange-ments. In addition, any changes in knowledge or skills that assist individuals oragencies in working with the targeted racial/ethnic minority community should havea sustained impact beyond the funding period. Network members and otherproviders who gained an understanding of the norms of the targeted cultural group




and how those norms may help or hinder acceptance of and help seeking for violencecan continue to utilize that knowledge beyond the funding period. Materials that aredeveloped to be culturally competent (i.e., in the appropriate language and with theappropriate cultural values emphasized) can still be retained and utilized after fund-ing ends, and the impact that networks have had on educating other providers andthe community regarding the services available may be lasting. Finally, althoughfunds may no longer be available, it may be that the CARE collaborative activitieswill become routinized in the member agencies so that they will be continued with-out specific funding mandates.

Evaluation Limitations and Considerations

The goal of this project is to document the implementation of the CARE Networksand to carefully document the processes by which collaborative relationships aredeveloped (or not developed) to better understand how domestic violence agenciescan work together to conduct culturally competent activities. This represents an ini-tial step in understanding how collaboration between VAW organizations can increaseculturally competent services for racial/ethnic minorities. Many questions remainabout the network model that must be addressed in more rigorous studies to under-stand which processes are important and whether the network model promotes cul-tural competence and improves services for the specified population. The presentstudy provides clues as to some of the issues that future work may address. Forexample, processes about which we have speculated, such as increased trust amongagency staff leading to increased referrals, could be measured. Important outcomes,such as client satisfaction with services and improved health outcomes, could also bemeasured. Answering these questions would require an evaluation study that wouldinclude more rigorous methodologies than were used here (e.g., comparison commu-nities, empirically defined outcome measures with rigorous measurement methods).Such studies are difficult to conduct with interventions that operate on a systemic ororganizational level for several reasons: assignment to intervention versus control isoften challenging, controlling for variations within organizations that may influenceorganizational behavior is difficult, and measurement of organizational- or community-level variables is less well developed than measurement of individual-level variables.For example, in the current case, organizations within a community that formed a net-work would need to be compared to organizations in the same (or similar) commu-nity that did not form a network. Given the current model in which service providersare locally based, this may not be realistic because it would be difficult to equatecommunities on local norms and to control for local events that may influence orga-nizational and individual behavior. Still, implementation data from the current studysuggest that the model is a viable and efficient way to expand VAW services to spe-cific racial/ethnic minority communities, and thus more work is warranted to under-stand the impact of the model.





Conclusion

Latino families may face particular challenges in accessing service delivery orga-nizations and in receiving care that is culturally sensitive. Because funds and per-sonnel resources are scarce in VAW service organizations, it is unrealistic to expectall service agencies to be able to provide linguistically appropriate services frombicultural staff for families of all racial and ethnic groups. Collaboration among ser-vice agencies can maximize the efficient use of financial and personnel resources sothat the culturally sensitive services can be provided to as many families as possible.

Note

1. The funding for rape crisis centers was cut by 67%, and funding for Refugee and Immigrant Safetyand Empowerment programs was eliminated.

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Daniel J. Whitaker received his PhD in social psychology from the University of Georgia in 1996. Heis a behavioral scientist and team leader in the Division of Violence Prevention at the Centers for DiseaseControl and Prevention. His research interests include primary prevention of partner violence and childmaltreatment.

Charlene K. Baker, PhD, is a behavioral scientist in the Division of Violence Prevention at the Centersfor Disease Control and Prevention. Her areas of interest are intimate partner violence and its relationshipwith parenting and homelessness and the development of multilevel responses to violence prevention. Asa community psychologist, she is particularly interested in developing comprehensive interventions toreduce the prevalence and impact of intimate partner violence that include all levels of social ecology(e.g., individual, family, systems, community, society).

Carter Pratt works for the Massachusetts Department of Public Health as an evaluator for theCollaborative for Abuse Prevention in Racial and Ethnic (CARE) Minority Communities Project. She hasworked in the field of violence and injury prevention for the past 10 years, conducting program evalua-tions and research. She graduated from the University of California, Berkeley’s School of Public Healthwith an MPH.

Elizabeth Reed is a doctoral candidate in the Harvard School of Public Health and an evaluator for theCollaborative for Abuse Prevention in Racial and Ethnic (CARE) Minority Communities Project.

Sonia Suri, PhD, is an anthropologist and an evaluator for the Collaborative for Abuse Prevention inRacial and Ethnic (CARE) Minority Communities Project.



Carlene Pavlos, MTS, is the director of the Division of Violence and Injury Prevention (DVIP) at theMassachusetts Department of Public Health, whose programs work to prevent injuries and violence andto promote and provide effective response systems for those impacted. She is the principal investigatorfor the Collaborative for Abuse Prevention in Racial and Ethnic (CARE) Minority Communities Project.

Beth Jacklin Nagy, MPH, has worked on violence prevention issues for more than 15 years. She worksat the Massachusetts Department of Public Health (MDPH) in the Division of Violence and InjuryPrevention as the program director of the Collaborative for Abuse Prevention in Racial and EthnicCommunities (CARE).

Jay Silverman, PhD, is assistant professor of society, human development and health, and director of vio-lence prevention for the Division of Public Health Practice at the Harvard School of Public Health. Hisresearch focuses on the etiology and prevention of violence against adolescent and adult women andagainst the children of abused women.




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