Part 1 of 3 parts

Social determinants of health is an issue that stretches across borders, touching every facet of many lives in Washington. Addressing it requires a shift in how individuals and institutions think about these determinants, including employment stability, neighborhood safety, accessibility to education and health care and discrimination.

The Verdant Health Commission brought four local researchers and educators together March 9 to discuss strategies for addressing social issues affecting mental and physical health. The presentations were part of a Verdant-sponsored Community Wellness Day.

Speakers included University of Washington Assistant Professor Rabi Yunusa and Professor Patience Jaman, Ph.D. student Daniela Muñoz Lopez, and primary care physician Dr. Margaret Towolawi. Attendees had the chance to interact with the speakers, engaging in discussions and asking questions.

“Today is the day about bringing resources to the community,” said Verdant Health Commission Superintendent Lisa Edwards, who opened the event. “It’s about connecting resources to our residents. We’re excited to bring together a distinguished array of presenters.”

In partnership with the Washington West African Center (WAWAC) and the UW School of Public Health, Lynnwood resident Yunusa covered the roots of domestic violence among West African women in the U.S. and ways to prevent it.

“People think violence is something physical or sexual,” she said. “If we don’t see blood, it’s not violence. That’s not true. There’s also emotional. Anything that has to do with having power and control over someone.”

Yunusa said that domestic violence in West African communities is gendered, meaning that there is a set of fixed gender norms. Men would go to work and most women would stay home and raise children. Anyone who steps out of these gender norms would get pushback from their community.

She also added that many West African immigrants face a loss of employment and income status when they come to the U.S. For example, men who worked as engineers or doctors in West Africa might not get employed in those professions in the U.S. because their qualifications don’t meet U.S. standards. Without an income or enough savings, they can’t afford to attend school to get the job they want.

“They went from taking care of patients in a hospital to cleaning floors in a hospital,” Yunusa said. “Now we have kids, who will support the kids? All these things, they increase the pressure in the home. Power dynamics happen and suddenly people lash out.”

Domestic violence is “worldwide, it doesn’t matter about your level of education,” she said. “We know things that make it worse, and it is those [social] pressures that make people react violently. The pressures: poverty, not having money, losing your job.” Several women in the audience nodded in agreement and said that they have experienced what Yunusa said. 

Yunusa added that:

• 38% of all murders of women worldwide were committed by their intimate partners
• Women in abusive situations are twice as likely as men to experience depression and have alcohol use disorders
• Women in abusive situations are 1.5% times more likely to get HIV
• Women in abusive situations are 16% more likely to have a low-birth-weight baby
• 42% of women in abusive situations have experienced an injury due to physical or sexual violence from their intimate partner

“Many cultures don’t know about marital rape,” Yunusa said. “Even our judges here, they’re like, ‘I don’t understand. You get married to somebody and that person needs to submit when it’s time for sex. How can your wife refuse you…sex?’”

To address this, Yunusa and her research team at the University of Washington partnered with WAWAC to provide resources and reach out to  West African women in the state. In addition, both parties collaborated to conduct a qualitative study last year to explore issues around survivors of domestic violence.

In a recent study of 34 West African women who were working with WAWAC, Patience Jaman – who works with Yunusa – reported that more than 25% of the sample population stayed in an abusive relationship because they “love” their partner, 17% stayed because they did not want police to be involved and 10% remained because of children and pregnancy. Other reasons include thinking the abuser will change, guilt for the abuser’s family, cultural norms, financial reasons, and immigration papers.

However, 50% of the abused women left the relationship because of family and peer support and 21% left because of “pregnancy loss” or “loss of children.” While such support is mostly financial, Yunusa said these women had family members or friends who would invite them to go back home or go out and have a chat – anything to take them out of the abusive environment.

Other reasons for leaving include personal safety, infidelity, education and awareness, and self-determination.

Some women also said they didn’t call the police because they were afraid that the situation would end in a police shooting. The Washington State Coalition Against Domestic Violence reported that out of 163 police shootings in Washington state in 2015 to 2019, 22 (13.5%) cases were related to intimate partner violence. Blacks, Pacific Islanders and Native Americans are 3.8 to 6.6 times more likely to be killed in an encounter with police than whites in Washington. 

A few of the women did not pursue legal actions against their abusers because they did not have legal documentation to stay in the U.S., Jaman said. Furthermore, if their husbands were taken into police custody, the women could not take care of their kids by themselves.

Yunusa said that Lynnwood Mayor Christina Frizzell had spoken at a WAWAC event last year and mentioned that when someone calls 911 for domestic violence, two Lynnwood police officers show up – one with a firearm and the other without. The officer without the gun then tries to de-escalate the situation. 

However, Yunusa said that relying on the police is not enough. The community has to be involved. “What if we improve education and economic opportunities?” she said. “Just pay more so people don’t have two or three jobs? Maybe we need some kind of pay scale. Why do people need to negotiate their salary? Why don’t we just offer them the right thing? It’s common sense.”

Yunusa suggests several ways to reduce and prevent domestic violence on both the societal and the individual level:

1. Support legislative measures that protect women, such as the federal Violence Against Women Act (VAWA).
2. Increase the marital age. Women with higher education are less likely to experience domestic violence than those with fewer years of education.
3. Engage children and teens in after-school programs.
4. Prevent children and teens from exposure to social media influencers and other media that promotes violence, especially violence to women.
5. Encourage community involvement with programs such as SASA!, which stands for Start, Awareness, Support, Action. (SASA! also means “now” in Kiswahili)

SASA! is an evidenced-based program that focuses on preventing violence at the community level by addressing the root causes of violence against women. Started in Uganda via Raising Voices in 2008, SASA! involves multiple strategies and activities that focus on power dynamics, gender, violence, activism and collective responsibility. 

Research has shown that:

• Physical violence against women was 52% lower in SASA! community groups compared to those that did not participate in SASA!.
• Women exposed to SASA! were three times more likely to get support when they reported violence.
• About 76% of women and men believed physical violence against a partner is unacceptable compared to 26% of women and men in the control group
• In the SASA! group, 28% more women and men believe that it is acceptable for women to refuse sex than the control group.

While there are no local SASA! groups in Washington, WAWAC uses its model as part of its programs, including its after-school programs.

“Last quarter, the students acted a drama where they were talking about the impacts of domestic violence, exposing them early to that kind of content and letting them know that this is not OK,” Yunusa said. “I believe this should start early [in life].”

She pointed out that WAWAC also has a robust Grandma Association where older African women are employed to help deter violence. They hold marital counseling sessions where they often “chastise the men” who have committed violence.

“West African grandmothers have a special power due to their age and resilience,” she said. “It is cultural because they are powerful interrupters of violence and patriarchy. Despite widespread patriarchy, the role of the African grandmother is one of a matriarch, highly respected. So, if they decree that a man must stop the violence, it works. 

“It is cultural to respect a woman because of her age in African culture, I have found that to be untrue in Western settings as elderly women in America lose their power and autonomy with age – high rate of elder abuse and all the elders in care homes,” she continued. “It is rare for African children to put their mother or grandmother in a care home no matter how old or frail she is.”

Yunusa said that men must be engaged with male youths to set positive examples, whether it is a father, a male relative or an imam. “Focusing on the women is a Band-Aid,” she said. “To find the root cause, we have to find out what is pushing this person to do these things, and then we can help. If it’s poverty, maybe this person can have one job instead of three jobs.”

Besides WAWAC, local resources about domestic violence include:

• Washington State Coalition Against Domestic Violence
• The Northwest Network
• Domestic Violence Services Snohomish County

Next: Part 2 –  Social media’s impact on youth mental health.

— Story and photos by Nick Ng