A Critique of Jane Doe, Inc. and the Importance of Branding, Storytelling and Physician Education in Curbing Domestic Violence- Marissa Burpee

Introduction

Across the globe, almost all individuals seek intimacy and companionship. Relationships can be a great source of joy, but for many their intimate relationships are plagued by violence and fear. Domestic violence affects more women, men and children than we know. Worldwide estimates indicate that one in three women is a victim of domestic abuse (1). In America, the CDC estimates that 25 million women have experienced domestic abuse (2). The statistics are alarming. Domestic violence has become one of the most important public health initiatives of our time. Increasing education, awareness, support and laws are just some of the initiatives necessary to minimize domestic violence. Jane Doe, Inc. is a Massachusetts Public Health initiative that aims to help victims of domestic abuse. The program has been successful in educating women and even encouraging men to stand up against domestic violence through their white ribbon campaign. However, Jane Doe, Inc. can improve its intervention by changing its name, by empowering women with survivor success stories, and by providing information for health care professionals on recognizing signs of domestic abuse.
Framing: The Dangers of Branding a Domestic Violence Campaign so Women feel Victimized Not Empowered

Women who have endured domestic abuse often describe feeling ashamed, worthless and alone. Many even blame themselves for the abuse. Ultimately, their sense of self is challenged or lost when they are abused. Lisa, a woman who experienced decades of abuse, describes her feelings by saying;
“I was in an emotionally, psychologically, and sexually abusive relationship for 21 years. I didn't know it was abuse because it happened so gradually. Eventually my self-esteem, self confidence and self-worth were destroyed, and I became afraid to do anything or make any decisions. I thought I was stupid, incompetent, a moron and an idiot. I hated myself (3).”

Women, like Lisa, need a place to turn to that encourages action and appeals to their sense of self. Based on Lisa’s words and the words of other women just like her, it is clear that framing a domestic violence intervention as a place for empowerment and strength is crucial to the intervention’s success and widespread appeal.
Framing theory in sociology and psychology is described as, “An inevitable process of selective influence over the individual's perception of the meanings attributed to words or phrases (4).” In simpler terms, framing provides context to words or phrases and greatly influences people’s perceptions and beliefs. Massachusetts has entitled their campaign against domestic violence as Jane Doe, Inc. Jane Doe is a widely used name for unknown or unidentified women (5-1). It is often seen in legal settings or on crime shows, such as CSI, to identify an unknown victim (5-2). The problem with using this name is that women who are battered or abused, emotionally or physically, feel like they have lost themselves to abuse. The title, Jane Doe, reinforces feelings of self-doubt, worthlessness and loss of identity. Selecting a different name may have a profound effect on the initiative’s success.
In recent years, social marketing has been employed by public health practitioners to increase the effectiveness of public health campaigns. Unlike typical marketing, public health officials are not selling a product, but rather they are selling healthy behaviors and sometimes to an uninspired audience. Even though public health officials are dealing with a challenging “product,” branding their product is still an essential component of the campaign’s success. In recent years, the CDC has created the VERB: It’s what you do campaign to encourage tweens ages 9 – 13 to maintain or increase physical activity (6). Before branding the campaign as VERB, the CDC did extensive research to uncover how to appeal to the tween age group and partnered with the advertising agencies Saachi and Saatchi and Frankel, an Arc Worldwide Company to ensure their campaign’s success (7). Ultimately, the advertising agencies encouraged the CDC to embrace branding as a way to connect children with the CDC’s healthy view. According to Asbury et al., “By creating a brand, a company defines how it wants consumers to think and feel when they see a brand’s logo, name, or message, and when they experience the brand (7 -2).” After researching how to engage tweens in physical activity, the CDC and its partners decided to name the campaign VERB because the word verb means action (7-3) and with it, a public health brand was born.
Jane Doe, Inc is an unfortunate brand for a domestic violence campaign. To reiterate, branding is important because it defines or frames how audiences think about or connect to a brand. In this case, Jane Doe, Inc has framed its initiative so that women of domestic violence do not feel they have an identity. Rather than spurring change and action in women who have experienced domestic violence, the name of the initiative may serve to remind them of their worthlessness.
There are several initiatives that have branded themselves to appeal to women who have experienced domestic violence and that should serve as examples to Jane Doe, Inc. One noteworthy initiative is a website called “Broken to Beautiful: A Virtual Oasis for Women Ascending out of Abuse (8).” The website offers a virtual place for women who have experienced domestic violence to share their stories and gain strength from each other. Unlike Jane Doe, Inc. the brand name exudes warmth, comfort and a sense of community.
Another example of an initiative that has branded itself to empower battered and abused women is the Joyful Heart foundation. The Joyful Heart Foundation says its mission is to “Heal, educate and empower survivors of sexual assault, domestic violence and child abuse and to shed light into the darkness that surrounds these issues (9).” This foundation appeals to the emotions of those who have experienced abuse. It shows that domestic violence survivors can still live with their heart and regain the confidence they need to move forward safely and happily. The Joyful Heart Foundation has created a brand that is about strength and hope and is another example of how Jane Doe, Inc may benefit from rebranding itself and reframing its campaign in a more positive light.
Transformative Learning Theory: The Absence of Storytelling may Impede Change for Domestic Violence Sufferers

Jane Doe, Inc. is an incredibly powerful website and campaign for information, statistics and facts, but one thing the initiative lacks is compelling survivor stories to show domestic violence sufferers that freedom from domestic abuse is possible. Survivor stories are an incredibly powerful public health tool. The use of personal stories has been implemented in anti-smoking campaigns, HIV/AIDS campaigns, cancer awareness campaigns and many others. Jane Doe, Inc. would be well served to learn from other campaigns how beneficial personal accounts can be to encouraging healthy behavior and driving change.
One poignant and heartbreaking example of how a single person’s story can change people’s behavior is the Massachusetts anti-smoking campaign featuring Pam Laffin. Pam, a 29-year-old mother of two with emphysema, shared her story with the people of Massachusetts (10). The story of her health decline and eventual death was bold, graphic and real. Pam’s story was chronicled through a series of anti-smoking advertisements as she waited for her second lung transplant. What resonated with people most was likely not her terrible disease, but rather her candor when discussing how smoking had stripped away her chance at being a great mom and living a full life. Pam was quoted as saying, “Cigarettes gave me asthma and bronchitis, but I couldn't quit. I didn't quit until I got emphysema and had a lung removed. I started to smoke to look older and, I'm sorry to say, it worked (11)." While her words and her story were controversial, the Massachusetts Department of Public Health reported a six-fold increase in calls to the state’s anti-smoking counseling line (10–2). Clearly, Pam’s story inspired others to change their behavior and finally quit smoking.
Even though Pam served as an example of what not to do, there are several examples of people who share their personal accounts to be positive role models. One study that looked at HIV/AIDS stories on the internet and its power to transform people’s behavior stated;
“The study of narratives in health care is a growing area of research. The use of personal stories for health care and therapy is documented in a wide range of contexts... suggesting that storytelling produces therapeutic effects in the cognitive, affective, interpersonal, and personal domains of both the teller and the listener (12).”

The paper written by Mohammed et al., demonstrates that survivor stories are a powerful transformation tool. Citing previous research, the study indicated that 97% of cancer patients agreed that it was easier to cope with cancer hearing other people’s stories and 85% agreed that they drew hope from other people’s stories (12-1). These statistics demonstrate how important storytelling is to hope and ultimately to healing.
Mohammed et al., explored how transformational learning is important for HIV/AIDS patients. They investigated a series of stages that patients typically experience. The stages include diagnosis, transformation, immersion, turning point, integration and disclosure (12-3). Their paper showed that most patients are initially shocked and fearful when they receive their diagnosis, but when they finally accept their diagnosis, they are eager to share their stories with others and educate others about HIV prevention. Sarah’s story demonstrates this transformational theory:
“I am at this time pursuing a master’s degree in the hopes that I can bring complementary therapies (i.e., art, movement, music, meditation, and prayer) into the mainstream areas of medicine connected with special populations, such as HIV=AIDS, cancer, the physically disabled, along with their support groups. I’d like to research the possibilities of using these therapies, with Western and possibly Eastern medicine to take a holistic approach to a circulatory way of addressing diseases . . . especially those that change lives radically. I know what they have done for me, and I’d like to help others also . . . with God’s grace, mercy, and help (12-4).”

It is clear through this research that storytelling is a powerful tool to spark transformation. Although contracting HIV or AIDS is very different from experiencing domestic violence, the principles of transformational learning hold true. Domestic violence sufferers must first recognize that their situation is a problem. Upon recognition, they will proceed through a series of transformational steps where they draw hope from others and feel inspired to share their own stories to prevent other women from experiencing the pain of domestic violence. Jane Doe, Inc. could improve its website and its campaign by strongly featuring personal accounts from women who have experienced domestic violence. Their stories will inspire others to stand up against violence and remove themselves from a dangerous relationship.
Jane Doe, Inc. does not feature any inspirational survivor stories, but it does feature a video of Diane Patrick, the Governor Deval Patrick’s wife. The video encourages women who have experienced domestic violence to talk about their experiences. While her video is filled with useful information about how to get help, it lacks the credibility of a survivor telling another survivor to get help. Through other campaign research, it has become abundantly clear that target audiences like to receive information from sources that they can relate to. In fact, receiving information from a source that is dissimilar can result in psychological reactance (13). In this case, Diane Patrick’s well-meaning video could actually have the opposite outcome of the videos intention. If women who have experienced domestic violence are unable to relate to Diane Patrick, they may ignore her advice to get help and continue to remain in an abusive relationship. Therefore, it is not only important that Jane Doe, Inc. inspire victims of domestic abuse with inspirational stories, but they must ensure that they use relatable spokeswomen to deliver their message.
Physician Advocates: Neglecting Physician Education is a Detriment to Domestic Violence Advocacy and Prevention

Jane Doe, Inc. is an incredibly victim-centered campaign and it does not provide support or learning materials for those who might come in contact with sufferers. The campaign takes the approach of educating women who are experiencing domestic violence on recognizing the signs of partner abuse and teaching sufferers where they can turn for help. While appealing to victims of domestic violence and empowering them with information is important, it may not be enough for women to take action. Since women who have experienced domestic abuse often feel weak and worthless, they may not have the confidence to remove themselves from a violent relationship without the advocacy and support of others. The National Center for Victims of Crime reiterates how women of domestic violence experience low self-esteem which may impede seeking help;
“Perpetrators of domestic violence may constantly criticize, belittle and humiliate their partners. Causing the victim to feel worthless, ugly, stupid and crazy does not allow for a survivor's healthy self-perception. Low self-esteem may contribute to victims feeling they deserve the abuse, affecting their ability to see themselves as worthy of better treatment (14).”

Feelings of self-doubt and guilt plague many domestic violence victims. Jane Doe, Inc. will be more successful if it recognizes that domestic violence sufferers may not have the strength to change on their own. They need the advocacy of others. Physicians, in particular, have the power to advocate for patients of domestic abuse, but are severely undereducated on how to do so (15-1).
Physicians see patients who experience all sorts of ailments and traumas. They are also often the first people, outside of the domestic partnership, to see victims of domestic abuse (15-2). Unfortunately, many times physicians miss the warning signs of domestic abuse sufferers. Many physicians expect victims of domestic violence to present with serious trauma wounds, when in fact many seek the help of physicians for stress-related illnesses (15–3). Physicians do not always know the warning signs of domestic violence when seeing patients. Educating physicians on recognizing domestic violence is a crucial element to reducing domestic violence. Physicians are in a position to advocate for their patients, help build a legal case against an abuser and identify victims before trauma becomes more severe.
Despite their unique position to be able to actively help women who are experiencing domestic abuse, few physicians are able to identify victims of domestic abuse and almost half think domestic violence is not a significant issue in their practice population (15-4). In general, family physicians are severely under educated on how to identify signs of domestic violence in their patients. Only 41% of family practice physicians report receiving formal training on recognizing domestic abuse and 57% feel their training is inadequate and that they would benefit from supplemental training (15–5). Evidently, physicians lack the education, tools and resources to identify patients experiencing domestic violence.
A later study by Harris et al., explored the effectiveness of internet-based trainings for physicians on recognizing domestic violence and voicing their concerns to patients (16-1). The article showed that, among other factors, physicians lacked confidence when screening for domestic violence and when discussing domestic violence with their patients. It is assumed that many physicians lack confidence in addressing domestic violence because of inadequate formal education on the subject. Estimates postulate that medical students only receive 4-5 hours of domestic violence training and that the courses are rarely formally evaluated (16-2). The Harris et al., study hypothesized that internet-based training could improve self-efficacy among physicians and in turn, the rate at which physicians intervene in domestic violence cases. The study was a randomized control trial in which half of the physicians in the study received internet training for two weeks and the other half did not. The study showed a marked increase (17.8%) in self-efficacy in physicians who received the internet-based intervention (16-3). This study serves as an example of how important physician education is to combating and addressing domestic violence.
Physicians and health professionals are truly in a unique position for intervention because, unlike the legal system, they are often seeing women who are experiencing domestic violence before they have decided to leave their abusive partners. In many other public health arenas, early intervention is considered a pillar for an initiative’s long-term success and for widespread prevention. In domestic violence, however, it seems most women only leave abusive relationships when they have reached a breaking point or are fearful for their lives. Patients of domestic abuse need advocacy so that they can make the decision to leave earlier than they would otherwise. Jane Doe, Inc. would be able to increase its preventative power if it educated Massachusetts physicians on domestic violence and promoted self-efficacy among physicians in dealing with domestic violence victims and perpetrators.
A Strategic Framework for Improving Jane Doe, Inc.
Jane Doe, Inc. offers victims of domestic violence important fact-based readings and provides outlets for sufferers to get help. While the campaign’s abundance of information is incredibly useful to victims of domestic abuse, the campaign can improve in a few key areas. Rebranding the campaign using social marketing theory to develop a brand name that resonates with domestic violence sufferers will increase the appeal of the campaign to the target audience. Furthermore, employing survivor success stories and capitalizing on the transformational learning theory will inspire current victims to change their lives and become survivors. Lastly, creating a physician and healthcare education provider portal will ensure that medical professionals are equipped to counsel domestic violence suffers on seeking help and advocating for their patient’s safety.
1. Using Social Marketing Theory to Re-brand Jane Doe, Inc. and Inspire Domestic Violence Sufferers to Seek Help

Branding a public health campaign is just as important as branding any other product. The goal of the brand name is to ensure that it inspires the target audience. It is nearly impossible to predict which brand name might resonate best with victims of domestic violence. Social marketing theory and its use of extensive consumer research aids public health branding by including the voice of the customer.
Social marketing theory has grown in popularity in the last couple decades and has been used broadly in several countries across the globe (17-1). At its most basic level, social marketing theory is, “typically defined as a program-planning process that applies commercial marketing concepts and techniques to promote voluntary behavior change (18).” This theory demonstrates how public health initiatives have advanced in recent years. In social marketing, public health officials and their teams are employing typical marketing strategies and using quantitative and qualitative market research to understand public reactions to their proposed ideas (17-2).
Jane Doe, Inc. would be well-served to use social-marketing theory to rebrand its campaign. First, the team should create a set of brand name suggestions that they feel will improve the campaign and will strongly resonate with victims and survivors of domestic abuse. Once the names are formulated, the team should develop a strategy for market research testing. A critical component of market research testing is determining a target audience for feedback. In other campaigns it has proven successful to speak with audiences with different exposure statuses (19). Jane Doe, Inc. can use this strategy by identifying women who are at various stages of domestic violence abuse and include sufferers who are just recognizing a pattern of family violence and those who have already escaped from a life of domestic abuse. Because domestic violence is also a cross-cultural problem, it is important that they have a culturally diverse and demographically diverse sample. By having a well-rounded target audience for research, Jane Doe, Inc. will learn about brand appeal from a spectrum of their target audience. Once the target audience is defined, the campaign can move forward with their qualitative research, most commonly in the form of focus groups, and their quantitative work, most commonly in-depth surveys (20 and 21). Research is a vital part of the branding process because it allows public health practitioners to “understand people’s aspirations, preferences, and other desires, in addition to their health needs, to identify the benefits most appealing to consumers (18-2).”
Social marketing theory is a powerful tool for public health officials to take direction and advice from their target audience. Jane Doe, Inc will learn what their target audience thinks of their current name and whether any of their new suggestions positively resonate with their target audience. Social marketing theory and research is also a way for public health officials to gather ideas for brand names from their respondents. It’s possible that a respondent might come up with a better name than the public health officials had developed. Social marketing theory is an opportunity for a campaign to vet its idea through others and do necessary testing before going live with a campaign. In the case of Jane Doe, Inc., which is already live, it is an opportunity to reformulate their strategy and ensure they are positively impacting domestic violence sufferers.
2. Survivor Stories to Stimulate Transformative Learning among Sufferers of Domestic Violence

For victims of domestic violence, sharing their story can be challenging and frightening. However, survivors who share their heartbreaking stories serve as an inspiration and a source of hope to current domestic violence sufferers (22). Jane Doe, Inc’s comprehensive, fact-based campaign will bring hope to survivors if they supplement their data with stories of other women who have broken the cycle of abuse. Research has shown that communication is a powerful tool in transformative learning and changing behavior (24–1).
Transformative learning is an educational theory that causes a learner to re-evaluate past experiences that they may not have previous questioned (25-1). An integral part of transformative learning is that other’s opinions and values shape individual opinions and values. Transformative learning theory focuses on three areas of change. The first area is psychological, in which a person gains a new understanding of self. The second area of change is convictional, in which a person changes his or her belief system. And the last are of change is behavioral, in which a person actually changes his or her behavior as a result of their new beliefs (25-2).
Transformative learning theory is applicable to domestic violence and should be employed by Jane Doe, Inc. to stimulate change. Those who experience domestic violence can benefit from re-evaluating their sense of self and moving from a place of self-doubt to self-worth. Furthermore, transformative learning theory indicates that if domestic violence sufferers gain confidence and change their beliefs, they will be more likely to make lifestyle changes. Hearing success stories from other victims of abuse has proven to be a successful way to utilize the transformative learning theory and stimulate change (24-2). A study done among women in transitional housing, either after being homeless or experiencing domestic violence, showed that women were empowered by other’s stories and often found their own voice through storytelling;
“All the group members are invited to share a significant experience in which they felt disempowered or ‘unable to take charge of their own life.’ Hearing stories from others often frees the silenced woman, and having someone listen intently to one’s own story can ‘hear one into speech.’ Stories engender compassion, laughter and sometimes tears. They remind us that we share common human experiences. Storytelling can help us find our voice (24-3).”

Clearly, storytelling is a powerful tool for inspiration and for motivation.

Jane Doe, Inc. should invite women they have helped escape domestic violence to share their stories of survival. These women who have already transitioned out of domestic violence can serve as inspiration to others. Additionally, Jane Doe, Inc. should hold support groups led by survivors so that current sufferers can share their own stories and draw strength from each other. Finding a voice and learning from other current sufferers and previous sufferers will encourage women to begin the transformative process of changing their beliefs and making healthy lifestyle changes to stand up against abuse.
3. A Healthcare Provider Portal on Domestic Abuse Education and Best-Practices

Physicians and medical professions are in a unique position for patient advocacy and prevention in domestic violence. Jane Doe, Inc. provides a plethora of reading materials and educational pieces for domestic violence victims, but does not provide any educational materials for the medical community. Physicians routinely screen for many illnesses in their patients, but research shows that only 7% routinely screen for domestic violence, even though it is highly prevalent (26-1). In a New York Times article, Dr. Marcus highlighted this discrepancy;
“Those who support routine questioning say domestic violence is as or more common in women than many diseases for which doctors regularly check, including breast and colon cancer, and its health risks are well documented. Despite these recommendations, screening for domestic abuse in seemingly healthy women is nowhere near as widespread among doctors as testing for breast cancer or high cholesterol (26-2).”

The inadequacies of domestic violence screening are not for a lack of compassion, but rather a lack of proper education. Several say their reason for not routinely screening on domestic violence is “lack of training and easy access to services that help patients (26-3).”
Not only is it important for physician’s to address domestic violence, but research shows that women value the opinion of their doctor’s and that just by screening and asking if they experience violence, it may plant the seed for change (26-4). Battered women do not always know the resources available to them and doctor’s can be a neutral source, especially more so than the police, to provide information and educate them on how to seek help (26-5).
Jane Doe, Inc. should incorporate a provider portal to educate physicians and medical professionals on screening for domestic violence. The portal should provide tutorial trainings and information on recognizing signs of domestic violence, big and small. It should also teach medical professionals how to be compassionate and empathetic when screening their patients. Women may be more likely to admit domestic abuse when they feel comfortable speaking with their physician. Furthermore, Jane Doe, Inc. should educate physicians on local support groups and safe houses for women who are experiencing domestic abuse. They should be able to educate their patients on how to seek help and remove themselves from a dangerous situation. With education and tools, medical professional can use the Jane Doe, Inc website to learn how to address domestic violence and help their patients seek refuge.
Conclusion
In conclusion, Jane Doe, Inc.’s mission to inform victims of domestic abuse and provide them with outlets for safety and support is noble. The campaign provides in-depth information, but falls short in a few key areas. Ultimately, the name Jane Doe reinforces feelings of self-doubt and worthlessness. The campaign can be more successful if it employs social marketing theory to develop a brand name that resonates with and inspires domestic violence sufferers. Furthermore, storytelling has been shown to have a profound effect on stimulating change through transformative learning in women who have experienced domestic abuse. Currently there are no survivor stories on Jane Doe, Inc., but the campaign would have a more pronounced effect if it featured women they have helped and who are enjoying rich, full lives after surviving domestic abuse. Lastly, Jane Doe, Inc. caters to educating victims, but it does not offer education for health professionals on how to address domestic violence with their patients. Jane Doe, Inc. should add a provider education portal to aid in prevention and advocacy of women who have experienced domestic violence. By improving in these areas, Jane Doe, Inc. can enjoy a greater impact on curbing domestic abuse.
















REFERENCES

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(26) Marcus, Dr. Erin N. Screening for Abuse may be Key to Ending It. The New York Time, 2008. http://www.nytimes.com/2008/05/20/health/20abus.html?pagewanted=all.