**2. Background**

### *2.1. Needs of Refugee and Immigrant Survivors*

A small number of qualitative studies have explored the experiences, concerns, and greatest needs related to domestic violence among refugee communities, but a larger literature explores the same among immigrant communities in the U.S. The term refugee is often used interchangeably with the terms migrant or undocumented immigrant; however, the legal definition of refugee is qualitatively di fferent from that of undocumented immigrant. Although refugees and undocumented immigrants experience similar traumatic trajectories brought on by persecution, war, or violence, in resettlement countries, refugees have legal status whereas undocumented immigrants do not. It is essential to understand the implications of this important di fference and, even more, recognize that groups within either of these categories are not culturally monolithic. That said, the literature demonstrates considerable overlap in risk and contextual factors for refugees and immigrants and thus, we review the literature with this in mind.

There is a robust body of literature that identifies language as one of the primary areas of concern in DV situations as it a ffects both their experience with DV and their ability to seek help (Bhuyan et al. 2005; Crandall et al. 2005; Latta and Goodman 2005; Menjívar and Salcido 2002; Shiu-Thornton et al. 2005; Sullivan et al. 2005). Some abusers use language as a means of control, discouraging or preventing women from learning English and thus, further isolating them from potential sources of help (Bhuyan et al. 2005; Sullivan et al. 2005; Runner et al. 2009). Additionally, women who are not fluent in English experience barriers at every turn when they seek help for their abusive situation. They may have trouble communicating with the police or social service providers, navigating a complex legal system, or filling out required paperwork (Bhuyan et al. 2005; Crandall et al. 2005; Latta and Goodman 2005; Menjívar and Salcido 2002; Ortiz Hendricks 2009; Shiu-Thornton et al. 2005; Sullivan et al. 2005). Combined with cultural and societal views of DV in the refugee survivor's country of origin, these language issues help to explain why many refugee and immigrant survivors lack awareness of domestic violence laws and available services, as well

as their challenges in seeking help (Bhuyan et al. 2005; Crandall et al. 2005; Latta and Goodman 2005; Menjívar and Salcido 2002; Ortiz Hendricks 2009; Shiu-Thornton et al. 2005; Sullivan et al. 2005; Runner et al. 2009).

Research suggests that these challenges can be mitigated by culturally responsive practices (Bhuyan et al. 2005; Crandall et al. 2005; Latta and Goodman 2005; Menjívar and Salcido 2002; Ortiz Hendricks 2009; Shiu-Thornton et al. 2005; Sullivan et al. 2005; Runner et al. 2009). Refugees and immigrants recommend that agencies should provide translation and interpretation services and have someone familiar with the cultural background of their clients. Additionally, community outreach and education should be a priority, both to inform women about available services and to educate men about domestic violence laws in the U.S. Additionally, refugees and immigrants indicate that services to help them become more independent and adapt to living in the U.S would help support their exit from violent relationships. This could include assistance with obtaining a driver's license, finding employment, becoming more proficient in the English language, understanding the legal system, and accessing other services to help them and their families. This body of research is particularly important as it centers the perspectives of refugee and immigrant survivors and helps guide practical and theoretical work in the domain of culturally responsive service provision.

### *2.2. Cultural Responsiveness and Refugee Survivors*

Cultural responsiveness is a critical factor and essential framework for providing relevant and effective services across multiple systems of care. Most health and social service systems are not inherently culturally responsive; however, evidence shows that when interventions within these systems are culturally adapted, they work better than non-adapted interventions and produce better outcomes for diverse populations (Bernal and Domenech-Rodriguez 2012). Beyond culturally adapted programs and interventions, Calzada and Suarez-Balcazar (2014) contend that culturally competent sta ff who administer programs from within a culturally responsive organizational climate are best positioned to serve the diverse needs of underrepresented groups. Their work reinforces Pyles and Kim (2005) study that highlighted the need for DV agencies specifically to adopt agency and system levels of cultural competence in order to best serve the needs of underserved DV survivors. This work is grounded in the idea that cultural competence is a multi-level phenomenon that must exist beyond the micro-level of service provider–survivor interaction.

There is an overwhelming literature base on cultural competence. For example, Shen (2015) review of cultural competence in the field of nursing identified 15 separate but overlapping models of cultural competence. Calzada and Suarez-Balcazar (2014) work integrates these disparate models and provides a heuristic way of understanding how cultural competence influences organizations. Extending Pyles and Kim (2005) and Hyde (2004) work on organizational cultural competence, they identify three levels (i.e., organizational, sta ff, and program) to characterize this framework and promote ongoing awareness, knowledge, and skill development for people serving the organization. Specific strategies for enacting cultural competence within these levels are based on substantial theoretical and empirical work across disciplines (see Georgetown University National Center for Cultural Competence 2020). According to Calzada and Suarez-Balcazar(2014), organizational cultural responsiveness helps agencies and providers develop and deliver more culturally appropriate services to diverse clients and can make those clients feel more comfortable with the service provider. By contrast, clients may feel misunderstood or even discriminated against when services are not culturally responsive, and this can discourage individuals and even entire communities from seeking needed services. Thus, cultural responsiveness is of special concern when working with refugee survivors of domestic violence.

### 2.2.1. Level 1: Culturally Competent Organizational Climate

Supported by the cognitive and behavioral cultural competence of sta ff, organizational leaders often begin by creating a mission and vision statement that embraces diverse and multicultural practices. These mission and vision statements drive corresponding action plans to ensure organizational accountability and might include a variety of practices including cultural competence training, recruitment/promotion/retention of diverse sta ff, mentoring, translation/interpretation services, coordination of health/social workers, and inclusion of family members. Being culturally competent at an organizational level might also include policies and practices that facilitate the support of outreach and information dissemination in ways that are transparent and inclusive (Calzada and Suarez-Balcazar 2014). In the context of the present study, the organization's relationship with refugee communities is of special consideration, and agencies should collaborate with community advisers to examine issues, problem solve solutions, and evaluate the cultural fit of the strategies being implemented (Dana et al. 1992; Ortiz Hendricks 2009; Runner et al. 2009).

### 2.2.2. Level 2: Culturally Competent Sta ff and Service Providers

Just as sta ff can support a culturally competent organizational environment, so too can the environment foster increased competence among sta ff members. At this level, people are asked to think about how the organization's mission and vision interplays with their own personal beliefs, values, and attitudes. This look inwards might include comparing and contrasting practices of di fferent cultural groups, taking an inventory of one's own explicit and implicit biases, and exploring one's capacity to serve culturally diverse clients. The integration of the cognitive and behavioral dimensions might be reflected in actions such as active listening or the asking of questions to gain knowledge about how best to support diverse families' health and wellbeing goals (Purnell 2002). In sum, culturally competent sta ff are those who have taken the time to immerse themselves in the cultural norms, communication practices, and celebrations of the people for whom they serve (Calzada and Suarez-Balcazar 2014). These culturally responsive sta ff and service providers contribute to the overall cultural responsiveness of the organization itself because they are part of the organizational climate and have the potential to advocate for programs and services that better serve the specific population or group with whom they are working (Calzada and Suarez-Balcazar 2014).

### 2.2.3. Level 3: Culturally Adapted/Responsive Programs and Evaluation

Finally, the implementation and evaluation of adapted programs illustrate the cultural competence of a well-supported organization and sta ff. Specifically, adapted programs are those that take into consideration the language, patterns of behavior, and cultural values of diverse families (e.g., translation, incorporating cultural values, o ffering childcare; Calzada and Suarez-Balcazar 2014). Existing research supports the value of these adaptations and suggests they have more e fficacy than non-adapted programs (Bernal and Domenech-Rodriguez 2012). Scholars, however, warn against adapting programs that focus on specific characteristics of an ethnic group, promoting instead adaptations made based on theory and existing evidence-based programs that have been previously successful (Calzada and Suarez-Balcazar 2014). In particular, the literature consistently identifies language services as being especially critical (Calzada and Suarez-Balcazar 2014; Dana et al. 1992; Ortiz Hendricks 2009; Purnell et al. 2011; Runner et al. 2009). This is consistent with the need for language services as identified by refugee domestic violence survivors. Runner et al. (2009) asserted that language is such a paramount issue that even if agencies only used their limited funds to provide communication services, it would be of grea<sup>t</sup> benefit to their refugee and immigrant clients. Because understanding the e fficacy of adaptation has such practical implications (i.e., whether that adaptation will be used again or in other contexts), evaluation becomes essential. Specifically, these evaluations should hold programs to standards that reflect cultural competence using both qualitative and quantitative methods (Calzada and Suarez-Balcazar 2014).

### *2.3. Present Study*

Previous research has outlined the unique risks and cultural considerations for refugees who have experienced domestic violence. Much of this research is qualitative and o ffers valuable insight from refugee survivors. These insights point to the practices and policies that agencies and helping professionals could enact to better serve diverse communities. Although there is a growing body of literature that underscores the importance of culturally responsive practices, little to no research exists that estimates the extent to which domestic violence organizations in the U.S. are enacting culturally responsive practices in their service provision for refugees. Thus, with Calzada and Suarez-Balcazar's assessment tool in mind, the current study's purpose is to assess culturally responsive organizational practices among domestic violence agencies in U.S. resettlement cities. Specifically, we ask:

