Original qualitative research – Recommendations for Canada's National Action Plan to End Gender-Based Violence: perspectives from leaders, service providers and survivors in Canada’s largest city during the COVID-19 pandemic

Abstract

Introduction: The Canadian government has committed to a national action plan (NAP) to address violence against women (VAW). However, a formalized plan for implementation has not been published. Building on existing recommendations and consultations, we conducted the first formal and peer-reviewed qualitative analysis of the perspectives of leaders, service providers and survivors on what should be considered in Canada’s NAP on VAW.

Methods: We applied thematic analysis to qualitative data from 18 staff working on VAW services (11 direct support, 7 in leadership roles) and 10 VAW survivor participants of a community-based study on VAW programming during the COVID-19 pandemic in the Greater Toronto Area (Ontario, Canada).

Results: We generated 12 recommendations for Canada’s NAP on VAW, which we organized into four thematic areas: (1) invest into VAW services and crisis supports (e.g. strengthen referral mechanisms to VAW programming); (2) enhance structural supports (e.g. invest in the full housing continuum for VAW survivors); (3) develop coordinated systems (e.g. strengthen collaboration between health and VAW systems); and (4) implement and evaluate primary prevention strategies (e.g. conduct a gender-based and intersectional analysis of existing social and public policies). 

Conclusion: In this study, we developed, prioritized and nuanced recommendations for Canada’s proposed NAP on VAW based on a rigorous analysis of the perspectives of VAW survivors and staff in Canada’s largest city during the COVID-19 pandemic. An effective NAP will require investment in direct support organizations; equitable housing and other structural supports; strategic coordination of health, justice and social care systems; and primary prevention strategies, including gender transformative policy reform.

Keywords: domestic violence, policy, federal government, Canada, Ontario

Introduction

Gender-based violence against women, or violence against women (VAW), is actual or threatened physical, psychological, economic or sexual violence that is disproportionately perpetrated against women or inflicted because the victim is a woman.^{Footnote 1Footnote 2} The most common form of VAW is intimate partner violence (IPV).^{Footnote 3} In Canada, 44% or 6.2 million women aged 15 years or older are estimated to have experienced IPV in their lifetime.^{Footnote 4} VAW, including IPV, is one of the key determinants of injury and disease among women and, at worst, can result in death.^{Footnote 5Footnote 6Footnote 7} The COVID-19 pandemic, including its attendant restrictions (e.g. lockdowns, quarantine and isolation, social distancing) and socioeconomic impacts (e.g. job loss, psychological distress, housing precarity), has led to increases in the incidence and severity of VAW and created and exacerbated barriers to accessing and delivering supportive services.^{Footnote 8Footnote 9Footnote 10Footnote 11}

For over three decades, Canadian advocates have been calling for a national action plan (NAP) to address VAW,^{Footnote 12Footnote 13} in line with Canada’s international human rights obligations.^{Footnote 14} The intended goal of NAPs is to create the necessary political, legislative, funding and research infrastructure to support sustained, coordinated action between all levels of government, civil society and other relevant stakeholders to more effectively prevent VAW. At the time of writing this manuscript, in Canada, only a “strategy to prevent and address gender-based violence” has been implemented, which solely involves federal departments.^{Footnote 12} At the same time, provinces and territories have their own diverse, and at times inconsistent, laws and policies around VAW (including, for instance, varying definitions of what constitutes IPV within and across jurisdictions), which need to be addressed in an effective Canadian NAP.^{Footnote 15} In 2022, the federal government affirmed in its budget an investment of CAD 600 million over five years to advance a NAP to end gender-based violence and, with the endorsement of provincial and territorial ministers, released a high-level framework of “opportunities for action.” While an important first step, this document has been critiqued for only presenting an optional set of actions for provinces and territories to consider, as opposed to commitments, without any directives for federal or national bodies.^{Footnote 16} As a result, what will be implemented, and how it will be implemented, as part of Canada’s NAP on VAW remains an open question.

There have been several consultations with experts (e.g. VAW survivors, staff, advocates, academic researchers) over the years on what actions should be included in the proposed NAP on VAW. Most recently, the federal government’s Women and Gender Equality (WAGE) ministry funded Women’s Shelters Canada to develop a roadmap for developing and implementing Canada’s NAP on VAW based on a list of 646 initial recommendations collected from prior reports, policy documents and other sources.^{Footnote 13} The recommendations were organized into four thematic pillars, with each assigned to one working group of VAW advocates, service providers, leaders and researchers to evaluate, edit and prioritize. The final report includes 100 wide-ranging recommendations across the four pillars of (1) enabling environment and social infrastructure, (2) prevention, (3) promotion of responsive legal and justice systems, and (4) support for survivors and their families. The report also addressed the need for an intersectional feminist monitoring and evaluation framework for the NAP and the implications of statutory differences in definitions of IPV across Canadian jurisdictions. Notably, the authors recommended ongoing engagement with VAW survivors (who were not part of the working groups), sector experts and advocates in the continued development and evaluation of Canada’s NAP.

We sought to build on this foundational work in the current study. We conducted the first, to our knowledge, formal and peer-reviewed qualitative analysis of the perspectives of leaders, service providers and survivors on what should be considered in the design and implementation of Canada’s NAP on VAW. In doing so, we aimed to increase the transparency and rigour of our conclusions, as well as the depth of information underpinning our recommendations. Due to resource constraints, past consultations have tended to focus on participants’ recommendations for the NAP, without giving space to share lived experiences with VAW, service access or sectoral work more broadly. These experiences may offer further insight into important factors to consider in VAW policy. We used data from a study of the VAW sector in Canada’s largest city, Toronto, during the COVID-19 pandemic to critically develop, nuance and prioritize recommendations for Canada’s NAP on VAW. The COVID-19 pandemic has changed the landscape of VAW—exacerbating existing challenges but also creating new opportunities for transformative policy and practice—making it an important time to reconsider priorities and identify innovations.

Methods

Ethics approval

The Unity Health Toronto Research Ethics Board (REB#20-124) and the Dalhousie University Research Ethics Board (REB#2022-6275) approved this study.

Data collection and analysis

Qualitative data were collected from April to September 2021 as part of a community-based, mixed-methods study on the processes, experiences and outcomes of adapting VAW programming during the COVID-19 pandemic in collaboration with 42 VAW organizations across the Greater Toronto Area (the MARCO-VAW Study).^{Footnote 11} The study’s co-leads (ARY, an academic VAW researcher, and PS, a community-based VAW researcher) and three peer researchers (women with lived experience of gender-based violence who received training on VAW research methods^{Footnote 17}) conducted interviews, typically in pairs. Eligible participants were either (1) direct support or leadership staff working on a VAW service (“VAW staff”) in the Greater Toronto Area since 11 March 2020, or (2) adult women who had accessed at least one VAW service in the Greater Toronto Area since 11 March 2020 (“VAW survivors”). We deemed any services and programs designed to support VAW survivors as relevant to the study to broaden the scope of our analysis and conclusions (Table 1).Participants provided informed consent by email prior to interviews; we used interpretation services whenever participants were not comfortable speaking in English. We provided participants with a $40 honorarium following their interviews.

We purposively sampled staff participants from the study’s larger sampling frame based on personal factors (e.g. ethnicity, race, age, years of experience), types of VAW services where participants worked, and the populations typically served. We recruited survivor participants via staff contacts in our collaborating networks, aiming to sample a diverse cross section in terms of personal factors and types of services accessed. Our goal in purposively sampling staff and survivor participants was to capture experiences across (1) different and intersecting forms of marginalization, and (2) the diversity of VAW practice and programming. With staff support, we ensured that survivors were in a physically and mentally safe space to participate (determined through staff and interviewer safety checks).^{Footnote 17Footnote 18} We provided survivor participants with a list of VAW mental health resources following their interviews. Interviews were conducted and recorded over Zoom (Zoom Video Communications, Inc., San Jose, CA, US) and transcribed verbatim using Trint (Trint Ltd., Toronto, ON, CA). At least two research assistants checked each transcript for accuracy and removed identifying information. Interviewers took field notes and were debriefed following each interview.

We used a reflexive thematic analysis methodology, which recognizes and embraces the subjectivity of researchers, encourages the use of flexible coding practices and emphasizes iterative and in-depth engagement with the data.^{Footnote 19} Our interviews were semistructured; staff and survivor interview guides are available online.^{Footnote 11} In this analysis, we have focussed on data on gaps in policy and practice as well as data collected in response to the following questions:

• Canada is currently investing CAD 600 million over five years to prevent gender-based violence under the National Action Plan to End Gender-Based Violence. This includes funds to enhance the capacity of VAW organizations, Indigenous women organizations and a crisis hotline.
  • What do you think would be helpful to include in this plan?
  • What immediate changes should be made in Canada to better respond to VAW?
  • What long-term changes should be made to prevent VAW from happening in the first place?

Four researchers collaborated on data analysis, three of whom were also interviewers. The analysis team first coded the same two interview transcripts and met to discuss initial codes, aiming to incorporate diverse perspectives on priorities and relevant features of the data. Each analyst was then assigned a subset of the dataset for inductive coding. Analysts met regularly to discuss the coding process. Once all data were initially coded, each analyst double coded a portion of the dataset to identify opportunities to add or refine codes and integrate perspectives. Two researchers then read through each code to develop an initial summary of the most salient data for recommendations for the NAP.

We generated recommendations based on patterns of ideas identified within the data and developed a thematic framework to summarize the relationships between these patterns. To further refine and situate our framework of recommendations, we referenced available reports on the NAP and theoretical and empirical literature on preventing VAW. Our analysis was informed by a critical feminist lens, aiming to identify the ways in which participants’ experiences and thoughts demonstrate how societal structures disadvantage women at the intersection of different social identities and ways the NAP can address this.^{Footnote 20Footnote 21Footnote 22} The analysis team shared outputs regularly with the broader research team, an advisory group of VAW leaders and VAW stakeholders for feedback through meetings and knowledge translation events. We have selected quotations to support our analysis and included anonymized participant identification numbers to locate and demonstrate the scope of the data used.

Results and discussion

Table 1 summarizes the characteristics of our sample by staff (n = 18) and survivor (n = 10) participants. Most staff and survivor participants self-identified as racialized persons (most commonly Black, Latin American, or South or Southeast Asian), cisgender women and heterosexual. Almost half of participants were born outside of Canada. Most survivor participants were unemployed and had an annual income below CAD 20 000. The services that staff participants worked on and survivor participants accessed during the pandemic were wide-ranging, including mental health, shelter, child protection, health care, transitional housing, legal support, and harm reduction at generalist and community-specific organizations. Below, we summarize the four themes and corresponding recommendations that we developed through our analysis.

Table 1 (section 1 of 2). Summary characteristics of the MARCO-VAW interview sample

Sociodemographic characteristic	N (%) or M (IQR)
	Staff (n = 18)	Survivors (n = 10)
Age (years)	47 (40–56)	43 (36–50)
Ethno-racial identityFootnote a
White	7 (36%)	3 (30%)
Black	4 (21%)	2 (20%)
Latin American	3 (16%)	2 (20%)
South or Southeast Asian	2 (11%)	3 (30%)
Middle Eastern	2 (11%)	0 (0%)
Other: Jewish	1 (5%)	0 (0%)
Gender identity
Ciswoman	18 (95%)	9 (90%)
Cisman	1 (5%)	0 (0%)
Gender diverseFootnote b	0 (0%)	1 (10%)
Sexual identity
Heterosexual or straight	15 (79%)	8 (80%)
Gay or lesbian	1 (5%)	0 (0%)
Bisexual	2 (11%)	1 (10%)
Something else (e.g. queer, not sure or questioning)	1 (5%)	1 (10%)
Country of birth
Canada	9 (47%)	5 (50%)
Other	10 (53%)	5 (50%)
Total household incomeFootnote c
< CAD 20 000	n/a	9 (90%)
CAD 20 000–CAD 50 000	n/a	1 (10%)
Employment statusFootnote c
Unemployed	n/a	6 (60%)
Casual paid employment	n/a	3 (30%)
Caregiver	n/a	1 (10%)
Highest level of educationFootnote c
High school	n/a	1 (10%)
Trades or college certificate/diploma	n/a	7 (70%)
University certificate/diploma	n/a	2 (20%)

Table 1 (section 2 of 2). Summary characteristics of the MARCO-VAW interview sample

Type of VAW work or access	Staff		Survivors (n = 10)Footnote d
	Leadership (n = 7)	Direct support (n = 11)
VAW organization
Generalist	4 (57%)	8 (73%)	10 (100%)
Community-specificFootnote e	3 (43%)	3 (27%)	4 (40%)
VAW service
Residential	2 (29%)	6 (55%)	8 (80%)
Nonresidential	5 (71%)	5 (45%)	10 (100%)
VAW programmingFootnote f
Mental health, counselling, crisis support, case management	n/a	3 (27%)	10 (100%)
Shelter	n/a	2 (18%)	8 (80%)
Transitional (second-stage) housing support	n/a	4 (36%)	4 (40%)
Children’s aid society	n/a	0 (0%)	6 (60%)
Partner assault response	n/a	1 (9%)	0 (0%)
Other:
Health care	n/a	1 (9%)	5 (50%)
Harm reduction	n/a	0 (0%)	1 (10%)
Legal advocacy and support	n/a	1 (9%)	4 (40%)

Invest in VAW services and increase accessibility of crisis supports

The accessibility of crisis supports for women experiencing violence was a common concern shared by both staff and survivor participants. Many survivor participants recommended investment in increasing public awareness of available VAW crisis supports (e.g. subtheme A in Table 2, [hereafter referred to as “Table 2A”], survivor C80).

Central to survivors’ recommendations for increasing public awareness was the idea that women will be more likely to seek help if they realize their own experiences constitute violence. For instance, survivor C78’s comments (Table 2A) demonstrate several ideas for raising public awareness, especially for women living with abusers (e.g. distributing information on the radio or in grocery stores, parks, malls, laundromats). This participant draws the connection that public information can be a first step to breaking the cycle of control of abusers, denormalizing VAW for survivors (“we are not crazy”) and empowering them to seek support (“we have options”). These ideas are borne out by existing evidence: the lack of awareness of IPV, including what constitutes violence, and the lack of available resources have been found to be among the greatest barriers to survivors seeking help.^{Footnote 23}

Table 2. Subthemes with example data under Theme 1: invest in VAW services and increase accessibility of crisis supports

Subtheme	Example data
	Participant	Excerpt
A. Raising awareness of VAW and available crisis supports to increase access and denormalize VAW	Survivor C80	As I know, not a lot of people like women victims know this kind of community service. […] I think the most important thing to do is promoting this service and advertising this service they can have.
	Survivor C78	They could make, like, more this information, more easily accessible. You know, like, because when you are living in this situation, like, you are sometimes, you are isolated. […] So, I think that it will be good if you can hear that information, maybe you are listening to a radio station and you can listen […] if you are going to get your groceries, maybe in there you can see a post like something like, “If you are living like this, call this number. You are not alone.” […] We were in the mall sometimes, we are in the park with the kids. We are doing, like, laundry. […] I mean, we need to know that we are not alone and like, we are not crazy, right? Because they [abusers] are saying, “Oh, you're crazy. You're just making this up.” You know, but we need to see that we have options, right?
	Leader P5	The more people that understand violence against women—whether that’s the layperson, the local church group, right, or if that’s a community agency somewhere, right—the more people that understand violence against women, the more we can get the supports to those women that are hard for me to reach.
B. Challenges in VAW referral mechanisms and the provision of wraparound supports	Direct support staff P95	[Referrals have] definitely been a challenge for us as well, because oftentimes even the information on various agencies’ websites aren’t necessarily always up to date with exactly which services are being run still or how it is that they’re being run. But I found that the way that we were able to actually reduce that barrier as much as possible was to actually—the old school way, pick up the phone and actually call those agencies and be able to have a formal discussion with either a program lead or an intake worker at another agency to see what they were still offering. And we would kind of trade off what we’re able to offer with their clients essentially as well.
	Leader P38	It would be good to have, like, kind of almost like a point person who’s, like, saying, “The shelters are open here.” […] Because at one point, like, we couldn’t even get in touch with [the Ontario VAW crisis line].
	Leader P109	Like I was talking about the continuum of services for [our community], it’s just like some things need to be done with a translator. […] There’s a big gap for [services specific to my community] already. But if you add to that, that most of the services were not done person-to-person no more, it had to go by virtual. […] We did some referrals of almost a year ago at some time that we still do not have responses. […] The referrals are already long, but it takes a lot more time.
	Survivor C73	I don’t know how much times my kids had to hear about my story and I felt pretty shitty about myself, to be honest. I wish my kids didn’t to have to hear as much they had to hear. But I had no other choice.
	Survivor C80	So when I wanted to reach out to Canadian community, always I worried if I could deliver my message exactly or not. […] Not everybody has […] English perfectly. Also, for culture, I cannot understand other people’s culture. How can they understand my culture?
C. Benefits of flexible funding in providing wraparound supports	Leader P137	That’s probably the biggest help because [clients] don’t have to be eating garbage [before we can help them]. And they could be, you know, “too much money for that, but not enough money for this.” We can provide clothing. We can provide money for summer activities. We can provide computers. We can provide winter coats. We can provide upgrading. So, some very concrete support we can provide.
D. Gaps in trauma-informed and specialized mental health supports	Leader P110	In terms of trauma-specific services like trauma treatment, I would love to have, to provide that service, but that requires a particular skillset that we don’t have here. […] I can’t afford to pay for staff that would be coming with those skillsets.
	Direct support staff P103	Have real therapy offered to people at a reasonable rate—you don’t have to be rich to afford real therapy [or have] a benefit plan to afford it, because most of our clients don’t.
	Survivor C76	The stress through the beginning of the pandemic was extremely hard for me. […] It made it worse too for my eating disorder because I just couldn’t do anything. […] I wish that there was more access for people with mental health conditions prior to the pandemic.

The importance of denormalizing VAW through public-facing campaigns was echoed by staff participants. For instance, leader P5 (Table 2A) makes the point that public information on VAW will not only support survivors reaching out to services on their own, but can also help community members, groups and agencies to understand VAW and connect survivors to available services (in addition to providing informal social support).  Indeed, evaluative research suggests that information campaigns should be long-term and involve engagement with multiple stakeholders, aiming to shift public discourse and societal norms around gender and violence.^{Footnote 24} To avoid unintended harms, campaigns should use inclusive definitions of IPV (which would be aided by a statutory definition of IPV in the NAP^{Footnote 9}) and avoid traumatizing or stigmatizing language or imagery.^{Footnote 25Footnote 26}

Information campaigns on their own, however, are not enough:^{Footnote 24} staff participants described innovations implemented during the pandemic to broaden the accessibility of crisis supports or made recommendations to make crisis supports more accessible in the future. These included a national crisis line to coordinate contact information for provincial supports (P5), virtual (online and text) chat lines (P38) and strengthening referral pathways between crisis lines and other VAW organizations to provide immediate and ongoing support to those in high-risk situations or non-VAW shelters (P68).

Strengthening referral pathways in particular has been a major implementation challenge for VAW services, exacerbated by the pandemic; many staff participants highlighted the difficulties of connecting clients to services through VAW referral mechanisms (e.g. Table 2B, direct support staff P95). These difficulties included, for instance, getting survivors into housing or legal support—as wait times severely increased due to a lack of stock or closed courts, respectively—as well as uncertainty over which services were open and available. Staff participants highlighted the need to increase investment into a systematic and centralized process for referrals to mitigate these challenges in future emergencies (e.g. Table 2B, leader P38). 

In addition, many VAW organizations refer out to community services or programs to meet the varying needs of survivors as part of their normal practice. When those services shut down or reduced their capacity during the pandemic, some VAW organizations did not have the capacity to offer survivors wraparound supports in-house. Leader P109 (Table 2B) provides one example of how challenges with referrals were even more difficult for community-specific services, for which the already limited pool of potential service providers became even more restricted due to the pandemic and the switch to virtual services. This loss was felt deeply by survivors. Consistent with P109’s comments, survivor participants commonly described being negatively impacted by insufficient programming for children (e.g. Table 2B, survivor C73), interpretation and culturally specific services (e.g. Table 2B, survivor C80).

Ensuring that VAW organizations can provide their own wraparound supports to consistently meet survivors’ varying needs, even during a pandemic, will require increased funding to expand VAW workforces, training and infrastructure. Staff participants who spoke positively about funding during the pandemic often highlighted the benefits of funders allowing flexibility for organizations to use their monies as they saw fit to respond to pandemic conditions. For instance, as leader P137 (Table 2C) illustrates, flexible funding empowered staff to better meet the needs of survivors during an otherwise disempowering time. However, VAW organizations need enough funds to benefit from flexible conditions. Across staff participants, this was more often the case for multiservice VAW organizations with larger pools of charitable and private donations to draw upon, highlighting the inadequacy of public VAW funding. 

A key area that participants highlighted as requiring increased funding to VAW organizations was trauma-informed and specialized mental health supports (e.g. Table 2D, leader P110). Participants recognized that survivors’ trauma has been compounded by the pandemic, with more survivors reporting more severe violence, high-risk situations (e.g. isolation with abusers, no access to finances) and COVID-19–related stress (e.g. children at home, fear of illness)—all of which have been found in other emerging research.^{Footnote 8} Effectively addressing the ongoing and exacerbated mental health burden among VAW survivors requires increasing VAW funding portfolios to develop the necessary expertise in the VAW workforce to deliver mental health support (i.e. through providing existing staff with appropriate training or hiring staff with the necessary qualifications). As both staff and survivor participants lamented, without greater and, critically, sustained investment, access to specialized mental health care will remain inequitable (e.g. Table 2D, direct support staff P103 and survivor C76), as is the case for access to mental health services more broadly.^{Footnote 27}

Enhance structural supports for VAW

Participants’ stories and recommendations highlighted the importance of developing the necessary infrastructure and funding streams within the NAP to support the full housing continuum specifically for VAW survivors—from emergency shelter to long-term supportive housing.^{Footnote 28} These limitations predated but were exacerbated by the pandemic, with the additional challenges in referral pathways and reduced availability of shelter and affordable housing.

Staff and survivor participants acknowledged the critical role that emergency VAW shelters play in supporting women fleeing violence, and the frustration of not always being able to gain access. Two participants had to access city homelessness shelters instead of, or prior to, VAW shelters. In these cases, there was a stark contrast drawn in the adequacy of the supports for VAW survivors. For instance, survivor C73 (Table 3A) described fearing for herself and her children at the city shelter, driven by the intersecting presence of men (in contrast to “a woman’s place”) and alcohol use, a precursor for violence experienced by many survivors.^{Footnote 29} This was amplified by the retraumatizing experience of being exposed to potential violence in the shelter (“you would hear people yelling”) and dealing with her own history of alcohol misuse without any social or psychological support (“they didn’t check on me every night to see if I’m alive”). These comments are in line with other staff and survivor participants’ accounts that demonstrated the ways in which housing and homelessness policy and practice, largely guided by the experiences of men (especially white cismen), have been insufficient for VAW survivors.^{Footnote 9}

Table 3. Subthemes with example data under Theme 2: enhance structural supports for VAW

Subtheme	Example data
	Participant	Excerpt
A. Inadequacy of supports available to VAW survivors in homelessness compared to VAW shelters	Survivor C73	Staff never checked up on you in the emergency shelter to just see how you’re doing. […] They didn’t check on me every night to see if I’m alive. I think I feel like the worst part, though, during the whole pandemic that I gone through was that emergency shelter. Yeah, because at least I could say at [the VAW shelter] I was a little bit more free. […] It was a woman’s place. So, like, I didn’t have to worry about anything else, no alcohol was involved. And before I was an alcoholic, when I was 17, so like going in a woman’s shelter when I actually got support over everything else, I felt more at ease. But with the emergency shelter, you see people burning out. You see people getting drunk there. Like it was a very disgusting place for kids, and it was scary—it was very, very scary. Some nights we would wake up because you hear it, felt like the walls were paper thin because you would hear people yelling. That will wake up my kids and we would be up for hours.
B. The need to invest in the full housing continuum for VAW survivors	Direct support staff P140	We have women in who have fled horrible situations, that are staying in homeless shelters with your kids, you know, which is then exposing themselves and kids to further trauma. So, I would say, housing, definitely […] You have to keep it real, you’re not going to get permanent housing, thousands of permanent housing built within a year. So, I would say, if we were to get more transitional housing for women and the kids who are fleeing violence, it’s a start. […] Because women leave and they go to shelters, they stay in a room with two or three kids in a room and they have to share a shower and the kitchen and the living space. If you were to get a bachelor unit, right, with independent showers and a kitchenette and a couch and a TV, couple beds—transitional housing—at least the woman and the kids will feel like they’re somewhat at home until they get the adequacy of an affordable place to move into. So, I am for housing. You know, if you don’t have housing, you don’t have anything. […] It provides independence, safety, you know, self-worth.
	Direct support staff P23	Like, I know the shelters reduced their capacity, so it’s really hard to get women into shelter. And also, like, many women don’t feel safe going there in the first place. So, we just need something more stable. Like, a shelter is only temporary. We need more affordable housing in the city. It’s just not right. People stay in relationships and then go through this violence and hardship because of the housing issues and poverty.
C. Gender-based inequities in social and economic resources and the determining role of Canadian law and policy	Leader P110	Violence looks differently, depending on your context, your… people. So, we decided what violence looks like at the provincial level. We decided that, yeah, in a relationship, usually there is a man and a woman and they have two kids and a dog or a cat and that both of them contribute equally to the relationship in terms of finances. They are codependent and that the both of their names are going to be in this nice lease. […] Who did we write that policy for? Not for the clients we serve because many of them do not have their names on the leases, and many of them don’t have the equitable relationship with their partners. Many of them… It’s insane. It’s like you’re trying to fit our clients in this mould that someone in the policy office thought of based on maybe on their own contacts and their own frame of reference of what a relationship is like.
	Survivor C76	So there’s tons and tons and tons [of housing programming for men], but where are the mass quantities for women?
	Survivor C72	Upstairs there was this man that was so unhelpful. He kept, unfortunately, kept trying to come on to me every time I would come home and stuff. […] Having trauma surrounding men and having PTSD and depression, I would—there was days that I just didn’t want to leave the house because, between my ex knowing my codes and then the landlord of that place being a male and then that guy that lived upstairs who wasn’t the landlord, but he was a tenant, but he paid well over what I paid […] When you’re living in a society that, where, you know, men have a lot of, are wielding a lot of the control and the power, it’s very, very difficult for female-identified individuals to even have a success rate.
	Survivor C78	I have to do my application, my humanitarian [and compassionate application for permanent residence], right? […] But I feel like, I mean, the difference between my friend who is getting all the help […] is that her husband did the sponsorship [for her permanent residence], right? And the difference of my husband, he didn’t, but it wasn’t my fault. You know, I’m here and I’m here trying to prove myself, trying to prove that I am, you know, like I am an asset. […] I think that the government should understand because I’m not faking this, right? […] I got married with my husband. I have a son with him, you know, like we have a son, a child together, right? And he’s having his free time, his life, right? And I’m here trying to prove myself every day. And I think it’s not fair because I didn’t fail, you know, I trust him.
	Leader P136	But after they’re willing to seek help, if their primary needs are not taken care of, right—they don’t have money, they don’t have food, shelter, they don’t have access to their kids—they would not leave. So that’s not something that we, as an agency, can help. That’s a systemic issue, right? There has to be wraparound supports for food, shelter, access to safe education without, you know, their dads picking up their kids from school, right? That’s something systemic that is only empowered by policy and public dollars.

It was clear from participants’ accounts that more investment is needed into VAW shelters as one solution—both in terms of strengthening referral pathways but also in terms of increasing funding and resourcing to support capacity, staffing and training to collaborate with other systems in the provision of VAW care (discussed further in the following section). However, participants recognized that there must also be greater focus on longer-term housing solutions for VAW survivors.^{Footnote 28} For instance, as direct support staff P140 suggests (Table 3B), greater investment in transitional (called “second-stage” in some parts of Canada) housing for VAW survivors (typically between 1 and 5 years) as a medium-term solution in the housing continuum is an important way to establish a sense of home for survivors and their families while awaiting independent housing, the ultimate goal.^{Footnote 30} Participants juxtaposed these longer-term housing options with shelter, which, being short-term and shared, does not provide that same enduring sense of stability and independence.

While shelter has lifesaving benefits for many survivors who access it, participants also acknowledged that it is not the right option for everyone, hence the need to invest in the full VAW-housing continuum.^{Footnote 9} For instance, as direct support staff P23 demonstrates (Table 3B), many women experience “hidden” homelessness (e.g. staying in violent relationships) without being able or feeling safe enough to access shelter and without adequate alternatives.^{Footnote 31} This was reflected in the stories of survivor participants: for instance, survivor C74, who returned to an abusive situation after shelter; C75, who faced discrimination in the housing market as a single, pregnant woman on disability support and had to accept housing with significant water damage; and C72 and C76, who were forced to endure harassment and abuse from male neighbours without recourse or the means to move.

Participants highlighted the structural barriers that have limited safe and affordable housing for VAW survivors and driven women’s risk of experiencing hidden homelessness. For instance, leader P110’s comments (Table 3C) spoke to the broader issue of Canadian housing policy and residential tenancy laws not reflecting the lived realities of VAW survivors.^{Footnote 9Footnote 32Footnote 33} This can result in, for instance, women fleeing their homes to leave an abuser because they are not named in the tenancy or mortgage agreement; being unable to demonstrate eligibility for supportive housing, including subsidized housing or portable housing benefits (which, for cases prioritized based on VAW, requires written proof of cohabitation with an abuser during a given time period or, for newcomers, sponsorship); or lacking the finances, credit history or assets to secure their own independent housing. Thus, as P110 highlights, the social inequities between VAW survivors and their abusers are, in some cases, widened by the very policies seeking to support them.^{Footnote 32}

This notion mapped onto participants’ broader expression of injustice at the inequitable distribution of social and economic resources in society based on gender and other intersecting factors (e.g. ethnicity, race, class). This included housing supports (e.g. Table 3C, survivor C76) and discrimination in the housing market (e.g. Table 3C, survivor C72), as well as the intersecting barriers for newcomer women (e.g. Table 3C, survivor C78). However, participants’ recommendations for more equitable structural supports went beyond housing, including financial (e.g. P37, increased basic need and shelter allowance), employment and education (e.g. P139, provision of training for professional certificates, resume guidance, interview coaching), legal (e.g. P138, increased funding for legal aid) and child care supports.

Leader P136’s comments (Table 3C) are one example of participants’ recommendations indicating the value of flexible, wraparound supports for survivors, but were clear that, in the long term, promoting gender equity and preventing VAW needs to be prioritized in all policy. Without policies that create a more equitable distribution of economic and social power in society, VAW services will not be able to prevent the reoccurrence of violence or its most extreme consequences, let alone prevent it in the first instance.

Develop coordinated systems to strengthen the response to VAW

Intersecting with the need to strengthen structural supports to respond to VAW, participants’ stories illustrated the importance of better coordinating VAW services with other systems with which survivors frequently interact—especially the health and justice systems. Participants described ways in which each of these systems has not been set up to account for intersections with the specific needs of VAW survivors. For instance, survivor C76 described being in and out of hospital over the last decade and struggling to receive the emotional, social and economic support needed for recovery—circumstances only exacerbated by the COVID-19 pandemic (Table 4A). C76 further pointed out that social assistance has been available to seniors requiring support in their day-to-day lives and accessing services. This contrasts with VAW survivors (of all ages), who are also often experiencing social isolation and physical and mental health symptoms and may benefit from similar levels of support. This service gap especially impacts survivors experiencing economic marginalization (e.g. C76, “it’s very difficult […] when you don’t have any money or access to any kind of support”).

Table 4. Subthemes with example data under Theme 3: develop coordinated systems to strengthen the response to VAW

Subtheme	Example data
	Participant	Excerpt
A. Health system not accounting for the specific needs of VAW survivors	Survivor C76	When I came into the hospital and the pandemic first happened, they had services for seniors and stuff. But for me, I was by myself and I had no help […] I had to go in and get [a colonoscopy] and then finding someone to come pick me up was really hard [crying] because I couldn’t find someone to pick me up because they needed someone to come and get me, because they put you under. And it was very shameful. […] Those are the things that I find most challenging especially during COVID-19. It is just, like, I don’t, look, I am not looking for a “handout,” just a “hand up” sometimes.
	Leader P68	I think there’s been some collaboration [between] VAW [and] health care. Again, you know, access to health care is limited right now. So just, I’m not aware of tables where VAW–health care discussions are happening. […] There’s a certain amount of work that’s happening around homelessness and very frail seniors. And so, some of those things may intersect, but health care tends to focus on health care [laughs]. So, it’s still a siloed system, I think.
	Direct support staff P115	Make us mandatory, I mean [laughs]. I think just really acknowledging that we are truly an essential service and having these clients navigate the emergency system on their own is not feasible. I’m an emergency nurse, so I see both ways.  And I am telling you right now, it is not the place. Like, as an emergency nurse, I cannot support a survivor in the emergency department. It’s just not possible. You don’t have the time and especially with these survivors, they need time. I think that’s key. Even when I do, like, an assessment on a patient, minimum, it’s about an hour and a half, sometimes up to eight hours, depending on the complexity of the case. So really, if, like I said, it’s just increasing forensic nurses in Ontario.
	Survivor C77	C77: My doctor knew. Actually all the time, when I visit doctor, my partner, he was going inside with me. […] He was always going with me and my doctor, a little, she had, like, she got the sense that I’m in stress. So, she asked me some questions that, “Do you have any friends or family here?” I said, “No.” And she knew that I’m on visitor visas, so I don’t have health card. So, every time he was going and paying, so, the fees of the doctor. Interviewer: Did the doctor ever turn around and say to him, or your partner, or whoever was with you, “I need to speak to the patient alone,” or “Unfortunately, I need to ask you to leave the room?” C77: No, she never asked that. But I think she got that sense. And she was asking me, “Do you have any stress? Do you have any stress?” I said, ”Yeah, I’m having stress because I can’t eat anything. I’m tired. This is…” And he was sitting there, so how I could—because at that time I was not having intention that I will leave this person or I can complain about him because I was pregnant I was not thinking to leave him, so I was just silent.
	Survivor C81	Interviewer: Did any doctor or any nurse or anybody in the hospital ask you, how did [the injuries from your partner] happen to you? Or has or did anybody ask you, is anybody hurting you? C81: No, they don’t ask you because they speak English and they don’t use translators and they just want to check you out and just get it done and that’s it. Interviewer: Can I ask how many times the last year have you been to the hospital? C81: Three or four times.
B. Justice system not accounting for the needs of VAW survivors	Direct support staff P43	Either more training for officers or a change to allow, kind of, more mental health workers, social workers to be deployed with frontline. […] So that […] clients know that there is more emotional support available for them right at the time that things happen.
	Direct support staff P139	Child protection […] it’s not only about the kid. I know that is important—I know that is what they are there to do. But there’s so many things involved that the family, the mother, has to be included and understand. Not that I—we don’t have to understand abuse or neglect, it’s not about it. It’s about that […] it’s not black and white. And sometimes they are very, very radical like. So, and the police as well, the police, you know the violence—so, so many times women, they don’t speak the language and they’re the ones that are charged that are put in jail because there is no mark, but there is a mark on the man. But they were defending themselves. So, you know, I think education. If they could provide more training for those and to have more opportunity for women.
	Survivor C75	The whole reason why I started my substance abuse is because I was going through physical abuse and I had to hide it for months, like years. I was hiding it. And then I—that’s how I coped. I wanted to forget. I wanted to numb the pain. I wanted all of that. And for them to help me deal with my problem, they took my kids away. But that doesn’t really help the problem. You take my kids away. And so that’s going to make me drink more because now I’m depressed. You know what I mean? And so, it started out as trauma, but then they just keep building on top of that trauma and then it’s kind of like, well, you just have to stop drinking. But they’re building that trauma. So how do they expect you to just stop when they keep building on top of what you’ve already gone through?
	Direct support staff P23	With mandatory charges […] it backfires. And, uh, yeah, it just creates this, really, the hardship for women. The system needs to change. They need to consider women’s experiences going through the system to be able to support and to prevent this from happening again. […] It’s up to the police to decide. […] They will separate people, they will mandate, like, the PAR [partner assault response] program. But at the same time, I feel like the supports are not really being provided, like it’s, “Oh well, you have your charge now. You have to deal with that on top of everything that you’ve experienced.” Like, I think police training needs to happen, really. That’s how they work with people, that’s problematic. I hear it from many clients, it’s very, very traumatic to go through something like that. […] If the police would say, “Okay, call here,” like, you know, “they will help you,”—that would make a difference and not leave you kind of hanging and waiting. […] After this COVID ends, we know that more programs need to be put in place. […] We need to really work more collaboratively in this, like, you know, uh, situation and to learn from this kind of situation and improve our services because we—I feel like many people are being left behind in this COVID crisis.

Although more limited in number in our sample, staff participants heavily involved in health systems work reinforced these points. For instance, leader P68, whose work is funded by the Ontario Ministry of Health, provided further context around the health care system (Table 4A), which has been operating “siloed” from the VAW sector, among others, and thus not strategically addressing the diversity of VAW survivors’ needs. P115, a direct service provider in the health care system, offered additional insight (Table 4A), raising the point that the solution for better health care outcomes for VAW survivors is not necessarily the provision of VAW training to health care providers (a common suggestion^{Footnote 34}), who may lack the capacity to provide intensive VAW-specific care within their regular practice.^{Footnote 35} Instead, the recommendation is to grow (and sustain) the workforce of VAW staff and advocates within the health care system—an approach that has shown promise internationally^{Footnote 36} and necessitates the strategic VAW–health care systems collaboration referred to by P68 (Table 4A).

This type of coordinated, advocate-based approach would not just support specific needs of VAW survivors navigating the health care system but would strengthen the identification and referral of at-risk patients^{Footnote 37}—issues exemplified by the experiences of survivor participants who accessed the health care system prior to accessing VAW services. For instance, throughout survivor C77’s pregnancy, her abusive partner, who was sponsoring her visitor’s visa, accompanied her for every appointment (Table 4A), a common tactic in controlling and coercive abuse.^{Footnote 38} Despite the psychological distress she was exhibiting (e.g. “I’m having stress because I can’t eat anything”) and the clear power imbalance in the relationship (“I don’t have a health card […] [my partner] was going and paying […] the fees”), her doctor never asked her partner to leave the room to safely discuss the potential of IPV, safety planning or available VAW services. Survivor C81 attended the hospital for injuries inflicted by her partner and, over the course of at least three visits, was not provided the necessary interpretation services to discuss the abuse she was experiencing (Table 4A). In both cases, neither C77 nor C81 had had prior contact with VAW services, and best practices for safe identification and referral should have been but were not implemented.^{Footnote 39}

Participants were further marginalized by the system as newcomers—lacking permanent resident status (C77) or comfort speaking in English (C81). These examples demonstrate that in the implementation of any coordinated systems approach, VAW advocates must also be trained and resourced to respond to the intersections between VAW and other forms of marginalization (e.g. in these cases, social assistance for survivors without permanent resident status; interpretation services).^{Footnote 37}

Challenges in the justice system for VAW survivors and staff in many ways mirrored those experienced in the health care system—including, for instance, survivors not being appropriately connected to VAW supports following contact with law enforcement (C77, C79, C81). As with the health care system, participants recommended VAW training across the justice system as a response, with certain specialized VAW staff based in the justice system recommending more of a coordinated, advocate-based approach (e.g. Table 4B, direct support staff P43). Ideally, such an approach ensures that survivors in crisis receive support from staff with specialized training in VAW and the capacity to respond appropriately.^{Footnote 40}

However, by virtue of VAW survivors’ interactions with the justice system typically involving others (e.g. partner, children), there were also more specific ways to address VAW that participants outlined. For instance, direct support staff P139 (Table 4B) raised two important challenges for VAW survivors interacting with the justice system discussed by participants: child protection and mandatory charging. Regarding child protection, staff and survivor participants spoke to P139’s point about the need to include VAW survivors in the conversation and decision-making around child protection (including child apprehension)—recognizing the potential harms of family separation^{Footnote 41Footnote 42} (“it’s not black and white”)—and provide appropriate supports to survivors throughout (and following) the process. Survivor C75’s story serves as one example of this (Table 4B). Specifically, C75 was not considered in the child protection process—including examining the root of her trauma (an abusive relationship) and providing appropriate treatment—and as a result, her mental health and substance use issues worsened. This removed the opportunity to keep mother and child together and reduced the likelihood of future family reunification, which, in many cases, has important benefits for both mother and child.^{Footnote 41}

Participants similarly articulated the importance of direct support workers (including police) being trained to identify and provide support for women’s experiences of violence in responding to domestic violence calls, which legally require charging (i.e. police must lay charges when they believe there is a reasonable likelihood that domestic violence has occurred). While P139 highlights the marginalization of survivors who do not speak English and are not provided with appropriate interpretation support, direct support staff P23 more broadly demonstrates the systematic gaps in this process (Table 4B). P23 illustrates the need for stronger coordination between the VAW and justice systems, including more trauma-informed supports for survivors involved in the justice system and stronger referral mechanisms at point-of-contact. These comments, along with P139’s and C75’s, speak to a larger observation around the weaponization of the justice system against VAW survivors—where survivors are criminalized (P139 and P23) or traumatized from child apprehension (C75).

In addition, participants described situations in which VAW survivors were manipulated and disempowered by abusive partners or professionals in high conflict cases (C74, C80, P137). Taken together, these accounts demonstrate how societal gender norms will continue to pervade the justice system if left unchecked—that is, without mandatory training and coordinated intersectoral action, including VAW- and trauma-informed advocacy—disadvantaging VAW survivors and allowing their continued exploitation by abusers, especially men who use violence.^{Footnote 43Footnote 44}

Implement and evaluate primary prevention strategies for VAW

The final set of participants’ recommendations for the NAP centred around policy action required to prevent VAW in the first instance. Within this domain, participants tended to focus on improving educational curricula and public awareness around healthy relationships, gender expression and what constitutes violence. There was a particular emphasis on ensuring such education begins early in life through the universal implementation in schools (e.g. Table 5A, direct support staff P92). Inherent in P92’s comments is a principle that participants widely articulated: the responsibility of preventing VAW should not fall to women alone but rather belongs to all of society—a rejection of the notion that women need to learn how to avoid “risky” situations.^{Footnote 45Footnote 46Footnote 47}

Table 5. Subthemes with example data under Theme 4: implement and evaluate primary prevention strategies for VAW

Subtheme	Example data
	Participant	Excerpt
A. Improving educational curricula and public awareness around VAW	Direct support staff P92	I think it’s very important, education in the schools. It’s not only education for the woman—because it’s always, like, oh, you have to teach the woman not to, like, whatever. But I think, so, it’s teaching, like, teaching students, like from Grade 3, 4, 5. […] It’s education about what is gender violence. And it is very, very important to start with the little ones and educate them about and around this and how to identify if you are having violence in your home. […] Because kids are the future. And if they know how to prevent or how not to do it, it will be better.
B. Preventive interventions must target boys and men	Direct support staff P140	When you work with a nonprofit, funding for “this and that” is always a concern. So, we have to work with what we have and our managers always tell us to be mindful. […] We go over and above because we’re also passionate about the work we do and we wish that this whole idea of abuse would go away. But it’s not, it’s not going to go away any time soon. And this is why I think more and more agencies are starting to do programing with young boys and young men now. So, you know, so I mean, you can’t just support the young girls and the women. You’ve got to, like, tap into and support the young men and boys as well. So, if we can prevent or educate them on the cycle of violence, then, you know, I think it will go a long way.
C. Redistributive and gender-transformative policies will benefit both responses to VAW and primary preventionFootnote a	Survivor C74	I think one of the material changes that I would advocate for heavily is a policy change around economic independence and financial independence. […] For those who identify as women or LGBTQ individuals, that, the deal breaker is this economic component. And so how can you leave an abusive relationship when you go through all the hurdles to move the systems? […] You do it and then there is no way to really recognize the disparity and the devastation of being economically marginalized because it’s not a thing that you can point to, it’s not recognized. […] It really is going to take a deft hand and a lot of very uncomfortable conversations—which, I think the timing is right. We’ve seen a pandemic, we’ve seen the disparity. […] But I don’t see a fundamental component that I’m not sure that I can be eloquent enough to speak to, and that is that there are people who have lived experience who are not being tasked with or given the stage for which to make meaningful change. It is in the best interest to keep things status quo. […] But we have to get to a policy. We have to stop talking about them. […] I think it is an allocation of resources and a political will. And I see that as part of the work that I will do. […] I’m not going to just drop it. […] I cannot. Chances are, statistics are, and I’ll just end on this note, that my daughter will experience the same thing because she’s witnessed it.
	Direct support staff P37	Sometimes they’re more talk than action. I guess whatever they say, they have to put the action first, too, not just talking about it.

Staff participants highlighted the importance of directing educational and, more broadly, supportive interventions to boys and men (e.g. Table 5B, direct support staff P140). Comments like P140’s make explicit the need to include boys and men in VAW prevention efforts as the most common perpetrators of VAW.^{Footnote 45} They also, however, highlight the current tension for VAW organizations—mandated to support women experiencing violence and chronically underfunded—in expanding their programmatic targets (e.g. only 14% of Canada’s federal budget for 2022 is dedicated to women-centred measures^{Footnote 48}). There is thus a need for increased funding dedicated to the design and delivery of educational and supportive interventions to boys and men—perhaps in some cases by VAW organizations and in others with their collaboration—but without limiting the funding pool for women-centred supports.

Both P92’s and P140’s comments (Table 5A and 5B) further speak to the emphasis that participants placed on interventions that stop the cycle of violence for younger generations, including and beyond educational interventions. This is congruent with the idea that strengthening the structural response to VAW (as discussed above) will also have implications for primary prevention, by equitably improving the social and economic supports and resources available to women whose children may otherwise be at higher risk for experiencing or perpetrating violence later in life.^{Footnote 46Footnote 49} In other words, policies that target the societal distribution of resources and social (including gender) norms are critical to all levels of VAW prevention (primary, secondary and tertiary).

This idea was reflected in the data, with participants discussing the importance of promoting gender and intersectional equity through policy and systems change in terms of both responding to VAW and preventing it in the first instance. These multilayered benefits are well captured in survivor C74’s comments (Table 5C). C74 illustrates the insidious consequences of gender-based and intersectional economic disparities in society—upheld by political systems that benefit from maintaining the “status quo”—which impact women’s capacity (and that of gender- and sexually diverse people) to leave violent relationships and increase the likelihood of intergenerational cycles of VAW (“chances are […] my daughter will experience the same thing”).^{Footnote 21Footnote 47} C74 makes the point, shared by other participants (e.g. Table 4C, direct support staff P37), that preventing VAW must move beyond hypothetical discussion into transformative policy action. This will require legitimate shifts in the distribution of power, resources and prestige in society, enshrined in law and policy, that promote the “economic independence” of all women, attending to intersecting structural barriers (e.g. racism, transphobia, ableism)— “uncomfortable” for the hegemonic classes who will inevitably lose power through redistributive policies.^{Footnote 21Footnote 45} Finally, C74 echoes a point well illustrated by our study: the often neglected value of meaningfully including the perspectives of VAW survivors in policy planning.

Summary of recommendations from this study

Table 6 summarizes the recommendations for Canada’s NAP on VAW based on our study findings and situates these recommendations in reference to existing literature, including the most recent NAP analyses.^{Footnote 9Footnote 13Footnote 50}

Table 6. Summary of our priority recommendations for Canada’s NAP on VAW

Recommendation	Details and reference to existing literature
Invest in VAW services and increase accessibility of crisis support
A. Increase public awareness of VAW and crisis supports	Design and implement long-term public awareness campaigns that educate about what constitutes VAW (in all its forms) and the availability of crisis supports, and transform societal norms around gender and violence. Information campaigns should use public avenues such as radio, television, grocery stores, parks, malls, laundromats, hospitals, community centres and other public spaces and involve translation in multiple languages. Public awareness campaigns have been a key recommendation in prior NAP consultations.Footnote 13Footnote 50 Information campaigns should avoid traumatizing or stigmatizing language or imagery, involve multiple stakeholders (e.g. survivors, service providers, advocates, researchers) in development and implementation, and be implemented within a multipronged strategy that aims to increase the availability and accessibility of supportive services.Footnote 24Footnote 25Footnote 26
B. Strengthen referral mechanisms to VAW programming	Develop a systematic and centralized process for referrals to VAW supports, including more accessible entry points for survivors (e.g. via virtual chat lines, with immediate availability of interpretation to multiple languages) and closer coordination between crisis lines and VAW organizations. Strengthening referral processes should include designating contact points who are responsible for keeping up to date on service availability and maintaining transparency and accountability throughout the referral process. This work necessitates more in-depth consultations with staff and survivors across the VAW and other intersecting sectors to determine priority steps for improvement (e.g. the utility of a national crisis line) and the implementation of a monitoring and evaluation system to ensure how well adaptations are working for the diversity of survivors in need. While prior NAP consultations have reviewed the importance of increased availability of VAW crisis supports, including crisis lines and integrated service delivery,Footnote 13Footnote 50 our study revealed important insights regarding the need for a more systematic, centralized and transparent referral system.
C. Increase the number of VAW organizations with the capacity to provide in-house wraparound supports to clients	Extending the call for the development of one-stop, multiagency hubs,Footnote 50 our study demonstrated the need for greater investment in the VAW sector to increase VAW workforces, training and infrastructure to expand the delivery of in-house wraparound supports, even amid emergency conditions. While not all VAW organizations may realistically have the capacity to offer multiple services to clients (and would therefore benefit from stronger referral mechanisms within the VAW sector), our findings highlight the difficulties in providing holistic support to clients in the face of staff shortages and the shutdown of in-person community services during the pandemic. Our results in particular emphasize the importance of accounting for the needs of community-specific VAW organizations and services with dedicated funding to strengthen capacity for in-house programming and referral supports. This action within the NAP should be supported by directed consultations with a diversity of these organizations and survivors, with consideration of intersecting social factors (e.g. ethnicity, race, immigrant status, language, age, socioeconomic status).
D. Provide flexible funding mechanisms to VAW organizations	Funders should allow more flexibility for VAW organizations to use their monies as they see fit to respond to client demand and needs, especially in the midst of emergency conditions—a new recommendation from our study that builds on the need for increased sustainable funding to VAW services recommended in prior NAP reportsFootnote 13Footnote 50 and reflects the evolving service context of the COVID-19 pandemic. Flexible funding would be benefitted by strengthening the monitoring and evaluation systems of VAW organizations, including improving client feedback and engagement processes, to ensure that organizations can maximize the likelihood that any adaptations meet the diverse needs of their clients.
E. Increase trauma-informed and specialized mental health supports in the VAW sector	Increase sustainable funding streams that support VAW organizations in developing and maintaining the necessary expertise (i.e. through providing existing staff with appropriate training or hiring staff with the necessary qualifications) to deliver specialized, trauma-informed mental health care to survivors, consistent with prior NAP recommendations.Footnote 13
Enhance structural supports for VAW
F. Increase investment into the full housing continuum for VAW survivors	Building on prior recommendations for the NAP to expand the full VAW-housing continuum,Footnote 9Footnote 13Footnote 50 our study highlighted the need for increased investment into VAW shelters, including strengthening referral pathways and increasing funding and resourcing to support capacity, staffing and training to collaborate with other systems in the provision of VAW care; second-stage (transitional) housing for VAW survivors (typically between 1 and 5 years) to provide medium-term housing solutions with psychological, legal, economic, employment and housing supports; and safe, accessible and affordable housing for VAW survivors, with wraparound supports, including attending to survivors’ safety needs in the neighbourhood and in the home, as well as greater collaboration between the VAW sector and private landlords to prevent discrimination towards VAW survivors. While the 2022 federal budget proposes that 25% of the CAD 1.5 billion earmarked for building new affordable housing units over the next two years go to women-focussed projects, it is critical that funding eligibility is inclusive of VAW organizations, and projects involving housing considerations and wraparound services for VAW survivors are supported.Footnote 9
G. Conduct Gender-Based Analysis Plus of housing, social and economic policies to inform policy reform that reduces gender and intersectional inequitiesFootnote a	Extending prior NAP recommendations,Footnote 9Footnote 13Footnote 50 our study illustrated priority areas for policy reform to strengthen the structural supports for VAW survivors, including revising residential tenancy laws to provide greater flexibility for survivors to be added to tenancies and the removal of partners who use violence; revising eligibility criteria for housing benefits to remove requirements of cohabitation with an abuser during a given time-period or, for newcomers, sponsorship; creating opportunities for low-barrier independent housing that allows women who lack the necessary finances, credit history or assets to secure their own independent housing; increasing the basic need and shelter allowance in the provision of social assistance; increasing funding for legal aid to support VAW survivors; improving the accessibility and affordability of child care options; and improving employment and educational opportunities for women, including training for professional certificates, résumé guidance and interview coaching for VAW survivors.
Develop coordinated systems to strengthen the response to VAW
H. Strengthen health-VAW systems coordination and collaboration	Prior NAP consultations have led to recommendations for VAW training for health care providers.Footnote 13Footnote 50 Based on our findings and existing evidence on intervention effectiveness,Footnote 35Footnote 36 this is necessary but not sufficient. We also recommend the development and sustainment of a coordinated system of VAW advocates based in the health system to support the specific needs of VAW survivors navigating the health care system and strengthen the identification and referral of at-risk patients. VAW advocates across sectors must also be trained and resourced to respond to the intersections between VAW and other forms of marginalization (e.g. social assistance for survivors without permanent resident status, interpretation services).
I. Strengthen justice-VAW systems coordination and collaboration	Paralleling the significant focus on justice system reform in Women Shelters Canada’s NAP implementation guide,Footnote 13 based on the current analysis, we recommend VAW training across the justice system and embedding designated VAW advocates in the family and criminal justice systems to strengthen trauma-informed and antiracist decision-making (e.g. including around child protection and mandatory charging) that is responsive to the intersectional needs of VAW survivors (e.g. based on ethnicity, race, disability, socioeconomic status, gender or sexual identity, age, location); ensure appropriate referral mechanisms are engaged for all VAW survivors; and prevent continued patterns of abuse against survivors within the justice system (e.g. by perpetrators or professionals). In addition, across all interactions with the justice system (including law enforcement), survivors who do not speak English should be provided with appropriate interpretation support.
Implement and evaluate primary prevention strategies for VAW
J. Improve educational curricula beginning in early years	In line with previous NAP consultations,Footnote 13Footnote 50 we recommend the development, implementation and evaluation of age-appropriate curricula for school-aged children to prevent VAW in collaboration with provincial education systems. Our findings highlight the importance of covering healthy relationships and gender expression and what constitutes violence.
K. Engage boys and men in VAW prevention	The Women Shelters Canada NAP implementation guide contains extensive recommendations around directing VAW preventive efforts towards boys and men.Footnote 13 Our analysis reinforces the importance of increased funding dedicated to the design and delivery of educational and supportive interventions to boys and men—perhaps in some cases by VAW organizations and in others with their collaboration—with the important caveat of not limiting the funding pool for women-centred supports.Footnote 48
L. Implement redistributive and gender-transformative policiesFootnote b	Strengthening the structural response to VAW (i.e. through redistributive and gender-transformative policies) will also have implications for primary prevention, by equitably improving the social and economic supports and resources available to women whose children may otherwise be at higher risk for experiencing or perpetrating violence later in life. The perspectives of a diversity of VAW survivors and experts should be meaningfully included in policy analysis and planning.

Strengths and limitations

This study offers the unique contribution of developing, prioritizing and nuancing recommendations for the NAP based on a rigorous analysis of the perspectives and experiences of survivors and staff accessing and delivering VAW services, respectively, in Toronto, Canada’s largest and most diverse city, during the COVID-19 pandemic. We relied on strong partnerships with VAW sector actors and women with lived experience of violence as research team members, advisors and knowledge users. As a result, our dataset came from staff and survivors from a diversity of VAW programming across residential and nonresidential services and we maintained active engagement with our VAW stakeholders throughout analysis and dissemination using integrated knowledge translation. Our sample was high in “informational power” for our research questions, providing rich and detailed data on participants’ experiences that allowed us to generate nuanced recommendations with in-depth justifications.^{Footnote 51}

We were committed to capturing the stories of staff and survivors with a diversity of personal and social identities and especially those experiencing different forms of marginalization. For instance, 70% of the survivors we interviewed identified as racialized persons, compared to the only other pandemic study of VAW services in Canada to interview VAW survivors to date, which included only White participants.^{Footnote 10}

Nonetheless, most of our sample identified as heterosexual ciswomen and most survivor participants were economically marginalized. We also found that community-specific organizations and racialized frontline staff tended to face more barriers to participating in this study (e.g. time in their workday); this speaks, at least in part, to the structural disadvantages that disproportionately impact them. In light of these limitations, there are nuanced experiences and perspectives within different communities that warrant further study.

In addition, our study provides an in-depth snapshot of Toronto-based perspectives. As Canada’s largest and most diverse city, with expansive health and social services, this is a critical context for informing the NAP, especially in terms of our recommendations focussed on cross-systems collaboration and wraparound supports for survivors that account for intersecting social factors. However, other municipalities and jurisdictions (including rural and remote areas with sparser or more condensed service contexts) will have unique needs that should be studied and addressed in the NAP. One important area for future research and policy is the further development and implementation of the NAP on missing and murdered Indigenous women and girls, which should be led by Indigenous communities.

Conclusion

While the federal government has made the initial commitment to fund a NAP on VAW, and suggested a high-level framework, now is the time to enact the recommendations derived from our study and from previous NAP reports. This must include the development and implementation of a clearly defined plan as well as an ongoing feminist, intersectional and trauma-informed monitoring and evaluation system to maximize the likelihood for sustainable, effective prevention.

Acknowledgements

We gratefully acknowledge funding from the Canadian Institutes of Health Research (PCS-183421), the Temerty Foundation and the University of Toronto through the Toronto COVID-19 Action Initiative; the University of Toronto’s Faculty of Medicine Equity, Diversity, and Inclusion fund; and the St. Michael’s Hospital Foundation.

We are extremely grateful to the MARCO-VAW study participants who made this work possible and the Toronto Region Violence Against Women Coordinating Committee, who served as the MARCO-VAW study’s advisory group. We thank the Woman Abuse Council of Toronto for supporting our peer researchers. We would also like to acknowledge the support of the broader MARCO study team, including principal investigators Ahmed Bayoumi and Michelle Firestone and research coordinators Fiqir Worku and Kimia Khoee.

Conflicts of interest

Priya Shastri and Elizabeth Tremblay are employed by the Toronto Region Violence Against Women Coordinating Committee (VAWCC). The VAWCC is funded by the Ontario Ministry of Children, Community and Social Services (MCCSS), which is a primary funder of many VAW organizations in the Greater Toronto Area. Maria Huijbregts is employed by Family Service Toronto, which receives funding from MCCSS.

Authors’ contributions and statement

ARY and PS led the conceptualization and design of the study in collaboration with CM, ET, MA, PO, RM, JDM, MH, LH and AS. ARY, PS, CM, ET and MA conducted the study interviews. ARY and BS led data analysis with the support of CM and MA. ARY and BS led data interpretation in collaboration with CM, ET, MA, PO, RM, JDM, MH, LH, AS and PS. ARY wrote the first draft of the paper with support from BS. ARY, BS, CM, ET, MA, PO, RM, JDM, MH, LH, AS and PS revised the paper and approved the final version for publication.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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