Introduction

The detrimental impact of interpersonal violence on public health is well documented and supported by numerous studies in both the social and medical sciences [1-8]. Empirical evidence gathered through retrospective and longitudinal analyses indicates that prolonged exposure to violence results in harmful, often irreversible consequences for individuals, communities, and systems [9-11]. At the individual level, the direct consequences include deterioration of physical, sexual, and mental health, reduced quality of life and well-being, diminished productivity and motivation, psychomotor slowing, and impaired performance in everyday activi­ties. At the societal level, violence exacerbates social inequalities and marginalization of victims, while also undermining social cohesion by eroding interpersonal bonds, weakening social capital, and decreasing trust in institutions tasked with providing support, protection, and assistance. At the systemic level – particularly in the healthcare sector – violence generates escalating costs associated with diagnosis, treatment, therapy, and both short- and long-term care. The occurrence of violence necessitates the reorganization of services, the redefinition of priorities in delivering aid, and the reallocation of public health resources to address the immediate needs of victims. Specifically, this often forces hospitals to redirect funding from scheduled or non-urgent procedures in order to secure emergency care for individuals affected by violence. Hospitals experience the burden of these costs acutely, frequently calling for increased funding and the establishment of interdisciplinary teams to develop effective prevention programs – aligning with the principle that “prevention is better than cure.”

A study conducted at Harborview Medical Center in Seattle, titled The Burden of Violence to U.S. Hospitals, and the research report based on it published in 2025, provide a comprehensive assessment of the financial toll of violence compared to other national expenditures. According to the report, the total annual cost of violence in the United States is estimated at $18.27 billion USD. Pre-incident costs – both in communities and within institutions – amount to approximately $3.62 billion and primarily involve preventive measures. Post-incident costs, including medical care, income loss, case management, staff replacement, and infrastructure repairs, are estimated at $14.65 billion. The majority of these expenses are linked to healthcare services required to treat injuries resulting from acts of violence. There are also more complex and less quantifiable consequences, such as damage to public image, difficulties in recruitment and staff retention, legal challenges, reduced job satisfaction, and psychological strain among healthcare workers – particularly stress and professional burnout [12]. Although these figures pertain to the U.S. system, extrapolation allows for the conclusion that violence places a similarly devastating financial burden on national budgets elsewhere. From a macroeconomic perspective, the reduction of violence contributes to increased population wealth and socio-economic well-being. In the long term, this translates into higher Gross Domestic Product (GDP) and Human Development Index (HDI), and a reduction in the Gini coefficient (a measure of income inequality). Thus, the elimination of violence is not only a social and ethical imperative but also a strategic objective for development and modernization. As such, it should be a central concern for those responsible for the well-being of citizens and national security. This underscores the urgent need to design interventions that effectively reduce interpersonal violence, with particular emphasis on domestic violence and intimate partner violence (IPV).

The empirical data presented in this article derive from research conducted within the framework of the international research project Untangled from Violence – Safe Again, which focused on post-separation violence. The study was entirely grounded in qualitative methodology, including observation, focus group interviews (FGIs), and in-depth interviews. This research approach is particularly well suited to diagnosing the complex nature of the issue, as it allows for identifying the deep-rooted determinants of the phenomenon and providing nuanced, detailed insights. Post-separation violence refers to intentional and methodical acts aimed at causing harm and suffering after the end of a relationship. It often emerges in the context of divorce-related conflicts, including disputes over child custody and parental authority. Since women are disproportionately affected by this form of violence [13-15], they constituted the primary subjects of this investigation. Their statements, grounded in their own biographical narratives, expressed personal experiences, evaluations, and beliefs. These accounts should be collectively acknowledged and treated as a foundational reference point for systemic modeling.

Material and methods

The first stage of the study involved conducting FGIs – a qualitative research technique based on guided discussions among individuals who possess complex, experience-based, and often professional knowledge of a given issue. This approach allows for the explora­tion of meanings (often taboo or hidden), while simultaneously revealing systemic deficits and areas in need of intervention or institutional support. In FGIs, the researcher obtains information of interest through group interaction [16, 17]. The participants in this study were adult women with lived experience of post-separation violence, which had been preliminarily verified and confirmed. The sampling process was based on a specially designed questionnaire assessing the scope of violence experienced. Specifically, the inclusion criterion was having suffered physical, psychological, sexual, or economic violence within the past year. Additionally, participants had to be receiving services from institutions or organizations providing support for victims of domestic violence. The sample was homogeneous in terms of key socio-demographic characteristics. All participants gave informed written consent prior to participation, and personal data – particularly sensitive information – were anonymized. The discussion, led by a trained moderator, lasted approximately 2.5 hours and followed a semi-structured format guided by a discussion protocol. The FGI session was conducted online, using digital communication technologies – a format deemed most comfortable by the participants. Interviews were audiovisually recorded and transcribed verbatim. All collected data were secured in accordance with the highest standards of confidentiality. The research process was carried out with particular attention to empathetic communication and linguistically sensitive practices, in order to avoid any retraumatizing effects. Given the sensitivity of the topic and the intimate nature of participants’ narratives, the moderator was required to be cognitively and emotionally prepared. According to established guidelines, the moderator paid close attention to both verbal and non-verbal cues, which often carry significant meaning. Additionally, the moderator needed strong interpersonal skills and active listening abilities to fully grasp and interpret the nuances of each statement [18]. The moderator’s appropriate stance was key to obtaining reliable and authentic data, which is critical for the validity and interpretability of the findings. The FGI followed a structured research protocol comprising several stages. It began with an introduction to the topic, the establishment of rapport, and efforts to encourage active participation among all group members [19], as an effective warm-up phase can significantly stimulate deeper engagement in the discussion [20]. Subsequently, participants were prompted to respond to questions. The group’s interactive dynamic [16] – including resonance of opinions, mutual elaboration, and at times confrontation of beliefs – facilitated the verbalization and contextualization of personal experiences, generating rich analytical material. Upon completion of the FGI session, participants’ statements were grouped into broader thematic categories. This allowed for qualitative analysis aimed at identifying the health-related risks associated with post-separation violence, with particular emphasis on areas requiring urgent systemic intervention.

FGI – as a method of data collection and knowledge generation through group discussion – may be used independently or in conjunction with other quali­tative or quantitative techniques to offer a multifaceted view of the studied phenomenon. It is especially useful at preliminary or exploratory stages of research when the aim is to “understand the specifics rather than the general” [16]. FGIs provide insights into multiple aspects and determinants of a given issue, its contextual emergence, and transformation. Through this method, “shared knowledge” is co-constructed – rooted in individual experiences, emotions, reflections, and beliefs, particularly those that are intimate or deeply personal. Group dynamics often enhance this process. The knowledge generated emerges from respondents’ mutual influence, shared effort, idea synergy, and the snowballing of opinions – together producing new perspectives on the issue. A distinctive strength of FGIs is their flexibility and adaptability across varied contexts, which allows for multi-dimensional interpretations [21]. In this study, FGIs were of fundamental importance, as they enabled the collection of first-hand accounts and lived experiences of post-separation violence, as well as an understanding of the needs arising from such circumstances. Their utility was further reinforced by the participants’ reflections on the consequences of this violence and their expectations for potential interventions, providing insight into how existing systems might better address these needs.

The primary aim of the FGIs was to gather foundational data concerning the origins, dynamics, consequences, and types of post-separation violence. This made it possible to diagnose the most frequently expressed needs of those affected by such violence and, in turn, the demands these needs place on public health systems. The empirical material gathered also provides a basis for designing tools to identify post-separation violence, as well as for developing comprehensive prevention and intervention programs. Furthermore, the data may be used to evaluate existing services and programs by highlighting their strengths and limitations. FGIs can be successfully applied not only in social sciences but also in health research [22] – particularly for understanding patients’ experiences of chronic illness and the subjective dimension of those experiences [21], such as in studies involving women with endometriosis [23].

Results

The empirical data collected in this study clearly indicate that post-separation violence constitutes a significant social and public health problem. Its gravity is heightened by the extensive socio-economic costs it gene­rates and its amplification of adverse events. Individuals experiencing such violence find themselves in a state of crisis and, consequently, expect the public health sector to offer comprehensive solutions and support strategies that integrate various types of assistance – including medical care, as well as psychological, legal, informational, and material support. Effective medical intervention must address not only the treatment of physical injuries (e.g., fractures, wounds, bruises), but also the psychological consequences such as anxiety disorders, depression, post-traumatic stress disorder (PTSD), chronic stress, and insomnia. From the first point of contact, symptoms of abuse should be recognized by healthcare professionals, who are often the initial and primary providers of care. It is therefore essential to enhance the competencies of physicians, nurses, and emergency responders in identifying both direct and indirect indicators of violence. Medical education should incorporate interdisciplinary training on this topic, ensuring that future professionals are adequately equipped to diagnose violence and provide both immediate and long-term support – particularly given that victims, during the early stages of leaving an abusive relationship, are often disoriented, fearful, helpless, and passive.

An in-depth analysis of participants’ narratives reveals that the specificity of post-separation violence lies in its complexity, variability, unpredictability, and rapid escalation – often triggered by the moment of separation or the woman’s departure. Perpetrators were typically motivated by revenge, jealousy, and a generalized drive for destruction. The effectiveness of their abusive actions was often grounded in a significant power imbalance favoring the perpetrator. A central aim of the abusive behavior was to maintain control and dominance over the former partner, manifested through systematic and deliberate acts of aggression. This form of violence aligns with broader patterns of IPV, where abuse functions as a tool for subjugation, coercion, and control. Importantly, the perpetrator’s actions were not impulsive, random, or episodic, but rather methodical, premeditated, and intentionally harmful – designed to inflict suffering and punish the woman for her decision to end the relationship. The violence described in these narratives reflects deep emotional deficiencies in the perpetrator, difficulties with impulse regulation, and traits of an emotionally immature personality. All participants reported experiencing early signs of violence at the beginning of the relationship – or even before its formal establishment – and retrospectively identified these as “red flags.” Many women also described a tendency to minimize or rationalize the abuse they experienced, often attributing their partner’s behavior to external factors such as a difficult childhood, dysfunctional family background, job-related stress, unemployment, a “difficult personality,” or struggles with adapting to life circumstances. These rationalizations were part of psychological defense mechanisms that allowed the women to survive within the relationship but simultaneously delayed the decision to leave and seek help. Respondents also admitted to maintaining an unwavering belief, often for extended periods, that their partner would change or improve. This “belief in redemption” was often reinforced by brief periods of reconciliation and affection – commonly referred to as the “honeymoon phase” – during which the perpetrator, fearing abandonment, would express remorse, apologize, make promises of change, and temporarily behave in a loving, attentive, or generous manner.

In light of the research findings, the primary forms of violence reported by participants encompassed: physical violence (e.g., beating, choking, slapping, pushing, shoving); psychological violence (e.g., humiliation, verbal abuse, toxic communication, disregard, manipulation, gaslighting, coercive control); sexual violence (e.g., rape, sexual abuse); economic violence (e.g., withholding money, restricting access to bank accounts, controlling expenditures); material violence (e.g., destruction or damage of property); as well as neglect and abuse of pets. These forms of abuse frequently co-occurred and mutually reinforced one another, thereby entrenching victims more deeply in cycles of violence and exacerbating the challenges associated with leaving the abusive environment.

Respondents reported extensive health consequences – stemming from both the physical injuries sustained and the psychological toll of chronic exposure to violence. Although some symptoms – such as chronic fatigue, blood pressure fluctuations, heart palpitations, headaches, apathy, and anhedonia – may not exclusively result from abuse (and may have other etiologies), participants strongly associated their physical and mental health deterioration with the stress and instability of their family situations. In addition to health-related outcomes, respondents also reported economic and legal consequences of abuse, including the cost of therapy and medical treatment, financial instability, and the burdens of ongoing legal proceedings. The cumulative and prolonged exposure to violence led some participants to suffer irreversible damage – particularly in terms of neurological functioning and overall mental health. Diagnosed conditions included affective disorders and complex post-traumatic stress disorder (C-PTSD). Through specific examples, the women emphasized the persistent feelings of fear, isolation, humiliation, rejection, and internalized guilt. Their suffering was further exacerbated by what they perceived as insufficient support from their social environments and state institutions – including the healthcare system – especially with regard to long-term care and rehabilitation.

Discussion

The violence under examination may be conceptualized as a disease exacerbating the “public health crisis,” which is a leading cause of numerous fatalities [24]. Health experts advocate for understanding violence as an “infection,” given its detrimental effects on psychophysical well-being, reduction of life expectancy, induction of addictions, elicitation of trauma and anxiety, reinforcement of social divisions and inequalities, and its role in causing severe injuries and often death [25]. Violence is recognized as a “contagious disease” due to its rapid propagation through routine interactions – transmitted person-to-person via a chain of contagion and often resulting in lethal outcomes. Addressing this malady requires consideration of individual susceptibility and acquired immunity; however, the cornerstone of recovery lies in effective remedies, vaccines, and the implementation of appropriate medical care and physician supervision [26]. Drawing parallels between the epidemiology of infectious diseases and violence, scholars delineate three strategies for reversing pathogenesis (restoring health): (1) early detection and interruption of actual or potential sources of infection; (2) identification of causative agents and vectors within affected groups alongside curtailment of transmission opportunities; and (3) transformation of behavioral and social norms towards recovery while simultaneously rectifying environmental conditions conducive to contagion [26]. A particularly effective and practical method for violence reduction is the Cure Violence Health Model (CVHM), which employs evidence-based interventions previously used in controlling epidemics and mitigating their often-lethal consequences [25]. This model is predicated on the assumption that violence, akin to untreated disease, is contagious and transmittable through all forms of contact. The application of this model to violence eradication unfolds in stages: commencing with the identification of sources and factors precipitating violence and disruption of their effects; proceeding to the identification of the pathogenic agent and administration of appropriate treatment; and culminating in mobilization and encouragement of at-risk populations to adopt behavioral change. Empirical studies substantiate that CVHM constitutes an effective approach in detecting, preventing, and managing violence, as well as in subsequent interventions. Comparative analyses of criminal trajectories that incorporate CVHM versus those that do not reveal significantly reduced rates of homicide, robbery, other criminal offenses, and overall arrests where the model has been implemented [4].

Given that foundational and applied research supports the utility of the CVHM in mitigating the aforementioned types of common crime, it appears plausible that a similar approach could be extended to the prevention and intervention of post-separation violence – an under-researched form of public health pathology. The insufficient recognition of this issue is attributable to its privatization and depoliticization; abuses and harms occurring within the private sphere are treated as individual matters, with personal accountability attributed to the victim. Moreover, intimate partner relations remain taboo due to the private nature of family life, thus remaining largely beyond state oversight. How­ever, this problem is structural and manifests on a global scale, necessitating that anti-violence efforts transcend isolated cases and instead reconfigure social structures and public health practices – with particular emphasis on enhanced health security supervision, systematic analysis and monitoring of victim situations, prevention and combat of violence in both public and private spaces, and promotion of a violence-free life. Accordingly, translating CVHM recommendations into concrete actions and practices allows for the design of a processual public health policy aimed at protecting and improving the health of women subjected to violence. The individual stages of this policy, alongside the corresponding set of activities and tasks, are delineated in Table 1.

Conclusions

The objective of the present study was to investigate the phenomenon of post-separation violence in relation to the autobiographical experiences of the participants, encompassing its genesis, consequences, typologies, forms of occurrence, mechanisms of action, dynamics, and risk factors. The application of FGIs, recommended in public health research, enabled the acquisition of in-depth empirical data, which constitute a significant illustrative material for the analysis of post-separation violence and its destructive impact on public health.

The FGI method proved appropriate for exploring a phenomenon characterized as “latent” in the sense of Robert K. Merton [27], which – in light of the absence of prior empirical research in this domain – can be regarded as an innovative contribution to the discourse on public health. The conducted analysis not only addresses the forms and dynamics of post-separation violence and its health, psychological, and social consequences but also identifies factors conducive to its escalation. Importantly, the study provides grounds for designing social policies within the realm of public health, aimed at identifying and meeting the needs of individuals experiencing violence, with particular emphasis on protective measures, crisis intervention, psychological support, and prevention.

The theoretical foundation of the analysis is situated within the CVHM, whose applicability to the study of post-separation violence proved significant for at least two reasons. Firstly, this model offers an effective tool for diagnosing the phenomenon of post-separation violence and can serve as a basis for the development of effective therapeutic, preventive, and intervention programs aimed at reducing the transmission of violence (i.e., the “contagion” of violence). Secondly, CVHM enables systematic identification of areas of particular risk and the selection of appropriate forms of support focused on mitigating the effects of violence and maximizing the well-being of individuals and groups affected by this phenomenon.

Based on the obtained results, it is possible to design protective environments and implement specia­lized actions within the public health system aimed at reducing post-separation violence. The study’s conclusions constitute essential premises for the development of social poli­cies, preventive strategies, and intervention programs grounded in the real experiences and needs of those affected by this form of violence.

Disclosures

1. Institutional review board statement: Not applicable.

2. Assistance with the article: AI assistance was used for language editing and grammar correction.

3. Financial support and sponsorship: Project funded by Iceland, Liechtenstein, and Norway through EEA Grants and Norwegian Funds under the Active Citizens Fund – Regional Fund Program.

4. Conflict of interest: None.

References