Increasing the Safety-Promoting Behaviors of Abused Women

Association Between Health-Promoting Behaviors and Reproductive Health Needs in Women Experiencing Domestic Violence

Violence against women is considered as one of the most serious social problems in all the societies. It is common that the abused women experience physical, psychological, and health problems, as well as reproductive health issues. Domestic violence affects women's health behaviors and ability to seek any form of health care. This study aimed to investigate the relationship between health-promoting behaviors and reproductive health needs in women experienced domestic violence. This cross-sectional study was conducted from May 5 to September 21, 2021, on 380 abused women. Cluster sampling was performed in health centers of Karaj. Data were collected using demographic survey questions, Domestic Violence Survey, Reproductive Health Needs of Domestic Violated Women scale, and health-promoting behaviors questionnaire. The mean (standard deviation) scores for reproductive health needs and health-promoting behaviors were 158.88 (20.24) and 131.08 (20.53), respectively. Psychological violence had the highest (69.5%) prevalence among all types and 37.6% of women reported severe violence. The results of Spearman's rank correlation coefficient test indicated that all dimensions of the reproductive health needs of abused women (men's participation, self-care, support and health services, and sexual and marital relationships) positively and significantly related to the total score and various dimensions of health-promoting behaviors (interpersonal relationship, health responsibility, physical activity, spiritual growth, nutrition, and stress management). The dimensions of health-promoting behaviors together can explain 21.6% of the changes in reproductive health needs based on linear regression. Violence is a global public concern and paying attention to the various health dimensions in abused women is an important aspect of the health policies. Developing health-promoting behaviors in abused women improves their reproductive health state and society as a whole.

Examining the Effectiveness, Acceptability, and Feasibility of Virtually Delivered Trauma-Focused Domestic Violence and Sexual Violence Interventions: A Rapid Evidence Assessment

The COVID-19 pandemic has forced a rapid shift to virtual delivery of treatment and care to individuals affected by domestic violence and sexual violence. A rapid evidence assessment (REA) was undertaken to examine the effectiveness, feasibility and acceptability of trauma-focused virtual interventions for persons affected by domestic violence and sexual violence. The findings from this review will provide guidance for service providers and organizational leaders with the implementation of virtual domestic violence and sexual violence-focused interventions. The REA included comprehensive search strategies and systematic screening of and relevant articles. Papers were included into this review (1) if they included trauma-focused interventions; (2) if the intervention was delivered virtually; and (3) if the article was published in the English-language. Twenty-one papers met inclusion criteria and were included for analysis. Findings from the rapid review demonstrate that virtual interventions that incorporate trauma-focused treatment are scarce. Online interventions that incorporate trauma-focused treatment for this at-risk group are limited in scope, and effectiveness data are preliminary in nature. Additionally, there is limited evidence of acceptability, feasibility and effectiveness of virtual interventions for ethnically, culturally, and linguistically diverse populations experiencing domestic violence and sexual violence. Accessing virtual interventions was also highlighted as a barrier to among participants in studies included in the review. Despite the potential of virtual interventions to respond to the needs of individuals affected by domestic violence and/or sexual violence, the acceptability and effectiveness of virtual trauma-focused care for a diverse range of populations at risk of violence are significantly understudied.

Concerned friends of intimate partner violence survivors: results from the myPlan randomized controlled trial on college campuses

BACKGROUND

Nearly half of intimate partner violence (IPV) survivors experience their first abusive relationship at college age (18-24 years). Most often they disclose the violence to friends. Existing college campus "bystander" interventions training peers to safely intervene have been effective in sexual assault prevention; similar interventions have rarely been tested for IPV. Therefore, we evaluated the effectiveness of an interactive, personalized safety decision and planning tool, myPlan app, on decisional conflict, decisional preparedness, confidence in intervening, supportive safety behaviors, and IPV attitudes with concerned friends of abused college women.

METHODS

We recruited college students (age 18-24, N = 293) of any gender who had a female-identified friend who had recently experienced IPV ("concerned friends") from 41 Oregon and Maryland colleges/universities. Participants were randomized to myPlan (n = 147) or control (usual web-based resources; n = 146). Outcomes included decisional conflict, decisional preparedness, confidence to intervene, safety/support behaviors, and IPV attitudes.

RESULTS

At baseline, concerned friends described the abused person as a close/best friend (79.1%); 93.7% had tried at least one strategy to help. Most (89.2%) reported concerns their friend would be seriously hurt by the abuser; 22.7% reported extreme concern. Intervention participants had greater improvements in decisional conflict (specifically, understanding of their own values around the decision to intervene and help a friend) and decisional preparedness immediately after their first use of myPlan, and a significantly greater increase in confidence to talk with someone about their own relationship concerns at 12 months. At 12-month follow-up, both intervention and control groups reported increased confidence to intervene, and did not differ significantly in terms of percentage of safety/support strategies used, whether strategies were helpful, or IPV attitudes.

CONCLUSIONS

A technology-based intervention, myPlan, was effective in reducing one aspect of decisional conflict (improving clarity of values to intervene) and increasing decisional preparedness to support a friend in an unsafe relationship. Information on IPV and related safety strategies delivered through the myPlan app or usual web-based resources both increased confidence to intervene with a friend. College students in the myPlan group were more likely to talk with someone about concerns about their own relationship, demonstrating potential for IPV prevention or early intervention.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT02236663, registration date 10/09/2014.

Telehealth for Women's Preventive Services for Reproductive Health and Intimate Partner Violence: a Comparative Effectiveness Review

BACKGROUND

Telehealth delivery of preventive health services may improve access to care; however, its effectiveness and adverse effects are unknown. We conducted a comparative effectiveness review on the effectiveness and harms of telehealth interventions for women's reproductive health and intimate partner violence (IPV) services.

METHODS

We searched MEDLINE, Cochrane Library, CINAHL, and Scopus for English-language studies (July 2016 to May 2022) for randomized controlled trials (RCTs) and observational studies of telehealth strategies for women's reproductive health and IPV versus usual care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using study design-specific standardized methods; disagreements were resolved through consensus.

RESULTS

Eight RCTs, 1 nonrandomized trial, and 7 observational studies (n=10 731) were included (7 studies of contraceptive care and 9 of IPV services). Telehealth interventions to supplement contraceptive care demonstrated similar rates as usual care for contraceptive use, sexually transmitted infections, and pregnancy (low strength of evidence [SOE]); evidence on abortion was insufficient. Outcomes were also similar between telehealth interventions to replace or supplement IPV services and comparators for repeat IPV, depression, posttraumatic stress disorder, fear of partner, coercive control, self-efficacy, and safety behaviors (low SOE). In these studies, telehealth barriers included limited internet access, digital literacy, technical challenges, and confidentiality concerns. Strategies to ensure safety increased telehealth use for IPV services. Evidence on access, health equity, or harms was lacking.

DISCUSSION

Telehealth interventions for contraceptive care and IPV services demonstrate equivalent clinical and patient-reported outcomes versus in-person care, although few studies are available. Effective approaches for delivering these services and how to best mobilize telehealth, particularly for women facing barriers to care remain uncertain.

TRIAL REGISTRATION

PROSPERO CRD42021282298.

Longitudinal Impact of the myPlan App on Health and Safety Among College Women Experiencing Partner Violence

The objective of this study was to examine differences in change over time in health and safety outcomes among female college students randomized to myPlan, a tailored safety planning app, or usual web-based safety planning resources. Three hundred forty-six women (175 intervention, 171 control) from 41 colleges/universities in Oregon and Maryland completed surveys at baseline, 6- and 12-months from July 2015 to October 2017. Generalized estimating equations were used to test group differences across time. Both groups improved on four measure of intimate partner violence (IPV; Composite Abuse Scale [CAS], TBI-related IPV, digital abuse, reproductive coercion [RC]) and depression. Reduction in RC and improvement in suicide risk were significantly greater in the myPlan group relative to controls (p = .019 and p = .46, respectively). Increases in the percent of safety behaviors tried that were helpful significantly reduced CAS scores, indicating a reduction in IPV over time in the myPlan group compared to controls (p = .006). Findings support the feasibility and importance of technology-based IPV safety planning for college women. myPlan achieved a number of its objectives related to safety planning and decision-making, the use of helpful safety behaviors, mental health, and reductions in some forms of IPV.

Risk Assessment Instruments for Intimate Partner Femicide: A Systematic Review

Intimate partner violence is a severe problem that has taken the lives of thousands of women worldwide, and it is bound to continue in the future. Numerous risk assessment instruments have been developed to identify and intervene in high-risk cases. However, a synthesis of specific instruments for severe violence against women by male partners has not been identified. This type of violence has specific characteristics compared to other forms of intimate partner violence, requiring individualized attention. A systematic review of the literature has been conducted to summarize the intimate partner homicide risk assessment instruments applied to this population. It has been carried out with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. The search strategy yielded a total of 1,156 studies, and only 33 studies met eligibility criteria and were included in the review. The data of these studies were extracted, analyzed, and presented on study characteristics (country and year, sample, data sources, purpose of the studies) and main findings (a brief description of the instruments, risk factor items, psychometric properties). The results indicate that the Danger Assessment, the Danger Assessment for Immigrants, the Danger Assessment for Law Enforcement, the Danger Assessment-5, the Taiwan Intimate Partner Violence Danger Assessment, the Severe Intimate Partner Risk Prediction Scale, The Lethality Screen, and the H-Scale are specific risk assessment instruments for predicting homicide and attempted homicide. There are differences in the number and content of risk assessment items, but most of them include the evidence's critical factors associated with homicide. Validity and reliability scores of these instruments vary, being consistency and accuracy medium-high for estimating homicide. Finally, implications for prediction and prevention are noted, and future research directions are discussed.

"Being Married Doesn't Mean You Have to Reach the End of the World": Safety Planning With Intimate Partner Violence Survivors and Service Providers in Three Urban Informal Settlements in Nairobi, Kenya

Intimate partner violence (IPV) harms women physically, sexually, and psychologically. Safety strategies, or harm reduction techniques implemented by women undergoing recurrent violence, may help mitigate the negative health, economic, and social consequences of IPV. This study aimed to understand recommended and utilized safety strategies among three urban informal settlements in Nairobi, Kenya. Semi-structured key informant discussions (KIDs; n = 18) with community-based service providers and focus group discussions (FGDs; n = 49) with IPV survivors were conducted. All interviews were audio-recorded, transcribed, and translated verbatim from Swahili to English. Inductive thematic analysis was used to structure codes. Convergence matrices were used to analyze emergent strategies by data source (service providers vs. IPV survivors). Women preferred safety strategies that they could implement unassisted as first line of harm reduction. Strategies included removing stressors, proactive communication, avoidance behaviors, sexual and reproductive health (SRH), economic, leaving partner for safety, child safety, and securing personal property. Strategies recommended by service providers and utilized by IPV survivors differed, with clear divergence indicated for leaving the abusive relationship, SRH, and personal property strategies. Innovative strategies emerged from IPV survivors for safeguarding property. Similar to upper-income and other low and middle-income contexts, women experiencing IPV in urban informal settlements of Nairobi actively engage in behaviors to maximize safety and reduce harm to themselves and their families. Integration of strategies known to be helpful to women in these communities into community-based prevention and response is strongly encouraged. Increased synergy between recommended and implemented safety strategies can enhance programming and response efforts.

Pregnant Women's Attitudes Toward and Experiences With a Tablet Intervention to Promote Safety Behaviors in a Randomized Controlled Trial: Qualitative Study

BACKGROUND

Intimate partner violence (IPV) is recognized as a global health problem. Women with low education and limited resources are more vulnerable, as are immigrant women. There is a lack of evidence on how health care professionals should communicate about and intervene against IPV during pregnancy. Earlier research has shown that when women manage digital questionnaires, they are more likely to disclose IPV. However, little is known about how women experience eHealth interventions with safety behaviors to prevent IPV.

OBJECTIVE

The aim of this study was to explore pregnant women's attitudes toward and experiences with a tablet intervention to promote safety behaviors in a randomized controlled trial (RCT) in antenatal care.

METHODS

Individual semistructured interviews were conducted with 10 women who participated in the Safe Pregnancy Study. The Safe Pregnancy Study was a randomized controlled trial (RCT) using a tablet intervention containing IPV questions and a film to promote safety behaviors. Six women from the intervention group and four women from the control group were recruited. The content was available in Norwegian, Somali, and Urdu. Five of the women participating in the interviews spoke Norwegian at home and five spoke another language. The majority of the women who did not speak Norwegian at home perceived themselves as relatively well integrated. The interviews were conducted at different maternal and child health centers (MCHCs) in Norway between March 2020 and June 2020. The analysis was guided by thematic analysis.

RESULTS

Women who participated in the tablet intervention appreciated being asked questions about IPV on a tablet. However, it was important to supplement the tablet intervention with face-to-face communication with a midwife. The MCHC was regarded as a suitable place to answer questions and watch a film about safety behaviors. Women suggested making the tablet intervention available in other settings where women meet health care professionals. Some women expressed uncertainty about their anonymity regarding their answers in the questionnaire. We found no real differences between ethnic Norwegian and immigrant women's attitudes toward and experiences with the tablet intervention.

CONCLUSIONS

Questions about IPV and a film about safety behaviors on a tablet, as a supplement to face-to-face communication, might initiate and facilitate communication about IPV in antenatal care. Uncertainty regarding anonymity has to be addressed when questions about IPV are being asked on a tablet.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03397277; https://clinicaltrials.gov/ct2/show/NCT03397277.

An Integrative Review of Safety Strategies for Women Experiencing Intimate Partner Violence in Low- and Middle-Income Countries

Intimate partner violence (IPV) is prevalent and a leading source of morbidity and mortality to women worldwide. Safety planning is a cornerstone of harm reduction and violence support in many upper income countries. Far less is known about safety strategies used by women in low- and middle-income countries (LMICs) where the IPV support service infrastructure may be more limited. This study aimed to review the literature regarding safety strategies in LMICs. A PubMed search was conducted using search terms "safety," "coping," "harm reduction," and "intimate partner violence." Inclusion criteria comprised IPV studies mentioning characterization and utilization of safety strategies that were written in English and conducted in an LMIC. Our search yielded 16 studies (in-depth interviews, n = 5; focus group discussions, n = 2; case study, n = 2; mixed qualitative methods, n = 4; mixed methods, n = 1; and semi-structured quantitative survey, n = 2). Four distinct themes of strategies emerged: engaging informal networks, removing the stressor/avoidance, minimizing the damage to self and family through enduring violence, and building personal resources. IPV-related safety strategies literature primarily emerged from site-specific qualitative work. No studies provided effectiveness data for utilized strategies. Across geoculturally diverse studies, results indicate that women are engaging in strategic planning to minimize abuse and maximize safety. Women highlighted that safety planning strategies were feasible and acceptable within their communities. Further research is needed to test the effectiveness of these strategies in decreasing revictimization and increasing health and well-being. Further adoption of safety strategies into violence programming could increase monitoring and evaluation efforts.

User-Involvement in the Development of a Culturally Sensitive Intervention in the Safe Pregnancy Study to Prevent Intimate Partner Violence

Intimate partner violence (IPV) during pregnancy has negative health impacts on the woman and the fetus. There is a lack of evidence supporting effective interventions to prevent IPV during pregnancy. This user-involvement study was conducted to get feedback on a culturally sensitive, tablet intervention containing questions about violence and safety-behaviors and a video promoting safety behaviors. This resulted in important feedback on the intervention content. Our findings show that women are in favor of disclosing IPV via a tablet. They suggested ways to address barriers for disclosure, such as safeguarding anonymity and creating a trustful relationship with the midwife.

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

Keeping it together for the kids: New mothers' descriptions of the impact of intimate partner violence on parenting

BACKGROUND

Intimate partner violence (IPV) affects 1 in 3 US women with the effects of IPV detectable for several generations. While IPV is known to have significant impacts on maternal-child outcomes, little is known about the mother's perspectives of the interplay between perinatal IPV exposure, parenting styles, and safety strategies.

METHODS

This secondary analysis of semi-structured, longitudinal qualitative interview data explored with pregnant women their histories of IPV, their parenting practices, and safety strategies. Data were derived from a randomized controlled trial, DOVE, with 22 interviews from 11 women collected during pregnancy and 12 or 24 months postpartum.

RESULTS

Data were analyzed using constant comparative analysis resulting in three themes: "broken spirit," "I want better for my kids and me," and "safety planning as an element of parenting." Women described at baseline having a "broken spirit" due to their experiences with household and family chaos and childhood abuse. However, when mothers ended the abusive relationship, they described a better life and several strategies to protect themselves and their children. During their final interviews, mothers discussed how their lives improved after ending the relationship as well as safety planning strategies they employed like looking for "red flags" in potential partners, struggles with finding trustworthy childcare, and stockpiling money should they choose to end the relationship.

CONCLUSION

These rich data add new information about how mothers of very young children navigate difficult parenting and safety decisions in the context of lifetime traumatic events and provide insights relevant for practice and research with this highly-vulnerable group of IPV survivors.

An Examination of the Lethality Assessment Program (LAP): Perspectives on Implementation, Help-Seeking, and Victim Empowerment

The Lethality Assessment Program (LAP) aims to empower law enforcement officers to screen victims of domestic violence for potential lethality and connect them to service providers. This research surveyed domestic violence victims seeking legal services (n = 141) to assess whether LAP receipt is associated with greater rates of self-protective measures, service use, or empowerment, and to examine victims' perspectives on the LAP process. Findings indicate no relationship between receipt of the LAP and use of self-protective measures or victim empowerment, mixed evidence between receipt of the LAP and service utilization, and room for improvement regarding how law enforcement officers explain the LAP to victims. Implications are discussed.

Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania

BACKGROUND

Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.

METHODS

Formative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).

RESULTS

We designed an 8-session intervention, termed Nguvu ('strength'), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.

CONCLUSIONS

We found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.

TRIAL REGISTRATION

ISRCTN65771265, June 27, 2016.

A realist review of which advocacy interventions work for which abused women under what circumstances

BACKGROUND

Intimate partner abuse (including coercive control, physical, sexual, economic, emotional and economic abuse) is common worldwide. Advocacy may help women who are in, or have left, an abusive intimate relationship, to stop or reduce repeat victimisation and overcome consequences of the abuse. Advocacy primarily involves education, safety planning support and increasing access to different services. It may be stand-alone or part of other services and interventions, and may be provided within healthcare, criminal justice, social, government or specialist domestic violence services. We focus on the abuse of women, as interventions for abused men require different considerations.

OBJECTIVES

To assess advocacy interventions for intimate partner abuse in women, in terms of which interventions work for whom, why and in what circumstances.

SEARCH METHODS

In January 2019 we searched CENTRAL, MEDLINE, 12 other databases, two trials registers and two relevant websites. The search had three phases: scoping of articles to identify candidate theories; iterative recursive search for studies to explore and fill gaps in these theories; and systematic search for studies to test, confirm or refute our explanatory theory.

SELECTION CRITERIA

Empirical studies of any advocacy or multi-component intervention including advocacy, intended for women aged 15 years and over who were experiencing or had experienced any form of intimate partner abuse, or of advocates delivering such interventions, or experiences of women who were receiving or had received such an intervention. Partner abuse encompasses coercive control in the absence of physical abuse. For theory development, we included studies that did not strictly fit our original criteria but provided information useful for theory development.

DATA COLLECTION AND ANALYSIS

Four review authors independently extracted data, with double assessment of 10% of the data, and assessed risk of bias and quality of the evidence. We adopted RAMESES (Realist and meta-narrative evidence syntheses: evolving standards) standards for reporting results. We applied a realist approach to the analysis.

MAIN RESULTS

We included 98 studies (147 articles). There were 88 core studies: 37 focused on advocates (4 survey-based, 3 instrument development, 30 qualitative focus) and seven on abused women (6 qualitative studies, 1 survey); 44 were experimental intervention studies (some including qualitative evaluations). Ten further studies (3 randomised controlled trials (RCTs), 1 intervention process evaluation, 1 qualitative study, 2 mixed methods studies, 2 surveys of women, and 1 mixed methods study of women and staff) did not fit the original criteria but added useful information, as befitting a realist approach. Two studies are awaiting classification and three are ongoing.Advocacy interventions varied considerably in contact hours, profession delivering and setting.We constructed a conceptual model from six essential principles based on context-mechanism-outcome (CMO) patterns.We have moderate and high confidence in evidence for the importance of considering both women's vulnerabilities and intersectionalities and the trade-offs of abuse-related decisions in the contexts of individual women's lives. Decisions should consider the risks to the woman's safety from the abuse. Whether actions resulting from advocacy increase or decrease abuse depends on contextual factors (e.g. severity and type of abuse), and the outcomes the particular advocacy intervention is designed to address (e.g. increasing successful court orders versus decreasing depression).We have low confidence in evidence regarding the significance of physical dependencies, being pregnant or having children. There were links between setting (high confidence), and potentially also theoretical underpinnings of interventions, type, duration and intensity of advocacy, advocate discipline and outcomes (moderate and low confidence). A good therapeutic alliance was important (high confidence); this alliance might be improved when advocates are matched with abused women on ethnicity or abuse experience, exercise cultural humility, and remove structural barriers to resource access by marginalised women. We identified significant challenges for advocates in inter-organisational working, vicarious traumatisation, and lack of clarity on how much support to give a woman (moderate and high confidence). To work effectively, advocates need ongoing training, role clarity, access to resources, and peer and institutional support.Our provisional model highlights the complex way that factors combine and interact for effective advocacy. We confirmed the core ingredients of advocacy according to both women and advocates, supported by studies and theoretical considerations: education and information on abuse; rights and resources; active referral and liaising with other services; risk assessment and safety planning. We were unable to confirm the impact of complexity of the intervention (low confidence). Our low confidence in the evidence was driven mostly by a lack of relevant studies, rather than poor-quality studies, despite the size of the review.

AUTHORS' CONCLUSIONS

Results confirm the core ingredients of advocacy and suggest its use rests on sound theoretical underpinnings. We determined the elements of a good therapeutic alliance and how it might be improved, with a need for particular considerations of the factors affecting marginalised women. Women's goals from advocacy should be considered in the contexts of their personal lives. Women's safety was not necessarily at greatest risk from staying with the abuser. Potentially, if undertaken for long enough, advocacy should benefit an abused woman in terms of at least one outcome providing the goals are matched to each woman's needs. Some outcomes may take months to be determined. Where abuse is severe, some interventions may increase abuse. Advocates have a challenging role and must be supported emotionally, through provision of resources and through professional training, by organisations and peers.Future research should consider the different principles identified in this review, and study outcomes should be considered in relation to the mechanisms and contexts elucidated. More longitudinal evidence is needed. Single-subject research designs may help determine exactly when effect no longer increases, to determine the duration of longitudinal work, which will likely differ for vulnerable and marginalised women. Further work is needed to ascertain how to tailor advocacy interventions to cultural variations and rural and resource-poor settings. The methods used in the included studies may, in some cases, limit the applicability and completeness of the data reported. Economic analyses are required to ascertain if resources devoted to advocacy interventions are cost-effective in healthcare and community settings.

The Safe Pregnancy study - promoting safety behaviours in antenatal care among Norwegian, Pakistani and Somali pregnant women: a study protocol for a randomized controlled trial

BACKGROUND

Intimate partner violence (IPV) around the time of pregnancy is a recognized global health problem with damaging consequences. However, little is known about the effect of violence assessment and intervention during pregnancy. We hypothesise that routine enquiry about IPV during pregnancy, in combination with information about IPV and safety behaviours, has the potential to increase the use of these behaviours and prevent and reduce IPV.

METHODS

The Safe Pregnancy study is a randomised controlled trial (RCT) to test the effectiveness of a tablet-based intervention to promote safety behaviours among pregnant women. Midwives include women who attend routine antenatal care. The intervention consists of a screening questionnaire for violence and information about violence and safety behaviours through a short video shown on a tablet. The materials are available in different languages to ensure participation of Norwegian, Urdu, Somali and English-speaking women. Eligible women answer baseline questions on the tablet including the Abuse Assessment Scale (AAS). Women who screen positive on the AAS will be randomized to an intervention video that contains information about violence and safety behaviours and women in the control group to a video with general information about a healthy and a safe pregnancy. All women receive information about referral resources. Follow up will be at three months post-partum, when the woman attends the maternal and child health centre (MCHC) for the baby's check-up. Outcome measures are: Use of safety behaviours and quality of life (primary outcomes), prevalence of violence, mental health measures and birth outcomes (secondary outcomes). Intention to treat analysis will be performed.

DISCUSSION

The project will provide evidence on whether enquiry about violence and a short video intervention on a tablet is effective and feasible to prevent or reduce harm from IPV among women who attend antenatal care.

TRIAL REGISTRATION

This study is registered in ClinicalTrials.gov. Identifier: NCT03397277 (Registered 11th January 2018).

Telehealth Interventions Designed for Women: an Evidence Map

BACKGROUND

Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women.

METHODS

We searched MEDLINE^® (via PubMed^®) and Embase^® from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of ClinicalTrials.gov .

RESULTS

Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (n = 96), prevention (n = 46), disease management (n = 63), family planning (n = 9), high-risk breast cancer assessment (n = 10), intimate partner violence (n = 7), and mental health (n = 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of clinical.trials.gov yielded 73 ongoing studies that show a shift in the use of non-telephone modalities.

DISCUSSION

Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women's health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.

Intimate partner violence: treating abuser and abused

Intimate partner violence is associated with significant psychiatric comorbidity. Treatment has focused on male perpetrators but recent studies indicate that this is of limited success in reducing male violence. This article reviews the current available treatments from three perspectives: that of the victim, the perpetrator, and the couple who wish to remain together. It also provides guidelines to assist the general psychiatrist in determining what treatment to offer patients who present with intimate partner violence. Guidelines emphasise the need for assessment of risk factors that indicate a potentially lethal relationship and the importance of the diagnosis and treatment of comorbidity, especially alcohol misuse and dependence.

The Longitudinal Impact of an Internet Safety Decision Aid for Abused Women

INTRODUCTION

Women experiencing intimate partner violence (IPV) navigate complex, dangerous decisions. Tailored safety information and safety planning, typically provided by domestic violence service providers, can prevent repeat IPV exposure and associated adverse health outcomes; however, few abused women access these services. The Internet represents a potentially innovative way to connect abused women with tailored safety planning resources and information. The purpose of this study was to compare safety and mental health outcomes at baseline, 6 months, and 12 months among abused women randomized to: (1) a tailored, Internet-based safety decision aid; or (2) control website (typical safety information available online).

DESIGN

Multistate, community-based longitudinal RCT with one-to-one allocation ratio and blocked randomization. Data were collected March 2011-May 2013 and analyzed June-July 2015.

SETTING/PARTICIPANTS

Currently abused Spanish- or English-speaking women (N=720).

INTERVENTION

A tailored Internet-based safety decision aid included priority-setting activities, risk assessment, and tailored feedback and safety plans. A control website offered typical safety information available online.

MAIN OUTCOME MEASURES

Primary outcomes were decisional conflict, safety behaviors, and repeat IPV; secondary outcomes included depression and post-traumatic stress disorder.

RESULTS

At 12 months, there were no significant group differences in IPV, depression, or post-traumatic stress disorder. Intervention women experienced significantly less decisional conflict after one use (β= -2.68, p=0.042) and greater increase in safety behaviors they rated as helpful from baseline to 12 months (12% vs 9%, p=0.033) and were more likely to have left the abuser (63% vs 53%, p=0.008). Women who left had higher baseline risk (14.9 vs 13.1, p=0.003) found more of the safety behaviors they tried helpful (61.1% vs 47.5%, p<0.001), and had greater reductions in psychological IPV ((11.69 vs 7.5, p=0.001) and sexual IPV (2.41 vs 1.25, p=0.001) than women who stayed.

CONCLUSIONS

Internet-based safety planning represents a promising tool to reduce the public health impact of IPV.

Developing an App for College Women in Abusive Same-Sex Relationships and Their Friends

Young women experiencing dating violence in same-sex relationships face significant barriers to help for safety planning. Therefore, our team developed a tailored smartphone safety decision aid app for dating violence survivors and their peers. College women survivors of same-sex dating violence, peers, and college staff reviewed the app, identifying users' barriers to information, resources, and services and key strategies for dissemination, inclusiveness, and safety for the app. Findings support the use of the app to assist college women experiencing same-sex dating violence and peers to connect with resources and develop tailored safety plans to reduce violence and increase their safety.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse

BACKGROUND

Intimate partner abuse is common worldwide, damaging the short- and long-term physical, mental, and emotional health of survivors and children. Advocacy may contribute to reducing abuse, empowering women to improve their situation by providing informal counselling and support for safety planning and increasing access to different services. Advocacy may be a stand-alone service, accepting referrals from healthcare providers, or part of a multi-component (and possibly multi-agency) intervention provided by service staff or others.

OBJECTIVES

To assess the effects of advocacy interventions within or outside healthcare settings in women who have experienced intimate partner abuse.

SEARCH METHODS

In April 2015, we searched CENTRAL, Ovid MEDLINE, EMBASE, and 10 other databases. We also searched WHO ICTRP, mRCT, and UK Clinical Research Network (UKCRN), and examined relevant websites and reference lists with forward citation tracking of included studies. For the original review we handsearched six key journals. We also contacted first authors of eligible papers and experts in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing advocacy interventions for women with experience of intimate partner abuse versus no intervention or usual care (if advocacy was minimal and fewer than 20% of women received it).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and undertook data extraction. We contacted authors for missing information needed to calculate statistics for the review and looked for adverse events.

MAIN RESULTS

We included 13 trials involving 2141 participants aged 15 to 65 years, frequently having low socioeconomic status.The studies were quite heterogeneous in terms of methodology, study processes and design, including with regard to the duration of follow-up (postintervention to three years), although this was not associated with differences in effect. The studies also had considerable clinical heterogeneity in relation to staff delivering advocacy; setting (community, shelter, antenatal, healthcare); advocacy intensity (from 30 minutes to 80 hours); and abuse severity. Three trials evaluated advocacy within multi-component interventions. Eleven measured some form of abuse (eight scales), six assessed quality of life (three scales), and six measured depression (three scales). Countries and ethnic groups varied (one or more minority ethnic groups in the USA or UK, and local populations in Hong Kong and Peru). Setting was associated with intensity and duration of advocacy.Risk of bias was high in five studies, moderate in five, and low in three. The quality of evidence (considering multiple factors such as risk of bias, study size, missing data) was moderate to low for brief advocacy and very low for intensive advocacy. Incidence of abuse Physical abuseModerate quality pooled data from two healthcare studies (moderate risk of bias) and one community study (low risk of bias), all with 12-month follow-up data, showed no effect on physical abuse for brief (< 12 hours) advocacy interventions (standardised mean difference (SMD) 0.00, 95% confidence interval (CI) - 0.17 to 0.16; n = 558). One antenatal study (low risk of bias) showed an association between brief advocacy and reduced minor physical abuse at one year (mean difference (MD) change - 1.00, 95% CI - 1.82 to - 0.18; n = 110). An antenatal, multi-component study showed a greater likelihood of physical abuse ending (odds ratio (OR) 0.42, 95% CI 0.23 to 0.75) immediately after advocacy (number needed to treat (NNT) = 8); we cannot exclude impact from other components.Low to very low quality evidence from two intensive advocacy trials (12 hours plus duration) showed reduced severe physical abuse in women leaving a shelter at 24 months (OR 0.39, 95% CI 0.20 to 0.77; NNT = 8), but not at 12 or 36 months. Sexual abuseMeta-analysis of two studies (n = 239) showed no effect of advocacy on sexual abuse (SMD - 0.12, 95% CI - 0.37 to 0.14), agreeing with the change score (MD - 0.07, 95% CI - 0.30 to 0.16) from a third study and the OR (0.96, 95% CI 0.44 to 2.12) from a fourth antenatal, multi-component study. Emotional abuseOne study in antenatal care, rated at low risk of bias, showed reduced emotional abuse at ≤ 12-month follow-up (MD (change score) - 4.24, 95% CI - 6.42 to - 2.06; n = 110). Psychosocial health Quality of lifeMeta-analysis of two studies (high risk of bias) showed intensive advocacy slightly improved overall quality of life of women recruited from shelters (MD 0.23, 95% CI 0.00 to 0.46; n = 343) at 12-month follow-up, with greater improvement in perceived physical quality of life from a primary care study (high risk of bias; MD 4.90, 95% CI 0.98 to 8.82) immediately postintervention. Depression Meta-analysis of two studies in healthcare settings, one at high risk of bias and one at moderate risk, showed that fewer women developed depression (OR 0.31, 95% CI 0.15 to 0.65; n = 149; NNT = 4) with brief advocacy. One study at high risk of bias reported a slight reduction in depression in pregnant women immediately after the intervention (OR 0.51, 95% CI 0.20 to 1.29; n = 103; NNT = 8).There was no evidence that intensive advocacy reduced depression at ≤ 12-month follow-up (MD - 0.14, 95% CI - 0.33 to 0.05; 3 studies; n = 446) or at two years (SMD - 0.12, 95% CI - 0.36 to 0.12; 1 study; n = 265). Adverse effectsTwo women died, one who was murdered by her partner and one who committed suicide. No evidence links either death to study participation.

AUTHORS' CONCLUSIONS

Results suggest some benefits from advocacy. However, most studies were underpowered. Clinical and methodological heterogeneity largely precluded pooling of trials. Therefore, there is uncertainty about the magnitude of benefit, the impact of abuse severity, and the setting.Based on the evidence reviewed, intensive advocacy may improve short-term quality of life and reduce physical abuse one to two years after the intervention for women recruited from domestic violence shelters or refuges. Brief advocacy may provide small short-term mental health benefits and reduce abuse, particularly in pregnant women and for less severe abuse.

Intimate partner abuse: identifying, caring for and helping women in healthcare settings

Intimate partner abuse (IPA) is experienced by around one in three women at some stage during their lifetime, and has serious health consequences. This paper reviews how clinicians can best identify when a woman is experiencing IPA, and provide appropriate care and assistance. Research supports use of sensitive inquiry about IPA when conditions or situations that can be associated with IPA are present. Subsequent responses recommended include validation, affirmation and support, safety assessment and planning (both for the woman and any children), counseling and referral to IPA specialist services. Better training is needed for clinicians in these areas. Future research is needed to compare identification methods, and further assess psychological, advocacy and safety planning interventions, primary prevention and perpetrator interventions.

I-DECIDE: An Online Intervention Drawing on the Psychosocial Readiness Model for Women Experiencing Domestic Violence

BACKGROUND

Domestic violence (DV) perpetrated by men against women is a pervasive global problem with significant physical and emotional consequences. Although some face-to-face interventions in health care settings have shown promise, there are barriers to disclosure to health care practitioners and women may not be ready to access or accept help, reducing uptake. Similar to the mental health field, interventions from clinical practice can be adapted to be delivered by technology.

PURPOSE

This article outlines the theoretical and conceptual development of I-DECIDE, an online healthy relationship tool and safety decision aid for women experiencing DV. The article explores the use of the Psychosocial Readiness Model (PRM) as a theoretical framework for the intervention and evaluation.

METHODS

This is a theoretical article drawing on current theory and literature around health care and online interventions for DV.

RESULTS

The article argues that the Internet as a method of intervention delivery for DV might overcome many of the barriers present in health care settings. Using the PRM as a framework for an online DV intervention may help women on a pathway to safety and well-being for themselves and their children. This hypothesis will be tested in a randomized, controlled trial in 2015/2016.

CONCLUSION

This article highlights the importance of using a theoretical model in intervention development and evaluation.

A safety app to respond to dating violence for college women and their friends: the MyPlan study randomized controlled trial protocol

BACKGROUND

Research demonstrates high rates of physical and sexual victimization of women by intimate partners on college campuses (Black et al. 2001). College women in abusive relationships must weigh complex factors (health, academics, economics, and social stigma) during critical decision-making regarding the relationship. Rather than access formal support systems (e.g., campus security, administrators, counselors), research indicates abused college women most often turn to informal networks; specifically friends (Perspect Psychiatr Care 41:162-171, 2005), who often lack the knowledge or resources to provide effective support (Nurs Res 54(4):235-242, 2005). Decision aids have been shown to assist with health-related decisions by improving knowledge, creating realistic expectations, and resolving decisional conflict (Cochrane Database Syst Rev 1:1-332, 2014).

METHODS/DESIGN

This study is a randomized controlled trial testing the effectiveness of an interactive safety decision aid web-based and smartphone application (App) for abused college women and their friends. Three hundred female college students experiencing abuse and three hundred friends of female college students experiencing abuse will be recruited in Maryland and Oregon and randomized to either the intervention safety decision aid, accessible by website or smartphone App, or a usual safety planning control website/App. The intervention App allows users to enter information on: a) relationship health; b) safety priorities; and c) severity of violence/danger in relationship. The App uses this information to provide personalized safety planning information and resources. Self-reported outcome measures for abused college women on safety seeking behaviors, decisional conflict, IPV exposure and mental health will be collected at baseline, six, and 12-months post-baseline via the study App/website. Outcomes measured for friends are IPV awareness, confidence to intervene, supportive behaviors and decisional conflict. Protocols for safely recruiting, retaining and collecting data from abused women via web/App are discussed.

DISCUSSION

This trial may provide important information on the impact of an App and web-based safety planning tool on college women's decisional conflict and safety behavior use when making difficult safety decisions. This study is the first, to our knowledge, to test an intervention that engages friends of abused college women. The trial may also inform researchers on the feasibility of safely conducting research with abused women using online recruitment and enrollment methods and collecting data via an App or website.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT02236663.

Protocol for a randomised controlled trial of a web-based healthy relationship tool and safety decision aid for women experiencing domestic violence (I-DECIDE)

Background

Domestic violence is a serious problem affecting the health and wellbeing of women globally. Interventions in health care settings have primarily focused on screening and referral, however, women often may not disclose abuse to health practitioners. The internet offers a confidential space in which women can assess the health of their relationships and make a plan for safety and wellbeing for themselves and their children. This randomised controlled trial is testing the effectiveness of a web-based healthy relationship tool and safety decision aid (I-DECIDE). Based broadly on the IRIS trial in the United States, it has been adapted for the Australian context where it is conducted entirely online and uses the Psychosocial Readiness Model as the basis for the intervention.

Methods/design

In this two arm, pragmatic randomised controlled trial, women who have experienced abuse or fear of a partner in the previous 6 months will be computer randomised to receive either the I-DECIDE website or a comparator website (basic relationship and safety advice). The intervention includes self-directed reflection exercises on their relationship, danger level, priority setting, and results in an individualised, tailored action plan. Primary self-reported outcomes are: self-efficacy (General Self-Efficacy Scale) immediately after completion, 6 and 12 months post-baseline; and depressive symptoms (Centre for Epidemiologic Studies Depression Scale, Revised, 6 and 12 months post-baseline). Secondary outcomes include mean number of helpful actions for safety and wellbeing, mean level of fear of partner and cost-effectiveness.

Discussion

This fully-automated trial will evaluate a web-based self-information, self-reflection and self-management tool for domestic violence. We hypothesise that the improvement in self-efficacy and mental health will be mediated by increased perceived support and awareness encouraging positive change. If shown to be effective, I-DECIDE could be easily incorporated into the community sector and health care settings, providing an alternative to formal services for women not ready or able to acknowledge abuse and access specialised services.

Trial registration

Trial registered on 15^th December 2014 with the Australian New Zealand Clinical Trials Registry ACTRN12614001306606

Comparing Online with Face-to-Face HELPP Intervention in Women Experiencing Intimate Partner Violence

Intimate partner violence (IPV) is a public health problem. The purpose of this study was to compare the effectiveness of the HELPP (Health, Education on Safety, and Legal Support and Resources in IPV Participant Preferred) intervention among IPV survivors. A sequential, transformative mixed-methods design was used. Participants were randomly assigned to one of three study groups: Online (ONL), Face-to-Face (FTF), and Waitlist Control (WLC). The HELPP intervention was offered to 32 adult female participants who were 45.2% Asian, 32.3% White, and 22.5% Black. Outcome measures were anxiety, depression, anger, personal, and social support. In total, 64% (n  =  20) of the participants reported having experienced IPV before the age of 18. The anger mean score pre-test to post-test difference was significant for ONL (p < 0.001) and WLC (p  =  0.01). The personal and social support pre-test to post-test mean score differences were significant for ONL (p < 0.001; p < 0.001) and WLC (p  =  0.01; p  =  0.006), respectively. The HELPP intervention (1) decreased anxiety, depression, anger, and (2) increased personal and social support in the ONL group. The HELPP information and intervention was shown to be feasible, acceptable, and effective among IPV survivors compared with participants in the WLC group. The WLC participants displayed (1) increased levels of anxiety, depression, and anger and (2) decreased levels of personal and social support, post-intervention. Further research could be conducted to determine if e-mail alone or e-mail plus mobile devices are more useful modes of delivering interventions.

Use of online safety decision aid by abused women: effect on decisional conflict in a randomized controlled trial

BACKGROUND

An Internet safety decision aid was developed to help abused women understand their risk for repeat and near-lethal intimate partner violence, clarify priorities related to safety, and develop an action plan customized to these priorities.

PURPOSE

To test the effectiveness of a safety decision aid compared with usual safety planning (control) delivered through a secure website, using a multistate RCT design. The paper evaluates the effectiveness of the safety decision aid in reducing decisional conflict after a single use by abused women.

DESIGN

RCT referred to as Internet Resource for Intervention and Safety (IRIS).

SETTING/PARTICIPANTS

Abused women who spoke English (n=708) were enrolled in a four-state RCT.

INTERVENTION

The intervention was an interactive safety decision aid with personalized safety plan; the control condition was usual safety planning resources. Both were delivered to participants through the secure study website.

MAIN OUTCOME MEASURES

This paper compares women's decisional conflict about safety: total decisional conflict and the four subscales of this measure (feeling: uninformed, uncertain, unsupported, and unclear about safety priorities) between intervention/control conditions. Data were collected from March 2011 to May 2013 and analyzed from January to March 2014.

RESULTS

Immediately following the first use of the interactive safety decision aid, intervention women had significantly lower total decisional conflict than control women, controlling for baseline value of decisional conflict (p=0.002, effect size=0.12). After controlling for baseline values, the safety decision aid group had significantly greater reduction in feeling uncertain (p=0.006, effect size=0.07) and in feeling unsupported (p=0.008, effect size=0.07) about safety than the usual safety planning group.

CONCLUSIONS

Abused women randomized to the safety decision aid reported less decisional conflict about their safety in the abusive intimate relationship after one use compared to women randomized to the usual safety planning condition.

Abused Women With Children Who Are First-Time Users of a Shelter or Applicants for a Protection Order

Worldwide, two models of care are offered most often to abused women—safe shelter and justice services. No evidence exists on the differential effectiveness of the services. To provide evidence, 300 abused women, 150 first-time users of a shelter and 150 first-time applicants for a protection order, signed informed consent to participate in a 7-year study. Safety, abuse, and functioning of the women and their children were measured. Compared with women seeking justice services, women in shelters reported more abuse and depression and less support. The baseline characteristics of these 300 women are presented with implications for practice and policy.

Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis

OBJECTIVE

To examine the effectiveness of screening for intimate partner violence conducted within healthcare settings to determine whether or not screening increases identification and referral to support agencies, improves women's wellbeing, decreases further violence, or causes harm.

DESIGN

Systematic review and meta-analysis of trials assessing effectiveness of screening. Study assessment, data abstraction, and quality assessment were conducted independently by two of the authors. Standardised estimations of the risk ratios and 95% confidence intervals were calculated.

DATA SOURCES

Nine databases searched up to July 2012 (CENTRAL, Medline, Medline(R), Embase, DARE, CINAHL, PsycINFO, Sociological Abstracts, and ASSIA), and five trials registers searched up to 2010.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised or quasi-randomised trials of screening programmes for intimate partner violence involving all women aged ≥ 16 attending a healthcare setting. We included only studies in which clinicians in the intervention arm personally conducted the screening, or were informed of the screening result at the time of the consultation, compared with usual care (or no screening). Studies of screening programmes that were followed by structured interventions such as advocacy or therapeutic intervention were excluded.

RESULTS

11 eligible trials (n=13,027) were identified. In six pooled studies (n=3564), screening increased the identification of intimate partner violence (risk ratio 2.33, 95% confidence interval 1.39 to 3.89), particularly in antenatal settings (4.26, 1.76 to 10.31). Based on three studies (n=1400), we detected no evidence that screening increases referrals to domestic violence support services (2.67, 0.99 to 7.20). Only two studies measured women's experience of violence after screening (three to 18 months after screening) and found no reduction in intimate partner violence. One study reported that screening does not cause harm.

CONCLUSIONS

Though screening is likely to increase identification of intimate partner violence in healthcare settings, rates of identification from screening interventions were low relative to best estimates of prevalence of such violence. It is uncertain whether screening increases effective referral to supportive agencies. Screening does not seem to cause harm in the short term, but harm was measured in only one study. As the primary studies did not detect improved outcomes for women screened for intimate partner violence, there is insufficient evidence for screening in healthcare settings. Studies comparing screening versus case finding, or screening in combination with therapeutic intervention for women's long term wellbeing, are needed to inform the implementation of identification policies in healthcare settings.

The association between protective actions and homicide risk: findings from the Oklahoma Lethality Assessment Study

This study focuses on the relationship between women's risk of homicide as measured by the Danger Assessment and 13 protective actions. Participants (N = 432) experienced an incident of police involved intimate partner violence (IPV) and subsequently completed a structured telephone interview. Most women in this sample experienced severe violence and were classified as being at high risk for homicide. Participants engaged in an average of 3.81 (SD = 2.73) protective actions. With the exception of the use of formal domestic violence services, women in the high-risk category were significantly more likely than women in the lower risk category to have used each of the protective actions examined. Implications for research and practice are discussed.

Intimate partner violence in the family: considerations for children's safety

Children's exposure to intimate partner violence (IPV) is increasingly recognized as a type of child maltreatment that has a level of impairment similar to other types of abuse and neglect. Despite advances in the area of IPV, the safety planning strategies recommended as part of the overall response to IPV need to be examined in terms of their implications for children. This article discusses these strategies within the context of child safety, comparing IPV safety planning with approaches aimed at reducing exposure to other types of violence such as child sexual abuse, as well as general child safety strategies. Despite the emphasis on safety planning in information available on responding to IPV, the actual effectiveness of such planning in improving safety and reducing violence is unknown. Safety planning provided to children by a parent experiencing IPV, especially when IPV is ongoing and not recognized by anyone outside the home, may lead to confusing messages for children, particularly if there is an emphasis on secrecy. While awaiting evidence about the effectiveness of specific safety planning strategies for children, we suggest basic principles and general strategies that emphasize universality in terms of education about any type of violence or abuse in the home being unacceptable, as well as the need to focus on safety in general.

Association of intimate partner violence and childhood sexual abuse with cancer-related well-being in women

BACKGROUND

Limited evidence suggests that intimate partner violence (IPV) may be associated with poorer cancer outcomes. We hypothesized that timing and type of IPV as well as childhood sexual abuse (CSA) may negatively affect depression, perceived stress, and cancer-related well-being.

METHODS

This was a cross-sectional study of women diagnosed with either breast, cervical, or colorectal cancer in the prior 12 months included in the Kentucky Cancer Registry. Consenting women were interviewed by phone (n=553). Multivariate analysis of covariance (MANCOVA) was used to determine the association between IPV (37% lifetime prevalence) and type, timing, and the range of correlated cancer-related well-being indicators, adjusting for confounding factors.

RESULTS

IPV (p=0.002) and CSA (p=0.03) were associated with the six correlated well-being indicators. Specifically, lifetime and current IPV were associated with lower Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) (p=0.006) and Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-SP) (p=0.03) scores, higher perceived stress at diagnosis (p=0.006), and depressive symptom scores at diagnosis (p<0.0001), whereas CSA was associated with lower FACT-B (p=0.02), increased number of comorbid conditions (p=0.03), and higher current stress levels (p=0.04). Current and past IPV, as well as psychologic abuse, were associated with poorer well-being among women with a recent cancer diagnosis.

CONCLUSIONS

Our results provide evidence that both IPV and CSA negatively influence cancer-related well-being indicators. These data suggest that identification of lifetime IPV and other stressors may provide information that healthcare providers can use to best support and potentially improve the well-being of female cancer patients.

The impact of victim-focused outreach on criminal legal system outcomes following police-reported intimate partner abuse

Randomized control designs have been used in the public health and psychological literatures to examine the relationship between victim outreach following intimate partner abuse (IPA) and various outcomes. These studies have largely relied on samples drawn from health providers and shelters to examine outcomes outside the criminal legal system. Based on the positive findings from this body of research, we expected that a victim-focused, community-coordinated outreach intervention would improve criminal legal system outcomes. The current study used a randomized, longitudinal design to recruit 236 ethnically diverse women with police-reported IPA to compare treatment-as-usual with an innovative community-coordinated, victim-focused outreach program. Findings indicated that the outreach program was effective in increasing women's engagement with prosecution tasks as well as likelihood of taking part in prosecution of their abusers. Results were particularly robust among women marginalized by ethnicity and class, and those still living with their abusers after the target incident.

Universal psychosocial screening and adverse pregnancy outcomes in an academic obstetric clinic

OBJECTIVE

To test the hypothesis that women screened for psychosocial factors, including partner abuse, as recommended by the American College of Obstetricians and Gynecologists would have higher neonatal birth weight, longer gestational age at delivery, higher Apgar scores, and fewer maternal complications.

METHODS

We evaluated a universal psychosocial screening intervention using a retrospective cohort (n=881 prenatal care patients). Pregnancy outcomes among patients screened beginning in 2008 (n=464) were compared with outcomes among women receiving care before universal screening was implemented (n=417). Data were obtained from medical records between 2007 and 2009. Multivariable logistic regression and analysis of covariance were used to estimate the association between screening and pregnancy outcomes among singleton births adjusting for confounders (prior preterm births, insurance, and mode of delivery).

RESULTS

Screened women were less likely than women not universally screened to have low birth weight neonates (4.5% of screened, 10.3% of unscreened; adjusted odds ratio [OR] 0.41, 95% confidence interval [CI] 0.23-0.73), preterm births (9.9% of screened, 14.9% of unscreened; adjusted OR 0.62, 95% CI 0.41-0.96), and any maternal complication (30.0% of screened, 41.2% of unscreened; adjusted OR 0.67, 95% CI 0.50-0.88). Newborn Apgar scores were higher (P=.01) among screened relative to unscreened mothers.

CONCLUSION

Our results provide evidence that universal screening was associated with improved pregnancy outcomes.

LEVEL OF EVIDENCE

II.

Safety-promoting behaviors of community-dwelling abused Chinese women after an advocacy intervention: a randomized controlled trial

OBJECTIVE

To examine the effect of an advocacy intervention on the use of safety-promoting behaviors in community-dwelling abused Chinese women as compared to a control condition of usual care.

DESIGN

This efficacy trial used a randomized controlled, parallel group design.

PARTICIPANTS AND METHODS

A total of 200 Chinese women in a community setting who screened positive for intimate partner violence using the Chinese version of the Abuse Assessment Screen were randomized to receive either an advocacy intervention (intervention group, n=100) or usual community care (control group, n=100). The outcome measured was the change in the self-reported safety-promoting behaviors as measured by the Safety-promoting Behavior Checklist over three time-points (baseline, 3-month follow-up and 9-month follow-up). Participants and assessors were blinded to the study hypothesis. Assessors were further blinded to the group membership of the participants.

RESULTS

The Safety-promoting Behavior Checklist scores in the intervention group increased from the baseline on average by 5.65 (95% confidence interval [CI], 4.92-6.39) at 3-month and 6.65 (95% CI, 5.90-7.39) at 9-month follow-ups, while the scores in the control group also increased by 1.71 (95% CI, 1.06-2.37) at 3-month and 1.79 (95% CI, 1.15-2.43) at 9-month follow-ups. After adjusting for baseline differences, the between-group differences in scores were significant at 3-month and 9-month follow-ups (p=0.04). The intervention group increased the scores by 3.61 (95% CI, 2.61-4.61, p<0.001) more than the control group at 3-month and by 4.53 (95% CI, 3.53-5.53, p<0.001) at 9-month follow-ups.

CONCLUSION

An advocacy intervention is efficacious in increasing the use of safety-promoting behaviors as compared to usual community care in community-dwelling abused Chinese women.

A brief intervention for prevention of sexually transmitted infection among battered women

OBJECTIVE

To test the feasibility and acceptability of a combined brief nursing intervention (BNI) to prevent sexually transmitted infections (STIs) and intimate partner violence (IPV) among rural women attending a family planning clinic. The primary outcomes of interest were frequency and severity of IPV, the number of safety behaviors implemented by women, and the number of safer sex strategies used at 3 months postintervention.

DESIGN

A one-group pretest/posttest design.

SETTING

Rural health department family planning clinics.

PARTICIPANTS

Eighty-eight women were screened for IPV. Nineteen (21.4%) screened positive for past-year history of IPV, and 18 completed the intervention and data collection (baseline and 3 months).

METHODS

Women who screened positive for IPV were given a BNI addressing IPV and STI prevention. Severity and frequency of violence, IPV safety behaviors, and safer sex behaviors were measured at baseline and 3 months.

RESULTS

The frequency of physical (p = .02) and sexual (p = .05) violence decreased from baseline to 3-month follow-up. Although not statistically significant the number of safer sex behaviors reported increased from baseline to follow-up.

CONCLUSIONS

This BNI shows promise, though findings must be interpreted with caution due to small sample, lack of a control group, and no randomization. It was feasible to deliver the intervention in clinic settings.

Mental and physical health symptoms of family court intimate partner violence petitioners

This paper explores the impact of intimate partner violence on victim health and proposes interdisciplinary coordination between legal and mental health services as a means to assist victims. Data was collected from 95 female petitioners at an upstate New York Domestic Violence Intensive Intervention Court (DVIIC). Study participants completed surveys on physical health, mental health, and social functioning. Survey results demonstrated decreased mental health and social functioning as well as a strong willingness to utilize court-based mental health services if offered. Findings from this study support court-based settings as appropriate sites for addressing mental health needs through collaborative efforts between legal and mental health professionals.

Relationships and betrayal among young women: theoretical perspectives on adolescent dating abuse

AIMS

Adolescent dating abuse is not specifically described by any current nursing theory, and this article presents discussion of some existing theories that could inform a nursing theory of adolescent dating abuse. To account for the effects of gender, this discussion is limited to young women.

BACKGROUND

Adolescent dating abuse is an important and understudied international issue for nursing. Theoretical frameworks can support development of nursing scholarship for such issues. No single theory yet exists in nursing to explain the experiences and health ramifications of dating abuse among young women.

DATA SOURCES

A summary table of theories is provided. Literature was gathered via database search and bibliographic snowballing from reference lists of relevant articles. Included literature dates from 1982 through 2010.

DISCUSSION

Theories of relationship formation and function are discussed, including attachment, investment, feminist and gender role conflict theories. Betrayal trauma theory is considered as a mechanism of injury following an abusive dating experience.

IMPLICATIONS FOR NURSING

Gender, relationship and adolescence combine in a complex developmental moment for young women. To improve nursing care for those at risk for or in the throes of abusive relationships, it is critical to develop specific nursing approaches to understanding these relationships.

CONCLUSION

Existing theories related to relationship and traumatic experiences can be combined in the development of a nursing theory of adolescent dating abuse among young women.

Computerized aid improves safety decision process for survivors of intimate partner violence

A computerized safety decision aid was developed and tested with Spanish or English-speaking abused women in shelters or domestic violence (DV) support groups (n = 90). The decision aid provides feedback about risk for lethal violence, options for safety, assistance with setting priorities for safety, and a safety plan personalized to the user. Women reported that the decision aid was useful and provided much-needed privacy for making safety decisions. The majority (69%) reported severe to extreme danger in their relationship as scored by Danger Assessment (DA); only 60% reported having made a safety plan. After using the safety decision aid, the women felt more supported in their decision (p = .012) and had less total decisional conflict (p = .014). The study demonstrated that a computerized safety decision aid improved the safety planning process, as demonstrated by reduced decisional conflict after only one use in a sample of abused women.

Intimate partner violence during pregnancy: a pilot intervention program in Lima, Peru

This pilot study examined the effectiveness of standard care and an empowerment intervention for abused pregnant women. Severe psychological abuse was most prevalent (42.2%) among this sample of women. Compared with women in the standard care group at the postintervention survey, women in the empowerment group were more likely to hide money (44.6% vs. 34.3%), establish a code with family or friends (19.6% vs. 16.2%), ask neighbors to call police if violence began (6.9% vs. 1.0%), had available bank account numbers (17.1% vs. 3.1%), had valuable jewelry (8.4% vs. 3.8%), and had available a hidden bag with extra clothing (9.0% vs. 3.1%). However, there was no statistically significant difference in health-related quality of life, adoption of safety behaviors, and use of community resources between women in the two groups. Simply asking pregnant women about abuse and offering referral could potentially interrupt and prevent further abuse.

Prevalence of intimate partner violence reported by homeless youth in Columbus, Ohio

No study to date has reported intimate partner violence (IPV) experiences among homeless youth. This study sought to uncover lifetime prevalence estimates of physical, sexual, and emotional IPV among a nonprobability sample of 180 homeless male and female youth in Columbus, Ohio. To that aim, self-reported IPV and the association between IPV and gender, race, age, and history of childhood abuse were examined. Results showed that physical violence and verbal abuse were the most commonly reported experiences of IPV in the current sample and ranged from 30.0% to 35.4%. Women and those with a history of childhood abuse were more likely to be victimized by their intimate partners. Specifically, multiple logistic regression analysis revealed that women were approximately twice as likely as men to be verbally and physically abused in intimate relationships. Moreover, youth who reported being victims of abuse in childhood were more than twice as likely to experience verbal abuse and physical violence in their relationships. Given the high lifetime occurrence of IPV among homeless youth, intervention efforts should target IPV to prevent future occurrence. Findings also suggest that intervention efforts should consider gender and history of childhood abuse.

Partner violence during pregnancy: prevalence, effects, screening, and management

The purpose of this review is to provide an overview of the current state of knowledge regarding the experience of intimate partner violence (IPV) during pregnancy. Pregnancy IPV is a significant problem worldwide, with rates varying significantly by country and maternal risk factors. Pregnancy IPV is associated with adverse newborn outcomes, including low birth weight and preterm birth. Many mechanisms for how IPV may impact birth outcomes have been proposed and include direct health, mental health, and behavioral effects, which all may interact. Screening for IPV during pregnancy is essential, yet due to time constraints and few clear recommendations for assessment, many prenatal providers do not routinely inquire about IPV, or even believe they should. More training is needed to assist health care providers in identifying and managing pregnancy IPV, with additional research needed to inform effective interventions to reduce the rates of pregnancy IPV and resultant outcomes.

An overview of intimate partner violence among Latinos

This article reviews the existing literature on intimate partner violence (IPV) among Latinos to put the findings of this special issue into context. This review of the literature suggests that IPV occurs as frequently among Latinos as among non-Latinos when confounders are controlled for. There is also some preliminary evidence that Latinas experience similar forms of IPV and suffer similar consequences. Many of the risk factors associated with its occurrence are the same as those observed among non-Latinos, except that beliefs approving IPV and alcohol-drinking patterns may not have much explanatory value for the occurrence of IPV among Latinos. Role strain, especially as a result of immigration and acculturation, might be unique to Latinos, and its importance, and the importance of male dominance among Latinas experiencing IPV, deserve more research.