Abusive experiences and psychiatric morbidity in women primary care attenders

Heart rate variability biofeedback intero-nociceptive emotion exposure therapy for adverse childhood experiences

Background: Psychiatric patients with adverse childhood experiences (ACE) tend to have dysfunctions in the interoceptive part of their emotional experience. The integration of interoceptive emotional activity in the insular and cingulate cortices is linked to the regulation of sympathovagal balance. This makes heart rate variability (HRV) an ideal measure for providing feedback on emotion regulation in real-time.

Methods: A sample of one hundred (n=100) outpatients was evaluated. Participants underwent eight 30-minutes ACE exposure sessions during which patients were guided to experience bodily sensations related to ACE while their HRV was monitored using a commercial biofeedback device.

Results: Comparing the results of the first to last therapeutic session, a significant decrease in heart rate and an increase in HRV at the onset of the session were observed.

Conclusions: This study suggests a physiological impact of therapeutic interventions on autonomic balance and underlines the interest in HRV biofeedback as clinical practice.

The maternal health study: Study design update for a prospective cohort of first-time mothers and their firstborn children from birth to age ten

BACKGROUND

Maternal health is critical to the health and well-being of children and families, but is rarely the primary focus of pregnancy and birth cohort studies. Globally, poor maternal health and the exposure of women and children to family violence contribute to the perpetuation and persistence of intergenerational health inequalities.

OBJECTIVES

The Maternal Health Study was designed to investigate the contribution of social and obstetric risk factors to common maternal physical and psychological morbidities. Over time, our focus has expanded to include mother-child pairs and investigation of intergenerational trauma and family violence.

POPULATION

A total of 1507 first-time mothers were recruited in early pregnancy from six public hospitals in Melbourne, Australia, in 2003-2005.

METHODS

Women completed questionnaires or telephone interviews in early pregnancy (≤24 weeks); at 32 weeks' gestation; at three, six, nine, 12 and 18 months postpartum; and at four and ten years. At ten years, women and children were invited to participate in face-to-face interviews, which included direct assessment of children's cognitive and language development. A wide range of obstetric, social and contextual factors have been measured, including exposure to intimate partner violence (IPV) (1-year, 4-year and 10-year follow-up).

RESULTS

1507 eligible women were recruited at a mean gestation of 15 weeks. At one year, four years and ten years postpartum, 90.0%, 73.1% and 63.2% of the original cohort took part in follow-up. One in three women in the study (34.5%) reported exposure to IPV in the first ten years of motherhood: 19% in the first 12 months postpartum, 20% in the year prior to four-year follow-up and 18.3% in the year prior to ten-year follow-up.

CONCLUSION

The study affords a unique opportunity to examine patterns of maternal and child health and health service use associated with exposure to IPV.

Sorority Membership and Sexual Victimization: An Examination of Potential Mediators of the Association

This study examined putative mediators of the association between sorority membership and sexual victimization among 718 women who were enrolled in their first year of college. Data were collected through anonymous, self-report surveys that assessed sexual victimization in college, two hypothesized mediator variables (i.e., alcohol misuse and number of sexual partners), and four control variables (i.e., minority racial status, residence in a coed dorm, behavioral and psychological problems before college, and sexual victimization before college). Values for both sexual victimization variables were collapsed into one of three categories (i.e., no victimization, moderately severe victimization, severe victimization). Bivariate analyses revealed sorority members had higher levels of alcohol misuse, number of sexual partners, and severe sexual victimization in college than did nonmembers. Multivariate analyses showed number of sexual partners mediated the association between sorority membership and both types of sexual victimization in college, whereas alcohol misuse mediated the association between sorority membership and severe sexual victimization in college only. Implications of the findings for future research and prevention, along with limitations of the study, are discussed.

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

Background

Domestic violence and abuse (DVA) is experienced by about 1/3 of women globally and remains a major health concern worldwide. IRIS (Identification and Referral to Improve Safety of women affected by DVA) is a complex, system-level, training and support programme, designed to improve the primary healthcare response to DVA. Following a successful trial in England, since 2011 IRIS has been implemented in eleven London boroughs. In two boroughs the service was disrupted temporarily. This study evaluates the impact of that service disruption.

Methods

We used anonymised data on daily referrals received by DVA service providers from general practices in two IRIS implementation boroughs that had service disruption for a period of time (six and three months). In line with previous work we refer to these as boroughs B and C. The primary outcome was the number of daily referrals received by the DVA service provider across each borough over 48 months (March 2013–April 2017) in borough B and 42 months (October 2013–April 2017) in borough C. The data were analysed using interrupted-time series, non-linear regression with sensitivity analyses exploring different regression models. Incidence Rate Ratio (IRR), 95% confidence intervals and p-values associated with the disruption were reported for each borough.

Results

A mixed-effects negative binomial regression was the best fit model to the data. In borough B, the disruption, lasted for about six months, reducing the referral rate significantly (p = 0.006) by about 70% (95%CI = (23,87%)). In borough C, the three-month service disruption, also significantly (p = 0.005), reduced the referral rate by about 49% (95% CI = (18,68%)).

Conclusions

Disrupting the IRIS service substantially reduced the rate of referrals to DVA service providers. Our findings are evidence in favour of continuous funding and staffing of IRIS as a system level programme.

Shame, dissociative seizures and their correlation among traumatised female Yazidi with experience of sexual violence

BACKGROUND

Survivors of Islamic State of Iraq and Syria (ISIS) captivity are at high risk of developing mental disorders such as post-traumatic stress disorder (PTSD).

AIMS

This study looks at the correlation between sexual abuse, shame, somatoform or bodily distress disorders, and dissociative seizures (psychogenic non-epileptic seizures).

METHOD

The psychological effects of traumatic events and dissociative seizure were assessed in Yazidi women who were held captive by ISIS in Northern Iraq between 2014 and 2018. These effects were examined comparing 64 women who were held captive and sexually abused by ISIS with 60 women suffering from PTSD who were not held captive and sexually abused by ISIS. Structured clinical-psychological interviews and established psychometric questionnaires were used to assess mental disorders especially dissociative seizures and somatoform disorders, and shame related to trauma.

RESULTS

Women who were held captive by ISIS showed a significantly higher prevalence of dissociative seizures (43.7%; P = 0.02) and somatisation disorder (38.7%; P = 0.02), as well as depressive (75.0%; P = 0.42) and anxiety disorders (62.5%; P = 0.44), than women who were not held captive and sexually abused by ISIS. Dissociative disorders were identified in 40.6% (P = 0.36) of those female Yazidi who experienced sexual violence while being held captive.

CONCLUSIONS

Shame in connection with sexual violence seems to play an important role in negative self-perception after rape. Dissociation not only plays an important role in unprocessed childhood trauma with feelings of shame, but also in more recent trauma experiences with shame.

Post-Traumatic Stress, Mother's Emotion Regulation, and Parenting in Survivors of Intimate Partner Violence

Post-traumatic stress symptoms (PTSS) are high among female survivors of intimate partner violence (IPV), and children of parents experiencing PTSS are at heightened risk for a wide range of emotional and behavioral problems. Parenting has significant influence on child adjustment, and although links have been found between parental psychopathology and maladaptive parenting, little is known about the factors that may explain this relation. The current study examines mother's emotion regulation (ER) as a factor influencing the relation between mother PTSS and parenting around children's emotions in a study sample of sixty-four female survivors of IPV and their 6- to 12-year-old children. Mothers reported on their own PTSS and their parenting. Respiratory sinus arrhythmia (RSA) was used as a psychophysiological index of mother's ER. Experiential components of mother's ER was also measured by observer coding of the Meta-Emotion Interview, a structured assessment that asks parents about their attitudes toward and experiences with emotions, including their regulation of emotions. Mother's RSA reactivity moderated the relation between PTSS and negative parenting. There was also a significant indirect relation between mothers' PTSS symptom severity and supportive parenting reactions through mothers' self-report of ER. Results suggest that mother's ER abilities represent factors that significantly affect associations between maternal PTSS and parent's emotion socialization practices. Implications for assessment and intervention with families exposed to the stress of IPV are discussed.

Exploring Australian psychiatrists' and psychiatric trainees' knowledge, attitudes and preparedness in responding to adults experiencing domestic violence

OBJECTIVE:

Examine knowledge, opinions and practices of psychiatrists and trainees in responding to domestic violence (DV).

METHOD:

Online survey including two sub-scales from PREMIS (Physician Readiness to Manage Intimate Partner Violence Survey): knowledge (10 items) and preparedness (10 items).

RESULTS:

Of psychiatrists completing the survey (216), 47% had received less than 2 hours of training in DV. PREMIS findings showed moderate knowledge of, and preparedness to deal with, DV. Participants with more clinical experience had significantly more knowledge and preparedness to deal with DV.

CONCLUSIONS:

Findings suggest more training in DV for psychiatrists is needed.

PTSD of rape after IS ("Islamic State") captivity

Research into the psychological consequences of rape on women in war and warlike situations is limited. The aims of this study were (a) to describe the prevalence and the nature of PTSD symptoms among Yazidi women reporting rape during IS captivity, (b) to describe comorbidity of other psychological disorders, and (c) to examine the risk factors associated with posttraumatic stress disorder.The study included 296 Yazidi women survivors of rape and has been conducted in Germany since January 2016 as part of a special-quota project in the German region of Baden-Wuerttemberg, designed to support the women and children who have escaped after being held hostage by IS.The survivors were recruited into a retrospective, cross-sectional study. Interviews in Germany were done through trained personnel to evaluate the mental health status of raped women.All the investigated women had been raped many times during IS captivity. About 82% of the women were also physically tortured. Of the sample, 67% suffered from somatoform disorder, 53% suffered from depression, 39% from anxiety, and 28% from dissociation. The prevalence of PTSD in those with rape events of more than 20 times was 57% (95% CI = 35.1-65.9%), less than 20 times was 41% (95%, CI = 28.7-4.8% and less than 10 times 39% [95% CI = 28.2-41.8%], respectively.The IS captivity and wartime rapes had deep immediate and long-term consequences on the mental health of women survivors. The high prevalence of PTSD emphasizes the need for culturally sensitive diagnostic and therapeutic services to address the intermediate and long-term consequences of wartime rape.

Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study

OBJECTIVES

To evaluate the cost-effectiveness of the implementation of the Identification and Referral to Improve Safety (IRIS) programme using up-to-date real-world information on costs and effectiveness from routine clinical practice. A Markov model was constructed to estimate mean costs and quality-adjusted life-years (QALYs) of IRIS versus usual care per woman registered at a general practice from a societal and health service perspective with a 10-year time horizon.

DESIGN AND SETTING

Cost-utility analysis in UK general practices, including data from six sites which have been running IRIS for at least 2 years across England.

PARTICIPANTS

Based on the Markov model, which uses health states to represent possible outcomes of the intervention, we stipulated a hypothetical cohort of 10 000 women aged 16 years or older.

INTERVENTIONS

The IRIS trial was a randomised controlled trial that tested the effectiveness of a primary care training and support intervention to improve the response to women experiencing domestic violence and abuse, and found it to be cost-effective. As a result, the IRIS programme has been implemented across the UK, generating data on costs and effectiveness outside a trial context.

RESULTS

The IRIS programme saved £14 per woman aged 16 years or older registered in general practice (95% uncertainty interval -£151 to £37) and produced QALY gains of 0.001 per woman (95% uncertainty interval -0.005 to 0.006). The incremental net monetary benefit was positive both from a societal and National Health Service perspective (£42 and £22, respectively) and the IRIS programme was cost-effective in 61% of simulations using real-life data when the cost-effectiveness threshold was £20 000 per QALY gained as advised by National Institute for Health and Care Excellence.

CONCLUSION

The IRIS programme is likely to be cost-effective and cost-saving from a societal perspective in the UK and cost-effective from a health service perspective, although there is considerable uncertainty surrounding these results, reflected in the large uncertainty intervals.

Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention

Background

Domestic violence and abuse remains a major health concern. It is unknown whether the improved healthcare response to domestic violence and abuse demonstrated in a cluster randomised controlled trial of IRIS (Identification and Referral to Improve Safety), a complex intervention, including general practice based training, support and referral programme, can be achieved outside a trial setting. Aim: To evaluate the impact over four years of a system wide implementation of IRIS, sequentially into multiple areas, outside the setting of a trial.

Methods

An interrupted time series analysis of referrals received by domestic violence and abuse workers from 201 general practices, in five northeast London boroughs; alongside a mixed methods process evaluation and qualitative analysis. Segmented regression interrupted time series analysis to estimate impact of the IRIS intervention over a 53-month period. A secondary analysis compares the segmented regression analysis in each of the four implementation boroughs, with a fifth comparator borough.

Discussion

This is the first interrupted time series analysis of an intervention to improve the health care response to domestic violence. The findings will characterise the impact of IRIS implementation outside a trial setting and its suitability for national implementation in the United Kingdom.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5865-z) contains supplementary material, which is available to authorized users.

What Women Think Should Be Done to Stop Intimate Partner Violence in Ghana

This aricle expands scholarship on intimate partner violence in Ghana by discussing what should be done to stop it, using data from the Northern region. The data came from 53 survey participants who provided useful responses to an open question: "what should we do to stop intimate partner violence"? The 53 respondents were part of 443 women non-randomly sampled at public health centers across the region to participate in a survey on intimate partner violence. Although the survey used a questionnaire, responses to the open question constituted qualitative data for this article. All 53 written responses were typed out verbatim into a Microsoft word document to generate a transcript for analysis. Responses entered in the transcript were numbered to distinguish one from another. Each numbered unit of text represented the complete response of a participant. Data were content-analyzed and reduced to five meaning categories for interpretation and conclusion-drawing. These are: provide behavior change support to couples; institute and enforce legal sanctions against perpetrators; empower women; provide public education for social change; and pray and preach against violence. Discussion of the findings is situated within discourse analysis and the article concludes with a note on implications for policy and practice.

Violence against women and mental disorder: a qualitative study in Bangladesh

Background

Violence affects 15-75% of women across the globe and has a significant impact on their health, well-being, and rights. While quantitative research links it to poor mental health, there is a lack of qualitative enquiry in how women experience it, and how it is related to the mental disorders in Bangladesh. This information is important in understanding the situation and structuring a locally appropriate and culturally sensitive program.

Methods

We adopted a phenomenological approach and conducted 16 in-depth interviews, three informal interviews, one focus group discussion, and one key informant interview. We also reviewed published reports and documents. We followed criterion sampling in selecting women with mental disorders who experienced violence. We explored their experiences and understanding of the issues and described the phenomenon.

Results

We found that Bangladesh society was largely controlled by men, and marriage was often forced on women. Women often were blamed for any mishap in the family and married women were under social and emotional pressure to keep the marital relationship going even when painful. We found all forms of violence (physical, emotional, sexual etc.) and most of the time found more than one type in women with mental disorders. Sexual violence is a reality for some women but rarely discussed. We found the society very tolerant with mental disorder patients and those who resorted to violence against them.We identified four theoretical understandings about the role of violence in mental disorders. Sometimes the violence predisposed the mental illness, sometimes it precipitated it, while other times it maintained and was a consequence of it. Sometimes the violence may be unrelated to the mental illness. The relationships were complex and depended on both the type of mental disorder and the nature and intensity of the violence. We found most of the time that more than one type of violence was involved and played more than one role, which varied across different types of mental disorders. Interestingly, not all violence that mentally disordered women faced was because they were women, but because of mental disorders, which brought violence to them as a consequence.

Conclusions

The findings of this first ever qualitative study into the experiences of violence by women with mental disorder in Bangladesh can be used in developing a culturally specific intervention to reduce both violence and mental disorders in women.

Recovering Process from Child Sexual Abuse During Adulthood from an Integrative Approach to Solution-Focused Therapy: A Case Study

In recent times, strengths-based recovery approaches that focus on the present and build strategies that look toward the future have become popular. However, some cases require the consideration of experiences from previous stages of the clients' development. This single-case study explores the psychotherapeutic process of a middle-aged woman who presented with a history of child sexual abuse (incest) and a long-term adult diagnosis of depression that was treated in public health services. This psychotherapy involved an integrative approach to solution-focused therapy; specifically, the approach proposed by Yvonne Dolan to work with adult survivors of sexual abuse, in conjunction with techniques and strategies from the transtheoretical model. Measures incorporating therapeutic working alliance and outcomes were administered over sessions. Results showed positive outcomes from this therapeutic intervention, which remained at 3-month and 12-month follow-ups. Implications for practitioners' specialist practice in health services are discussed, given the complexity of comorbid mental health conditions with a history of child sexual abuse.

Sexual violence associated with poor mental health in women attending Australian general practices

OBJECTIVE

Sexual violence (SV) against adult women is prevalent and associated with a range of mental health issues. General practitioners could potentially have a role in responding, however, there is little information to help guide them. Data around prevalence of all forms of adult SV (not just rape) is inconsistent, particularly in clinical samples, and the links between other forms of SV and mental health issues are not well supported. This study aimed to address these gaps in the knowledge base.

METHODS

A descriptive, cross-sectional study was conducted in Australian general practice clinics. Two hundred and thirty adult women completed an anonymous iPad survey while waiting to see the doctor.

RESULTS

More than half the sample had experienced at least one incident of adult SV. Most commonly, women reported public harassment or flashing, unwanted groping and being coerced into sex. Women who had experienced adult SV were more likely to experience anxiety than women who had not, even after controlling for other factors. Women who had experienced adult SV were more likely to feel down, depressed or hopeless than women who had not; however, this association disappeared after controlling for childhood sexual abuse.

CONCLUSIONS

The findings support the association between SV and poor mental health, even when 'lesser' incidents have occurred. Implications for public health: General practitioners should consider an experience of SV as a possible factor in otherwise unexplained anxiety and depressive symptoms in female patients.

Qualitative study to explore the health and well-being impacts on adults providing informal support to female domestic violence survivors

OBJECTIVES

Domestic violence (DV) is hazardous to survivors' health, from injuries sustained and from resultant chronic physical and mental health problems. Support from friends and relatives is significant in the lives of DV survivors; research shows associations between positive support and the health, well-being and safety of survivors. Little is known about how people close to survivors are impacted. The aim of this study was exploratory, with the following research question: what are the health and well-being impacts on adults who provide informal support to female DV survivors?

DESIGN

A qualitative study using semistructured interviews conducted face to face, by telephone or using Skype. A thematic analysis of the narratives was carried out.

SETTING

Community-based, across the UK.

PARTICIPANTS

People were eligible to take part if they had had a close relationship (either as friend, colleague or family member) with a woman who had experienced DV, and were aged 16 or over during the time they knew the survivor. Participants were recruited via posters in community venues, social media and radio advertisement. 23 participants were recruited and interviewed; the majority were women, most were white and ages ranged from mid-20s to 80.

RESULTS

Generated themes included: negative impacts on psychological and emotional well-being of informal supporters, and related physical health impacts. Some psychological impacts were over a limited period; others were chronic and had the potential to be severe and enduring. The impacts described suggested that those providing informal support to survivors may be experiencing secondary traumatic stress as they journey alongside the survivor.

CONCLUSIONS

Friends and relatives of DV survivors experience substantial impact on their own health and well-being. There are no direct services to support this group. These findings have practical and policy implications, so that the needs of informal supporters are legitimised and met.

Depressive Symptoms in College Women: Examining the Cumulative Effect of Childhood and Adulthood Domestic Violence

The purpose of this study was to examine the cumulative effect of childhood and adulthood violence on depressive symptoms in a sample of Jordanian college women. Snowball sampling technique was used to recruit the participants. The participants were heterosexual college-aged women between the ages of 18 and 25. The participants were asked about their experiences of childhood violence (including physical violence, sexual violence, psychological violence, and witnessing parental violence), partner violence (including physical partner violence and sexual partner violence), experiences of depressive symptoms, and about other demographic and familial factors as possible predictors for their complaints of depressive symptoms. Multiple linear regression analysis was implemented to identify demographic- and violence-related predictors of their complainants of depressive symptoms. Logistic regression analysis was further performed to identify possible type(s) of violence associated with the increased risk of depressive symptoms. The prevalence of depressive symptoms in this sample was 47.4%. For the violence experience, witnessing parental violence was the most common during childhood, experienced by 40 (41.2%) women, and physical partner violence was the most common in adulthood, experienced by 35 (36.1%) women. Results of logistic regression analysis indicated that experiencing two types of violence (regardless of the time of occurrence) was significant in predicting depressive symptoms (odds ratio [OR] = 3.45, p < .05). Among college women's demographic characteristics, marital status (single vs. engaged), mothers' level of education, income, and smoking were significant in predicting depressive symptoms. Assessment of physical violence and depressive symptoms including the cumulative impact of longer periods of violence on depressive symptoms is recommended to be explored in future studies.

Sexual Contact in Childhood, Revictimization, and Lifetime Sexual and Psychological Outcomes

Using data from the 2010 to 2011 wave of the National Social Life, Health, and Aging Project-a nationally representative probability sample of older U.S. adults-this study queried distinctive linkages of mild and of severe childhood sexual contact with lifetime sexual and psychological outcomes among women and men aged 60-99 years (N = 3283). In addition, we examined stratification of these associations by sexual revictimization (forced sex and/or harassment). Among women, sequelae of childhood contact seemed consistently negative for the mild rather than severe variant-but only in the co-presence of revictimization-a pattern that may have remained obscured in previous analysis of event effects. Men's results suggested lifelong eroticizing but not psychological effects of this early experience-with the co-presence of revictimization potentially enhancing rather than lowering their mental health. Overall, findings appeared to reflect gendered patterns of risk-with mild childhood contact potentially channeling women but not men into revictimization and finally to elevated sexuality and poor mental health in late life. Early sexual experiences should thus be conceptualized not as singular events, but as part of a lifelong career with regularities and rhythms that may influence their pathogenic potential.

Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services

Background

Domestic violence and abuse (DVA) are associated with increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services.

Objective

Our goal was to characterise the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators.

Design

Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors were analysed. We report the prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. The following mental health measures were used: Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalised Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale to measure posttraumatic stress disorder (PTSD). The Composite Abuse Scale (CAS) measured abuse.

Results

Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and more than three-quarters of respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA.

Conclusions

Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.

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.

Spouses of male psychiatric patients are more prone to intimate partner violence

Intimate partner violence (IPV) is a great public health concern. Most studies have evaluated different risk factors of IPV in general population, but few have evaluated the perpetration of IPV by subjects with psychological disease. We evaluated the prevalence of IPV among spouses of men with psychiatric disease. In this descriptive study, we questioned 119 women whose husbands were in-patient or out-patients of psychology clinic. A validated questionnaire was used for evaluation IPV and its different subtypes. All women reported to encounter some kind of IPV in some periods. Women reported emotional abuse in 100%, physical abuse in 99.2% and sexual abuse in 81.5%. None of the patients were eager to tell anyone about being victim of IPV due to religious beliefs, society culture and believing in their marital status and trying to keep their marriage. IPV is higher among families with men having psychological disease. Policy makers and clinicians should predominantly target these families. Also, empowering women may reduce the risk of intimate partner violence.

Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services

Background

Domestic violence and abuse (DVA) are associated with an increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services.

Objective

To characterize the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators.

Design

Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors was analyzed. We report prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. Mental health measures used were: Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalized Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale (PDS) to measure posttraumatic stress disorder. The Composite Abuse Scale (CAS) measured abuse.

Results

Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and all respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA.

Conclusions

Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or may have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.

Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil, following an experience of sexual violence

OBJECTIVE

To present the sociodemographic characteristics and psychiatric symptoms of women who have been raped.

METHODS

Between 2006 and 2010, a retrospective study was conducted of 468 women who underwent psychiatric evaluation at a university referral center in Brazil after an experience of sexual violence.

RESULTS

The women had a mean age of 24.1 years; were predominantly white, unmarried, childless, and employed; had 9-11 years of education; and had a religion. Rape was the first sexual intercourse for 124 (26.8%) of 462 for whom data were available; 53 (13.6%) of 389 had a personal history of sexual violence and 29 (8.0%) of 361 had a family history. No psychiatric symptoms were reported in 146 (32.9%) of 444 women, mild/short-term symptoms were reported in 107 (24.1%), and a psychiatric diagnosis was made for 191 (43.0%). Psychiatric comorbidity was seen in 59 (12.6%) women, and 174 (38.0%) received pharmacologic treatment. All follow-up consultations were attended by 215 (45.9%) of 468 women; 166 (35.5%) attended some, and 87 (18.6%) attended only one during the 6-month follow-up period.

CONCLUSION

The frequency and severity of psychiatric symptoms and mental disorders among women who have been raped highlights the importance of mental health monitoring.

The Social Health Intervention Project (SHIP): protocol for a randomized controlled clinical trial assessing the effectiveness of a brief motivational intervention for problem drinking and intimate partner violence in an urban emergency department

BACKGROUND

There is a strong reciprocal association between two highly prevalent public health problems: intimate partner violence and heavy drinking, both of which remain major sources of morbidity and mortality. Brief interventions in the Emergency Department setting have been found to be effective in reducing alcohol-related injury but neither classic intimate partner violence nor substance abuse interventions have adequately integrated assessment and treatment for these co-occurring conditions. The overall goal of this study is to determine whether a motivational intervention delivered at the time of an Emergency Department visit will reduce heavy drinking and improve the safety of women experiencing intimate partner violence.

METHODS AND DESIGN

We are completing data collection for a randomized controlled trial enrolling 600 female patients, age 18-64, presenting to one of two urban Emergency Departments, who self-disclose both problem drinking and intimate partner violence. Eligible patients are randomized to a brief manual-guided motivational intervention, and a phone booster at 10 days. The intervention, which is delivered by masters-level therapists during the Emergency Department visit, is recorded and monitored for fidelity. Primary outcomes are episodes of heavy drinking and incidents of intimate partner violence, assessed weekly by Interactive Voice Response System for 12 weeks and at 3, 6 and 12 months by interviewers blinded to group assignment. To identify the impact of assessment alone, we included a no-contact control group assessed only once at 3 months. Secondary outcomes include violence severity, changes in the Composite Abuse Scale and alcohol quantity/frequency, along with other health-related behaviors. The analysis will also explore the impact of likely mediators and moderators of the intervention.

DISCUSSION

While screening and intervention for intimate partner violence is now recommended for women of child bearing age in health care settings, there is a need for rigorous evaluations of what works for whom. Upon completion, we will have high-quality evidence regarding the effectiveness of a low-intensity, brief motivational intervention, delivered by social workers in the Emergency Department setting, for decreasing episodes of heavy drinking and intimate partner violence. Ultimately, this is a model could be generalizable to other acute health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov

REGISTRATION NUMBER

NCT01207258.

History of abuse and its relationship to pain experience and depression in women with chronic pelvic pain

OBJECTIVE

We sought to determine the relationship among a history of physical or sexual abuse, pain experience, and depressive symptoms among women with chronic pelvic pain (CPP).

STUDY DESIGN

This was a cross-sectional study of women who presented to a tertiary referral center for evaluation of CPP (N = 273). All participants completed standardized questionnaires to assess a history of physical or sexual abuse, pain severity, pain disability, and depressive symptoms. Subjects were grouped by abuse category and compared to CPP participants without history of abuse. Multinomial logistic regression models were used to determine the association between adolescent or adult and childhood physical or sexual abuse with pain intensity, pain-related disability, and depressive symptoms.

RESULTS

Logistic regression analyses indicated that, after controlling for age and education, none of the abuse categories was associated with pain severity. However, adolescent or adult sexual abuse predicted greater pain-related disability (odds ratio, 2.39; 95% confidence interval, 1.05-5.40), while both adolescent or adult physical and sexual abuse were associated with higher levels of depression (both P < .05). Level of education was significantly associated with pain intensity, pain disability, and depression.

CONCLUSION

For our sample of women with CPP, a history of abuse during childhood or adulthood was not associated with differences in pain intensity, but adolescent or adult sexual abuse was associated with greater pain-related disability. A history of physical abuse or sexual abuse appears to hold a stronger relationship with current depressive symptoms than pain experience for women with CPP. Educational achievement holds a robust relationship with pain morbidity and depression for this population.

A cross-sectional study identifying the pattern of factors related to psychological intimate partner violence exposure in Slovenian family practice attendees: what hurt them the most

BACKGROUND

Intimate partner violence (IPV) is yet to be fully acknowledged as a public health problem in Slovenia. This study aimed to explore the health and other patient characteristics associated with psychological IPV exposure and gender-related specificity in family clinic attendees.

METHODS

In a multi-centre cross-sectional study, 960 family practice attendees aged 18 years and above were recruited. In 689 interviews with currently- or previously-partnered patients, the short form of A Domestic Violence Exposure Questionnaire and additional questions about behavioural patterns of exposure to psychological abuse in the past year were given. General practitioners (GPs) reviewed the medical charts of 470 patients who met the IPV exposure criteria. The Domestic Violence Exposure Medical Chart Check List was used, collecting data on the patients' lives and physical, sexual and reproductive, and psychological health status, as well as sick leave, hospitalisation, visits to family practices and referrals to other clinical specialists in the past year. In multivariate logistic regression modelling the factors associated with past year psychological IPV exposure were identified, with P<0.05 set as the level of statistical significance.

RESULTS

Of the participants (n=470), 12.1% (n=57) were exposed to psychological IPV in the previous year (46 women and 11 men). They expressed more complaints regarding sexual and reproductive (p=0.011), and psychological and behavioural status (p<0.001), in the year prior to the survey. Unemployment or working part-time, a college degree, an intimate relationship of six years or more and a history of disputes in the intimate relationship, increased the odds of psychological IPV exposure in the sample, explaining 41% of the variance. In females, unemployment and a history of disputes in the intimate relationship explained 43% of the variance.

CONCLUSIONS

The prevalence of psychological IPV above 10% during the past year was similar to earlier studies in Slovenia, although the predominance of better-educated people might be associated with lower tolerance toward psychological abuse. GPs should pay special attention to unemployed patients and those complaining about family disputes, to increase early detection.

Quality of care for intimate partner violence in South African primary care: a qualitative study

Intimate partner violence (IPV) makes a substantial contribution to the burden of disease in South Africa. This article explores the current quality of care for IPV in public sector primary care facilities within the Western Cape. Only 10% of women attending primary care, while suffering from IPV, were recognized. Case studies, based on in-depth interviews and medical records, were used to reflect on the quality of care received among the women who were recognized. Care tended to be superficial, fragmented, poorly coordinated, and lacking in continuity. The recognition, management, and appropriate documentation of IPV should be prioritized within the training of primary care providers. It may be necessary to appoint IPV champions within primary care to ensure comprehensive care for survivors of IPV.

Psychological advocacy toward healing (PATH): study protocol for a randomized controlled trial

Background

Domestic violence and abuse (DVA), defined as threatening behavior or abuse by adults who are intimate partners or family members, is a key public health and clinical priority. The prevalence of DVA in the United Kingdom and worldwide is high, and its impact on physical and mental health is detrimental and persistent. There is currently little support within healthcare settings for women experiencing DVA. Psychological problems in particular may be difficult to manage outside specialist services, as conventional forms of therapy such as counseling that do not address the violence may be ineffective or even harmful. The aim of this study is to assess the overall effectiveness and cost-effectiveness of a novel psychological intervention tailored specifically for survivors of DVA and delivered by domestic violence advocates based in third-sector organizations.

Methods and study design

This study is an open, pragmatic, parallel group, individually randomized controlled trial. Women ages 16 years and older experiencing domestic violence are being enrolled and randomly allocated to receive usual DVA agency advocacy support (control) or usual DVA agency support plus psychological intervention (intervention). Those in the intervention group will receive eight specialist psychological advocacy (SPA) sessions weekly or fortnightly, with two follow-up sessions, 1 month and then 3 months later. This will be in addition to any advocacy support sessions each woman receives. Women in the control group will receive usual DVA agency support but no additional SPA sessions. The aim is to recruit 250 women to reach the target sample size. The primary outcomes are psychological well-being and depression severity at 1 yr from baseline, as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures include anxiety, posttraumatic stress, severity and frequency of abuse, quality of life and cost-effectiveness of the intervention. Data from a subsample of women in both groups will contribute to a nested qualitative study with repeat interviews during the year of follow-up.

Discussion

This study will contribute to the evidence base for management of the psychological needs of women experiencing DVA. The findings will have important implications for healthcare commissioners and providers, as well as third sector specialist DVA agencies providing services to this client group.

Trial registration

ISRCTN58561170

Longitudinal measurement of cortisol in association with mental health and experience of domestic violence and abuse: study protocol

BACKGROUND

Domestic violence and abuse is threatening behavior, violence/abuse used by one person to control the other within an intimate or family-type relationship. Women experience more severe physical and sexual domestic violence and abuse and more mental health consequences than men. The current study aims at exploring of the role of hypothalamic-pituitary-adrenocortical axis activity in abuse impact on women's mental health.

STUDY OBJECTIVES

1) To evaluate diurnal cortisol slope, cortisol awakening response, and the mean cortisol concentration in women with a current or recent experience of abuse; 2) To estimate whether cortisol secretion is associated with type, severity, duration and cessation of abuse; 3) To investigate whether cortisol acts as mediator between abuse and mental health condition; 4) To examine whether there is any distinction in cortisol levels between those women exposed to both childhood abuse and domestic violence and abuse and those experienced only the latter. 4) To explore whether cortisol secretion differs between women living in refuge and those still living in the community.

METHODS/DESIGN

To meet study objectives 128 women will be recruited in a domestic violence agency and local communities. Baseline and 3-month follow-up measures will be taken over 6 months after recruitment. Each assessment will include: (1) standardized self-administered questionnaires to evaluate socio-demographics, experience of violence and abuse, mental and physical health; (2) weight and height measurement; (3) self-completion of wakening, post-wakening and evening saliva samples. Saliva will be analysed for cortisol and cortisone using Ultra performance liquid chromatography-tandem mass spectrometry. We will compare diurnal cortisol parameters between non-abused controls and abuse survivors with and without mental health conditions. First following descriptive statistics for all the cortisol and mental health outcomes, relationships between them will be investigated using appropriate regression models. Second, these techniques will be used to investigate the extent to which cortisol measures act as potential mediators between type, severity, duration of abuse and mental disorders.

DISCUSSION

Results of the study will increase our understanding of the pathophysiological mechanisms of abuse-related mental health disorders in women and inform researchers and practitioners on the possibility of using salivary cortisol as a biological marker for prognosis, diagnosis, and treatment evaluation among abuse survivors.

TRIAL REGISTRATION

ClinicalTrials.gov registration NCT01632553.

Violência sexual: estudo descritivo sobre as vítimas e o atendimento em um serviço universitário de referência no Estado de São Paulo, Brasil

A violência sexual é problema de saúde pública global e ações têm sido implementadas para estimular estudos no tema, a fim de propor intervenções de prevenção e atendimento adequado. Este trabalho objetivou caracterizar a população de mulheres que sofreram violência sexual, e descrever as características da agressão e do atendimento dispensado em um serviço universitário de referência. Estudo quantitativo e retrospectivo com atendimentos por violência sexual de junho de 2006 a dezembro de 2010. Avaliadas 687 mulheres, a maioria branca, solteira, sem filhos, com idade média de 23,7 anos, escolaridade entre fundamental e média, empregadas, com religião e prática religiosa. Um quarto sem relação sexual anterior. Violência sexual principalmente à noite, na rua, por agressor desconhecido e único, via vaginal e com intimidação. A maioria contou para outras pessoas e se sentiu apoiada. Atendimento precoce para quase 90% das mulheres, instaurando medidas profiláticas. Ocorreu aumento da procura precoce ao longo do período. Conhecer melhor as características da população e do evento pode auxiliar a estruturação e qualificação de modelos de atendimento.

Influence of interpersonal violence on maternal anxiety, depression, stress and parenting morale in the early postpartum: a community based pregnancy cohort study

BACKGROUND

Research has shown that exposure to interpersonal violence is associated with poorer mental health outcomes. Understanding the impact of interpersonal violence on mental health in the early postpartum period has important implications for parenting, child development, and delivery of health services. The objective of the present study was to determine the impact of interpersonal violence on depression, anxiety, stress, and parenting morale in the early postpartum.

METHODS

Women participating in a community-based prospective cohort study (n = 1319) completed questionnaires prior to 25 weeks gestation, between 34-36 weeks gestation, and at 4 months postpartum. Women were asked about current and past abuse at the late pregnancy data collection time point. Postpartum depression, anxiety, stress, and parenting morale were assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale, the Spielberger State Anxiety Index, the Cohen Perceived Stress Scale, and the Parenting Morale Index, respectively. The relationship between interpersonal violence and postpartum psychosocial health status was examined using Chi-square analysis (p < 0.05) and multivariable logistic regression.

RESULTS

Approximately 30% of women reported one or more experience of interpersonal violence. Sixteen percent of women reported exposure to child maltreatment, 12% reported intimate partner violence, and 12% reported other abuse. Multivariable logistic regression analysis found that a history of child maltreatment had an independent effect on depression in the postpartum, while both child maltreatment and intimate partner violence were associated with low parenting morale. Interpersonal violence did not have an independent effect on anxiety or stress in the postpartum.

CONCLUSION

The most robust relationships were seen for the influence of child maltreatment on postpartum depression and low parenting morale. By identifying women at risk for depression and low parenting morale, screening and treatment in the prenatal period could have far-reaching effects on postpartum mental health thus benefiting new mothers and their families in the long term.

A comprehensive model for intimate partner violence in South African primary care: action research

BACKGROUND

Despite extensive evidence on the magnitude of intimate partner violence (IPV) as a public health problem worldwide, insubstantial progress has been made in the development and implementation of sufficiently comprehensive health services. This study aimed to implement, evaluate and adapt a published protocol for the screening and management of IPV and to recommend a model of care that could be taken to scale in our underdeveloped South African primary health care system.

METHODS

Professional action research utilised a co-operative inquiry group that consisted of four nurses, one doctor and a qualitative researcher. The inquiry group implemented the protocol in two urban and three rural primary care facilities. Over a period of 14 months the group reflected on their experience, modified the protocol and developed recommendations on a practical but comprehensive model of care.

RESULTS

The original protocol had to be adapted in terms of its expectations of the primary care providers, overly forensic orientation, lack of depth in terms of mental health, validity of the danger assessment and safety planning process, and need for ongoing empowerment and support. A three-tier model resulted: case finding and clinical care provision by primary care providers; psychological, social and legal assistance by 'IPV champions' followed by a group empowerment process; and then ongoing community-based support groups.

CONCLUSION

The inquiry process led to a model of comprehensive and intersectoral care that is integrated at the facility level and which is now being piloted in the Western Cape, South Africa.

Trauma Exposure in Anxious Primary Care Patients

The present study examined rates of trauma exposure, clinical characteristics associated with trauma exposure, and the effect of trauma exposure on treatment outcome in a large sample of primary care patients without posttraumatic stress disorder (PTSD). Individuals without PTSD (N = 1263) treated as part of the CALM program (Roy-Byrne et al., 2010) were assessed for presence of trauma exposure. Those with and without trauma exposure were compared on baseline demographic and diagnostic information, symptom severity, and responder status six months after beginning treatment. Trauma-exposed individuals (N = 662, 53%) were more likely to meet diagnostic criteria for Obsessive Compulsive Disorder and had higher levels of somatic symptoms at baseline. Individuals with and without trauma exposure did not differ significantly on severity of anxiety, depression, or mental health functioning at baseline. Trauma exposure did not significantly impact treatment response. Findings suggest that adverse effects of trauma exposure in those without PTSD may include OCD and somatic anxiety symptoms. Treatment did not appear to be adversely impacted by trauma exposure. Thus, although trauma exposure is prevalent in primary care samples, results suggest that treatment of the presenting anxiety disorder is effective irrespective of trauma history.

Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians

BACKGROUND

Domestic violence affects one in four women and has significant health consequences. Women experiencing abuse identify doctors and other health professionals as potential sources of support. Primary care clinicians agree that domestic violence is a healthcare issue but have been reluctant to ask women if they are experiencing abuse.

AIM

To measure selected UK primary care clinicians' current levels of knowledge, attitudes, and clinical skills in this area.

DESIGN AND SETTING

Prospective observational cohort in 48 general practices from Hackney in London and Bristol, UK.

METHOD

Administration of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), comprising five sections: responder profile, background (perceived preparation and knowledge), actual knowledge, opinions, and practice issues.

RESULTS

Two hundred and seventy-two (59%) clinicians responded. Minimal previous domestic violence training was reported by participants. Clinicians only had basic knowledge about domestic violence but expressed a positive attitude towards engaging with women experiencing abuse. Many clinicians felt poorly prepared to ask relevant questions about domestic violence or to make appropriate referrals if abuse was disclosed. Forty per cent of participants never or seldom asked about abuse when a woman presented with injuries. Eighty per cent said that they did not have an adequate knowledge of local domestic violence resources. GPs were better prepared and more knowledgeable than practice nurses; they also identified a higher number of domestic violence cases.

CONCLUSION

Primary care clinicians' attitudes towards women experiencing domestic violence are generally positive but they only have basic knowledge of the area. Both GPs and practice nurses need more comprehensive training on assessment and intervention, including the availability of local domestic violence services.

Male Perpetrators of Intimate Partner Violence: Support for Health Care Interventions Targeted at Level of Risk

The mental health correlates of male aggression or violence against an intimate partner (IPV) are examined using exploratory cluster analysis for 81 men who self-reported risk factors for IPV perpetration on a computer-based health risk assessment. Men disclosing IPV perpetration could be meaningfully subdivided into two different clusters: a high pathology/high violence cluster, and lower pathology/low violence cluster. These groups appear to perpetrate intimate partner violence in differing psychoemotional contexts and could be robustly identified using multiple distinct analytic methods. If men who self-disclose IPV in a health care setting can be meaningfully subdivided based on mental health symptoms and level of violence, it lends support for potential new targeted approaches to preventing partner violence perpetration by both women and men.

Recognizing intimate partner violence in primary care: Western Cape, South Africa

INTRODUCTION

Interpersonal violence in South Africa is the second highest contributor to the burden of disease after HIV/AIDS and 62% is estimated to be from intimate partner violence (IPV). This study aimed to evaluate how women experiencing IPV present in primary care, how often IPV is recognized by health care practitioners and what other diagnoses are made.

METHODS

At two urban and three rural community health centres, health practitioners were trained to screen all women for IPV over a period of up to 8 weeks. Medical records of 114 thus identified women were then examined and their reasons for encounter (RFE) and diagnoses over the previous 2-years were coded using the International Classification of Primary Care. Three focus group interviews were held with the practitioners and interviews with the facility managers to explore their experience of screening.

RESULTS

IPV was previously recognized in 11 women (9.6%). Women presented with a variety of RFE that should raise the index of suspicion for IPV- headache, request for psychiatric medication, sleep disturbance, tiredness, assault, feeling anxious and depressed. Depression was the commonest diagnosis. Interviews identified key issues that prevented health practitioners from screening.

CONCLUSION

This study demonstrated that recognition of women with IPV is very low in South African primary care and adds useful new information on how women present to ambulatory health services. These findings offer key cues that can be used to improve selective case finding for IPV in resource-poor settings. Universal screening was not supported by this study.

The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis

BACKGROUND

Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.

METHODS AND FINDINGS

A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16-2.04], emotional abuse [OR = 3.06; 95% CI 2.43-3.85], and neglect [OR = 2.11; 95% CI 1.61-2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67-2.20], emotional abuse [OR = 1.41; 95% CI 1.11-1.79], and neglect [OR = 1.36; 95% CI 1.21-1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17-5.32], emotional abuse [OR = 3.37; 95% CI 2.44-4.67], and neglect [OR = 1.95; 95% CI 1.13-3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50-2.10], emotional abuse [OR = 1.75; 95% CI 1.49-2.04], and neglect [OR = 1.57; 95% CI 1.39-1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.

CONCLUSIONS

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.

Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial

OBJECTIVE

The Identification and Referral to Improve Safety (IRIS) cluster randomised controlled trial tested the effectiveness of a training and support intervention to improve the response of primary care to women experiencing domestic violence (DV). The aim of this study is to estimate the cost-effectiveness of this intervention.

DESIGN

Markov model-based cost-effectiveness analysis.

SETTING

General practices in two urban areas in the UK.

PARTICIPANTS

Simulated female individuals from the general UK population who were registered at general practices, aged 16 years and older.

INTERVENTION

General practices received staff training, prompts to ask women about DV embedded in the electronic medical record, a care pathway including referral to a specialist DV agency and continuing contact from that agency. The trial compared the rate of referrals of women with specialist DV agencies from 24 general practices that received the IRIS programme with 24 general practices not receiving the programme. The trial did not measure outcomes for women beyond the intermediate outcome of referral to specialist agencies. The Markov model extrapolated the trial results to estimate the long-term healthcare and societal costs and benefits using data from other trials and epidemiological studies.

RESULTS

The intervention would produce societal cost savings per woman registered in the general practice of UK£37 (95% CI £178 saved to a cost of £136) over 1 year. The incremental quality-adjusted life-year was estimated to be 0.0010 (95% CI -0.0157 to 0.0101) per woman. Probabilistic sensitivity analysis found 78% of model replications under a willingness to pay threshold of £20 000 per quality-adjusted life-year.

CONCLUSIONS

The IRIS programme is likely to be cost-effective and possibly cost saving from a societal perspective. Better data on the trajectory of abuse and the effect of advocacy are needed for a more robust model.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN74012786.

Investigation of telomere length and psychological stress in rape victims

BACKGROUND

Women are at an increased risk of depression and other mental health problems following rape. Various etiological factors for depression, including predisposing genetic factors, have been identified. Telomeres are repetitive nucleoprotein structures located at chromosomal ends that protect them from premature degradation. Telomeres reduce in length with each cell division, resulting in cellular senescence and apoptosis.

METHODS

Relative quantification of telomeric repeats using qPCR was performed to investigate whether shorter relative leukocyte telomere length (LTL) in a cohort of 64 rape victims was associated with resilience, the development of rape trauma-related major depressive disorder (MDD) or the development of posttraumatic stress disorder (PTSD) after 3 months.

RESULTS

Out of the 64 participants, 23 participants were diagnosed with MDD at baseline and 31 after 3 months. Nine participants were diagnosed with PTSD (MDD and PTSD specifically related to the trauma). No significant associations were observed between relative LTL and resilience or the development of MDD at either baseline or after 3 months in this cohort. However, a marginally significant association was evident between relative LTL and PTSD status.

CONCLUSIONS

The significant association between relative LTL and PTSD suggests that shorter relative LTL might have acted as a predisposing factor in the development of PTSD after a severely traumatic event. The results of this study indicate that telomere shortening may be an important marker of PTSD risk, with implications for early intervention and timely treatment, and as such warrant replication in a larger cohort.

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

BACKGROUND

Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services.

METHODS

In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786.

FINDINGS

We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded.

INTERPRETATION

A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services.

FUNDING

Health Foundation.

Prevalence and effects of violence against women in a rural community in Minia governorate, Egypt

This study was carried out to investigate prevalence and the characteristics of domestic violence (DV) against women in a rural area in Minia governorate, Egypt, as well as its physical and psychological consequences. Seven hundred and seventy-two women were interviewed. Sociodemographic data were collected; the WHO questionnaire was used to identify the abuse; the Structured Clinical Interview for DSM IIIR (SCID) to detect psychiatric disorders. Abused females constituted 57.4% of the total sample. There were significant relationships between DV and low education, low income, higher number of children, and husband's education. Psychiatric disorders occurred in 18% of the sample. There were statistically significant relationships between psychological and physical abuse of women and the occurrence of psychiatric disorders. In conclusion, DV against women was related to various negative health outcomes, and it is recommended to be given its real importance in both Forensic Medicine Council and in psychiatric assessment.

Intimate partner violence identification and response: time for a change in strategy

BACKGROUND

While victims of intimate partner violence (IPV) present to health care settings for a variety of complaints; rates and predictors of case identification and intervention are unknown.

OBJECTIVE

Examine emergency department (ED) case finding and response within a known population of abused women.

DESIGN

Retrospective longitudinal cohort study.

SUBJECTS

Police-involved female victims of IPV in a semi-rural Midwestern county.

MAIN MEASURES

We linked police, prosecutor, and medical record data to examine characteristics of ED identification and response from 1999-2002; bivariate analyses and logistic regression analyses accounted for the nesting of subjects' with multiple visits.

RESULTS

IPV victims (N = 993) generated 3,426 IPV-related police incidents (mean 3.61, median 3, range 1-17) over the 4-year study period; 785 (79%) generated 4,306 ED visits (mean 7.17, median 5, range 1-87), which occurred after the date of a documented IPV assault. Only 384 (9%) ED visits occurred within a week of a police-reported IPV incident. IPV identification in the ED was associated with higher violence severity, being childless and underinsured, more police incidents (mean: 4.2 vs 3.3), and more ED visits (mean: 10.6 vs 5.5) over the 4 years. The majority of ED visits occurring after a documented IPV incident were for medical complaints (3,378, 78.4%), and 72% of this cohort were never identified as victims of abuse. IPV identification was associated with the day of a police incident, transportation by police, self-disclosure of "domestic assault," and chart documentation of mental health and substance abuse issues. When IPV was identified, ED staff provided legally useful documentation (86%), police contact (50%), and social worker involvement (45%), but only assessed safety in 33% of the women and referred them to victim services 25% of the time.

CONCLUSION

The majority of police-identified IPV victims frequently use the ED for health care, but are unlikely to be identified or receive any intervention in that setting.

Sexual Violence Victimization of Women

Sexual violence is a serious public health problem with devastating health-related consequences. In this article, the authors review the prevalence, characteristics, vulnerability factors for, and impacts of sexual violence victimization for women. Some key factors are reviewed that have been shown to increase vulnerability for victimization, including certain demographic characteristics, previous victimization, and use of drugs or alcohol. The impacts of rape and other sexual violence are described, including physical and sexual health; psychological, social, and societal impacts; as well as impact on risky health behaviors. The authors conclude with a discussion of the public health approach to sexual violence, primary prevention, the relevance of sexual violence research for health care practitioners, and recommendations for health care practice.

A global perspective on child sexual abuse: meta-analysis of prevalence around the world

Our comprehensive meta-analysis combined prevalence figures of childhood sexual abuse (CSA) reported in 217 publications published between 1980 and 2008, including 331 independent samples with a total of 9,911,748 participants. The overall estimated CSA prevalence was 127/1000 in self-report studies and 4/1000 in informant studies. Self-reported CSA was more common among female (180/1000) than among male participants (76/1000). Lowest rates for both girls (113/1000) and boys (41/1000) were found in Asia, and highest rates were found for girls in Australia (215/1000) and for boys in Africa (193/1000). The results of our meta-analysis confirm that CSA is a global problem of considerable extent, but also show that methodological issues drastically influence the self-reported prevalence of CSA.

Domestic violence and mental health

There are clear gender differences in the experience of domestic violence and associated mental health outcomes. There is also increasing evidence of chronic, severe and often long-term adverse mental health effects for victims. This paper explores these gender differences and the evidence on how mental health care services should respond to domestic violence. The authors argue that any strategy to reduce the burden of women's mental health problems should include efforts to identify, prevent or reduce violence against women.

Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study

BACKGROUND

Mental health service users are at high risk of domestic violence but this is often not detected by mental health services.

AIMS

To explore the facilitators and barriers to disclosure of domestic violence from a service user and professional perspective.

METHOD

A qualitative study in a socioeconomically deprived south London borough, UK, with 18 mental health service users and 20 mental health professionals. Purposive sampling of community mental health service users and mental healthcare professionals was used to recruit participants for individual interviews. Thematic analysis was used to determine dominant and subthemes. These were transformed into conceptual maps with accompanying illustrative quotations.

RESULTS

Service users described barriers to disclosure of domestic violence to professionals including: fear of the consequences, including fear of Social Services involvement and consequent child protection proceedings, fear that disclosure would not be believed, and fear that disclosure would lead to further violence; the hidden nature of the violence; actions of the perpetrator; and feelings of shame. The main themes for professionals concerned role boundaries, competency and confidence. Service users and professionals reported that the medical diagnostic and treatment model with its emphasis on symptoms could act as a barrier to enquiry and disclosure. Both groups reported that enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional.

CONCLUSIONS

Mental health services are not currently conducive to the disclosure of domestic violence. Training of professionals in how to address domestic violence to increase their confidence and expertise is recommended.