Increasing the Safety-Promoting Behaviors of Abused Women

Women's evaluation of abuse and violence care in general practice: a cluster randomised controlled trial (weave)

BACKGROUND

Intimate partner abuse (IPA) is a major public health problem with serious implications for the physical and psychosocial wellbeing of women, particularly women of child-bearing age. It is a common, hidden problem in general practice and has been under-researched in this setting. Opportunities for early intervention and support in primary care need to be investigated given the frequency of contact women have with general practice. Despite the high prevalence and health consequences of abuse, there is insufficient evidence for screening in primary care settings. Furthermore, there is little rigorous evidence to guide general practitioners (GPs) in responding to women identified as experiencing partner abuse. This paper describes the design of a trial of a general practice-based intervention consisting of screening for fear of partner with feedback to GPs, training for GPs, brief counselling for women and minimal practice organisational change. It examines the effect on women's quality of life, mental health and safety behaviours.

METHODS/DESIGN

weave is a cluster randomised controlled trial involving 40 general practices in Victoria, Australia. Approximately 500 women (16-50 years) seen by the GP in the previous year are mailed a short lifestyle survey containing an item to screen for IPA. Women who indicate that they were afraid of a partner/ex-partner in the last year and provide contact details are invited to participate. Once baseline data are collected, GPs are randomly assigned to either a group involving healthy relationship and responding to IPA training plus inviting women for up to 6 sessions of counselling or to a group involving basic education and usual care for women. Outcomes will be evaluated by postal survey at 6 and 12 months following delivery of the intervention. There will be an economic evaluation, and process evaluation involving interviews with women and GPs, to inform understanding about implementation and outcomes.

DISCUSSION

The weave trial responds to an urgent need for more evidence on what can be achieved in primary care with regard to responding to women who experience IPA. It will provide important knowledge about the effectiveness of a brief method of screening, professional IPA training program and brief counselling for women.

TRIAL REGISTRATION

[ACTRN12608000032358].

Can a health clinic-based intervention increase safety in abused women? Results from a pilot study

BACKGROUND

Intimate partner violence (IPV) has been related to a number of adverse physical and mental health consequences. Research has identified relatively high IPV victimization rates among women seeking care in primary healthcare and emergency department settings. Studies have shown the potential usefulness of screening and intervention in these settings.

METHODS

This article reports results from a pilot study designed to assess the effect of a clinic-based intervention on women's engagement in safety-promoting behaviors. This study was conducted in a primary healthcare clinic for the uninsured in Baltimore, Maryland. Women who screened positive for recent IPV were randomly assigned to an intervention or control group. The intervention consisted of an on-site counseling session and six telephone counseling sessions over a 3-month period. Women in the control group received health information brochures, a list of community resources, and a monthly telephone call to confirm contact information.

RESULTS

A total of 41 women participated in the study. Results demonstrated that women who received the clinic-based intervention engaged in significantly more safety-promoting behaviors than did women in the control group.

CONCLUSIONS

The results of this study and others indicate the potential usefulness of screening and intervention in a medical setting.

Behaviors of Children Following a Randomized Controlled Treatment Program for Their Abused Mothers

OBJECTIVE

To determine if a treatment program offered to abused mothers positively affects the behaviors of their children.

METHODS

A randomized, two-arm, clinical trial was used to measure child behavior at 6, 12, 18, and 24 months following the application of two levels of abuse treatment services to abused mothers: (1) abuse assessment and receipt of a wallet-size referral card, or (2) abuse assessment, receipt of a wallet-size referral card, and nurse case management sessions. The setting was public primary care clinics. The participants were 233 women who reported physical or sexual abuse within the preceding 12 months, and who had at least one child, ages 18 months to 18 years, living with them. Outcome measures were scores on the Child Behavior Checklist (CBCL) at baseline, 6, 12, 18, and 24 months. CBCL scores for a clinically-referred sample of children served as a comparison group.

RESULTS

All children improved significantly (p < .001) on CBCL scores from intake to 24 months, regardless of which treatment protocol their mother received. By 24 months, the majority of children and adolescents had scores significantly less than the referred norms. Children ages 18 months to 5 years showed the most improvement and teenagers showed the least improvement.

CONCLUSIONS

Disclosure of abuse, such as that which happens during abuse assessment, was associated with the same improvement in child behavior scores as a nurse case management intervention. Routine abuse assessment and referral have the potential to positively improve the behavioral functioning of children exposed to domestic violence.

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 in all societies and damages the health of survivors and their children in the short and long term. Advocacy may decrease the impact of this abuse on women's health.

OBJECTIVES

To assess the effects of advocacy interventions conducted within or outside of health care settings on women who have experienced intimate partner abuse.

SEARCH STRATEGY

We searched: CENTRAL and DARE (Cochrane Library Issue 3, 2008), MEDLINE (1966 to 31/7/08), EMBASE (1980 to 2008 week 30), and 11 other databases, to end July 2008. We also searched relevant websites, reference lists and forward citation tracking of included studies, and handsearched six key journals. We contacted principal investigators and experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing advocacy interventions for women with experience of intimate partner abuse against usual care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and undertook data extraction. For binary outcomes we calculated a standardised estimation of the odds ratio (OR) and for continuous data we calculated either a standardised mean difference (SMD) or a weighted mean difference (WMD), both with a 95% confidence interval.

MAIN RESULTS

We included ten trials involving 1527 participants. The studies were heterogeneous in respect of: intensity of advocacy, outcome measures and duration of follow-up (immediately post-intervention to three years), permitting meta-analysis for only a minority of outcomes. Intensive advocacy (12 hours or more duration) may help terminate physical abuse in women leaving domestic violence shelters or refuges at 12-24 months follow-up (OR 0.43, 95% CI 0.23 to 0.80), but not at up to 12 months follow-up. The evidence indicates that intensive advocacy may improve quality of life at up to 12 months follow-up, but the confidence intervals included zero (WMD 0.23, 95% CI 0.00 to 0.46). Depression did not improve following intensive advocacy at up to 12 months follow-up (WMD -0.05, 95% CI -0.19 to 0.09), nor did psychological distress (SMD -0.16, 95% CI -0.39 to 0.06). Only two meta-analyses of brief advocacy interventions (less than 12 hours duration) were possible; an increased use of safety behaviours was consistent with the receipt of brief advocacy both at up to 12 months (WMD 0.60, 95% CI 0.14 to 1.06) and at 12-24 months (WMD 0.48, 95% CI 0.04 to 0.92) follow up.

AUTHORS' CONCLUSIONS

Based on the evidence reviewed, it is possible that intensive advocacy for women recruited in domestic violence shelters or refuges reduces physical abuse one to two years after the intervention but we do not know if it has a beneficial effect on their quality of life and mental health. Similarly, there is insufficient evidence to show if less intensive interventions in healthcare settings for women who still live with the perpetrators of violence are effective.

Interpersonal violence is associated with depression and chronic physical health problems in midlife women

This research describes interpersonal violence (IPV) exposure in a community-based sample of midlife women from three ethnic groups and explores relationships among these exposures and variables associated with health outcomes. IPV, physical health, depression, and social support were measured by self-report questionnaires. More than 33% reported a history of physical abuse or sexual abuse and at least 20% reported both. Approximately 20% experienced sexual harassment in the past year. IPV exposure was associated with more chronic health problems and depressive symptoms. IPV, whenever it occurs, is detrimental to women's health regardless of socioeconomic status or ethnicity.

An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum.

METHODS

Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum.

RESULTS

The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5-31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7-43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25-2.75, number needed to treat=7, 95% CI 4-19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15-2.22, number needed to treat=9, 95% CI 6-29).

CONCLUSION

An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum.

Strategies for successful recruitment and retention of abused women for longitudinal studies

Researchers agree that high recruitment and retention rates are essential for longitudinal studies and can be a daunting task. This paper examines retention rates for longitudinal studies of abused women and presents strategies to maximize recruitment and retention. The techniques presented resulted in subject retention rates of 89% to 100% in longitudinal prevalence, quasi-experimental, and randomized clinical trials that followed participants for up to 24 months. The findings point to the importance of establishing and sustaining collaborative partnerships with agencies, multiple contacts sources with study participants, incremental monetary incentives, and a detailed field tracking protocol that includes safety practices.

Nursing protocol for telephonic supervision of clients

Access to care, client vulnerabilities, technology, and health costs affect not only the delivery of health care but also the roles, responsibilities, and opportunities for nurses. Patients are often managed in the home or discharged from hospitals before they or their families are ready. To address some of these needs, nurses are utilizing telehealth opportunities. For many nurses, telehealth translates to telephonic nursing. This article provides an algorithm that nurses can utilize in order to safely monitor patients in their homes. This can be a cost-effective program, particularly for those who are homebound or for persons, such as the elderly or those with chronic illness, who have long-term needs that vary between relative health and acute illness. This algorithm serves as a guide in our nursing practice for the telephonic supervision of patients in the home environment.

Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide

In order to establish the frequency of substance use, following and attributed to sexual assault, and describe the danger for femicide and suicidality for women physically and sexually abused compared to physically-abused only women, a personal interview of 148 African-American, Hispanic, and white English and Spanish-speaking abused women was completed. Women who reported more than one sexual assault were 3.5 (95% CI, 0.9, 13.4) times more likely to report beginning or increasing substance use compared to women who reported only one sexual assault. Sexually assaulted women reported significantly (p=.002) more risk factors for femicide compared to physically- abused only women. Specific to suicide, women reporting sexual assault were 5.3 (95% CI, 1.3, 21.5) times more likely to report threatening or attempted suicide within a 90-day period compared to physically-abused only women. The health assessment and intervention of intimate partner violence must extend beyond injury to include behavior risk sequelae of substance abuse and suicidality.

Behaviors of children exposed to intimate partner violence before and 1 year after a treatment program for their mother

Children exposed to intimate partner violence against their mothers are at increased risk for emotional, behavior, physiological, cognitive, and social problems. To compare the behavioral functioning of children exposed to intimate partner violence before and 1 year after their mother received treatment, 206 Black, White, and Hispanic children, age 18 months to 18 years, were administered the Child Behavior Checklist. Behavior problems of all children significantly improved 1 year following treatment of their mother. When compared with a clinically referred sample of youngsters, scores of children of abused mothers were not significantly different before their mothers received treatment but most scores were significantly different after their mothers were treated. Screening and a treatment for abused women can have a positive effect on the behavior of their children.

What we know and what we still need to learn

Research has changed the conceptualization of the causes and consequences of violence. Yet some questions remain unanswered. Infants and young children have largely been overlooked, and intraethnic and cultural group variations have not been addressed. There is still a need to address macro-level systematic discrimination in the health care system along with the intrapersonal physiological changes that result from exposure to violence. Fortunately, studies are beginning to show how longitudinal and intervention research can be safely conducted.

Intimate Partner Sexual Assault Against Women: Frequency, Health Consequences, and Treatment Outcomes

OBJECTIVE

To describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted-only women, and measure the risk of reassault after victim contact with justice and health services.

METHODS

A personal interview survey of 148 African-American, Hispanic, and white English- and Spanish-speaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related sexually transmitted diseases and pregnancy, symptoms of posttraumatic stress disorder (PTSD) and depression, and risk of reassault after treatment were measured.

RESULTS

Sixty-eight percent of the physically abused women reported sexual assault. Fifteen percent of the women attributed 1 or more sexually-transmitted diseases to sexual assault, and 20% of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. One significant (P = .003) difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African-American women (P = .005) and White women (P = .012). The risk of sexual reassault was decreased by 59% and 70% for women who contacted the police, or applied for a protection order, after the first sexual assault. Receiving medical care decreased the woman's risk of further sexual assault by 32%.

CONCLUSION

Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of reassault is decreased if contact is made with health or justice agencies.